Variables influencing physical therapists' perceptions of continuing education.

The changing health care environment is well documented. (1-5) Lifelong learning and professional development through continuing education (CE), whether voluntary or mandatory, have been identified as ways to foster self-development and equip professionals to meet change. (4,6-9) Multiple definitions have been used to describe lifelong learning; all are grounded in ongoing personal development specific to the individual and the situation. Lifelong learning involves continuous personal and professional growth. (10,11)

Although the concept of lifelong learning sounds simple, the ideas and behaviors associated with lifelong adult learning are more complex. (12,13) For example, rapid changes in technology and society directly affect adult education. Professionals in fields such as medicine are at particular risk for quickly becoming obsolete because of factors such as accelerated growth of knowledge, new products, and continually emerging legal and ethical issues.12 Continuing education and lifelong learning have been described as major components of the health care educational process, following formal education and professional certification. (14)

In order to maintain their license to practice, physical therapists in 30 states have mandatory CE requirements. Conversely, 20 states have not enacted mandatory CE requirements for licensure maintenance, leaving engagement in CE to the discretion of the individual physical therapist or to his or her employer. As of October 1, 2002, license-holding physical therapists in Illinois were mandated to engage in CE. The legislative act, which was passed by the state of Illinois in the spring of 2001, requires that physical therapists obtain 40 CE hours every 2 years. These changes first affected licensure renewal in 2004. Prior to this legislation, no mandate for licensure renewal existed in the state. (15) The current mandatory CE requirements for physical therapists practicing in Illinois are similar to the mandatory CE requirements for physical therapists in other states. (16)

Physical therapists have been increasingly called upon to meet the challenges of an evolving health care environment, (1,3) and CE, as one component of lifelong learning, has been described as a likely component for negotiating this dynamic process. (2,4) Although the need to remain current in the field and engage in lifelong learning has unquestionable importance, opinions among professionals have differed concerning the roles of CE and mandatory CE for physical therapists. (2,6,17-19) Despite these differences in opinion, CE has been identified as a significant component of professional development, (20) with a recent investigation suggesting that mandatory CE does increase the number of CE hours taken by physical therapists. (21)

Regardless of the potential usefulness of CE, new professional requirements are most successful when the needs and desires of those who are affected are considered. Therefore, researchers have investigated perceived barriers to, preferences for, and motivating factors related to participating in CE. (22-25) On the basis of the results of a large-scale survey, Karp (25) found that significant barriers to participation for physical therapists in Georgia included cost and travel distance. A lack of information about available courses, a lack of pertinent programs, and time away from family were additional barriers to participation. Seminars and workshops were the preferred instructional methods, with convention centers or hotels being the preferred locations. Participants wanted activities to be held throughout the state and favored course offerings in the fall and winter. Specific topics of interest included classes related to orthopedics. Respondents did not indicate a desire to use computer-assisted instruction or self-study courses. (25) The desire to increase personal knowledge was found to be the primary motivation for seeking CE. Fulfilling requirements for state relicensure was a secondary motivating factor, as was present job advancement. (24) In a similar vein, Tassone and Speechley (22) studied physical therapists practicing in Ontario, Canada. Like Karp, (25) they found conferences and workshops to be the preferred means for CE delivery.

Much of the literature related to physical therapy CE hails from survey investigations or editorials. Little focus has been given to the potential rich description of data from qualitative investigations focusing on both people and the organizational environment in which CE occurs. Although survey methods can produce meaningful findings, this type of method may fail to capture the subtle and potentially important intricacies associated with the complex phenomenon of the lifelong learning environment in which CE occurs. Investigators have given limited attention to the study of the recent mandate for physical therapists to engage in CE and have not compared the perspectives of physical therapist clinicians and managers in order to examine potential departmental influence on CE. Therefore, given these areas of limited study, we used a qualitative approach to examine the perceptions of physical therapist clinicians and managers concerning the barriers to and facilitators of CE, given the recent state mandate, and to identify how clinicians and managers perceive the role of their department in the CE process. The data are part of a larger investigation that also focused on physical therapists' views on the role and effectiveness of CE.

For the purposes of this investigation, CE was considered any activity that met the state CE requirements. Acceptable CE activities include formal or traditional CE courses, post-professional academic course work, clinical specialist certification, professional research or writing, journal clubs, district meeting programs, and departmental in-service events. Other activities that likely fall under the realm of professional development but that are not acceptable for generating CE credit include in-service activities that take place at places of employment and that are a conditional requirement for employment, such as infection control, new employee orientation, and hospital accreditation activities. (15) If participants had questions regarding acceptable activities, one investigator (TMA) clarified the activities at the outset and during the course of the interviews.

Method

Design and Participants

Qualitative methods were selected as the primary data source because it facilitated in-depth discussions regarding participants' perspectives concerning CE and mandatory CE and the perceived role of their department in the CE process. Because individual voices of participants were allowed to be heard, a more personalized and deeper understanding of the purposes of this investigation was facilitated. The proposal stipulated that 24 physical therapists (3 clinicians and 1 manager) from 6 different hospitals in Illinois would be interviewed. A physical therapist clinician was defined as someone whose primary responsibility was patient care, and a physical therapist manager was defined as the individual who was generally responsible for departmental oversight and the administrative tasks of the physical therapy department. By selecting multiple therapists from each of 6 facilities, we were able to compare and contrast participants' responses within the same hospital and among different hospitals. Interviewing multiple therapists from the same hospital was critical for analysis of the potential impact of the department on the CE process.

Two large-size hospitals, with 400 or more patient beds, 2 medium-size hospitals, with between 150 and 399 beds, and 2 small-size hospitals, with fewer than 150 beds, were identified. The 2 large-size hospitals, both considered teaching hospitals, were located in urban areas; the 2 medium-size hospitals were located in more suburban communities; and the 2 small-size hospitals were located in rural areas. The hospitals were situated in various geographic regions in Illinois and were within a reasonable travel distance from one investigator (TMA). Hospitals of various sizes and in different locations in Illinois were selected with the belief that participants' viewpoints regarding CE may differ with geographic location and hospital demographics.

The physical therapist manager at each hospital was contacted by telephone and asked whether he or she and 3 staff members would be willing to participate in the investigation. All of the managers agreed to participate and to allow access to 3 willing physical therapist clinicians. The only guidelines stipulated to the managers were that all participants had to be practicing physical therapists in Illinois under their direct management. If their facilities had multiple practice environments, the managers were encouraged to invite physical therapists practicing in both inpatient and outpatient settings. One of the small-size hospitals, however, had only 3 physical therapists; therefore, the total number of participants was reduced to 23.

Of the 23 participants, 20 were women (87.0%) and 3 were men (13.0%). The participants' average age was 35.21 years (range= 25-64), and they had an average of 11.82 years of physical therapy experience (range=0.75-37). Eighteen of the 23 participants (78.3%) held professional association membership (17 were members of the American Physical Therapy Association [APTA], and 1 was a member of the Canadian Physical Therapy Association). Sixteen of the participants (69.6%) reported clinical practice as their primary job responsibility. The remaining 7 participants (30.4%) had full or partial managerial responsibilities, with 5 of the 7 managers having partial clinical practice responsibilities in addition to their administrative duties. Of the 21 therapists who reported full or partial clinical practice responsibilities, 10 (47.6%) were primarily outpatient based, 9 (42.9%) were primarily inpatient based, and 2 (9.5%) reported dividing their time equally between inpatient and outpatient practice settings.

Twelve of the participants (52.2%) possessed a bachelor's degree, 10 (43.5%) had a master's degree, and 1 (4.3%) held a PhD degree. None of the participants had a professional (entry-level) or transition Doctor of Physical Therapy (DPT) degree. Of the 23 participants, 2 (8.7%) were pursuing a PhD degree, 1 (4.3%) was pursuing a transition DPT degree, and 2 (8.7%) were pursuing a master's degree. Two (8.7%) of the physical therapists had practiced in states with mandatory CE and had completed the necessary requirements for relicensure. The remaining 21 therapists (91.3%) did not have to fulfill CE requirements for licensure maintenance previously. Before the interviews were conducted, the purposes of the investigation were explained to the participants, and each participant signed a letter of informed consent.

With regard to the characteristics of the participants in this investigation compared with physical therapists nationally, we can only compare the participants with the national demographic profile of members of APTA. (26) We acknowledge that a small number of the participants in this investigation were not members of APTA; however, the characteristics of the participants in this investigation and members of APTA were similar. The percentage of female members of APTA decreased gradually from 70.1% in 1999 to 67.8% in 2004, and the percentage of male members increased from 29.9% in 1999 to 32.2% in 2004. The mean ages of members of APTA were 39.4 years in 1999 and 41.8 years in 2004; the mean years in professional practice in 2004 were 16.6, an increase of 20.3% from 1999. The percentages of members of APTA with the highest earned degree being a bachelor's degree were 48.2% in 1999 and 37.3% in 2004, the percentages with the highest earned degree being a master's degree were 46.2% in 1999 and 47.9% in 2004, and the percentages with the highest earned degree being a doctorate other than a doctorate in physical therapy were 2.5% in 1999 and 6.1% in 2004. Finally, the largest percentage of members of APTA reported working in outpatient settings in 2004.

Data Collection and Procedure

Three types of data were collected and analyzed: interviews with the 23 participants, document analysis of materials available at each hospital, and field journals kept by one investigator (TMA) throughout the study.

Interviews. The primary sources of data were the individual interviews with the participants. The standardized open-ended interview consisted of a preplanned series of questions with allowances for probe or follow-up questions. This format ensured that all participants were asked the same questions and allowed the interviews to remain highly focused, maximizing the time spent with each participant. (27) The informal conversational interview allowed participants to elaborate on particular subject areas and often deepened the level of communication between the interviewee and the interviewer. (27) The guiding questions addressed both clinicians' and managers' views with regard to obstacles or barriers to engaging in CE, facilitators of CE, their preferences for CE, what variables were the easiest to manage, and what variables were the most difficult to overcome. In addition, the participants were asked to discuss how CE was addressed at the workplace.

Although each participant was asked to comment on the same guiding questions during the audiotaped interview, ample opportunities were given for each participant to individually frame the issue of CE and mandatory CE. This goal was accomplished through probe questions from the investigator (TMA) during the audiotaped interview, requests for additional comments or thoughts at the end of each audiotaped interview, and informal conversational interviews that occurred before and after each audiotaped session. Each interview lasted 35 to 90 minutes and was audiotaped and later transcribed. To ensure the confidentiality of the information shared, no proper names of participants were used, and a number was assigned to each therapist. Numbers following quotes refer to specific therapists.

Document analysis of hospital materials. When available, relevant materials at each facility were reviewed; these materials included formal departmental CE plans, informational brochures for hospital patients and visitors, schedules of in-house educational sessions, and flyers for CE opportunities. It was the investigators' goal to become as familiar as possible with the educational networks present at the departmental, hospital, and community levels. (27-29)

Field journals. Field journals kept by one investigator (TMA) included a log of day-to-day activities documenting events directly related to the investigation; a personal log documenting individual reflections on the data collection process, expectations of future interviews, and any emerging themes; and a methodological log documenting any decisions made in reference to the design of the investigation. (29) No substantial design changes were made, with the exception of having 23 interviews instead of 24.

Credibility and Trustworthiness of Findings

Issues of accuracy were addressed by triangulation of data sources, peer debriefing, negative case analysis, and member checking. (27,29,30) These procedures, which are commonly used in qualitative research, are similar to procedures used for establishing validity and reliability in quantitative research.

First, triangulation, the comparison of multiple data sources, added credibility to the findings by increasing the confidence that the conclusions drawn were indeed true. (27,29) Field journals kept throughout the investigation and relevant documents from each hospital were compared with the transcripts from the audiotaped interviews to compare and confirm emerging and final themes for consistency and accuracy. Second, a peer "debriefer," someone unassociated with the investigation but familiar with qualitative research, was selected to serve as a "devil's advocate. (29(p308)) The role of this individual was to search for any potential biases of the investigators. Third, negative case analysis, or the process of comparing and refining all cases throughout the investigation, was used to confirm emerging themes. (29) Themes that aimed to fit the largest number of cases were generated. (27) The peer debriefer continually encouraged the investigators to look for negative cases (cases that do not support emerging themes) (27) to ensure that emerging themes were maximally representative of the total data set. Minor discrepancies in the initial findings were resolved after subsequent discussions with the peer debriefer.

Finally, 2 phases of member checking were conducted with participants. Initially, each participant was sent his or her individual interview transcript and asked to confirm the accuracy of the transcript. This process also gave each participant the opportunity to assess whether or not his or her perceptions were portrayed accurately by the investigator. (29) Only grammatical comments were received. Subsequently, after data analysis, attempts were made to contact all participants; the majority of them were located. A draft of tentative themes was sent to the participants requesting input with regard to the representativeness of the themes. Only confirmatory feedback was received from participants who responded, and no changes in the themes occurred as a result of the second phase of member checking.

Data Analysis

Although this investigation was primarily a descriptive study, data were analyzed with both inductive and deductive procedures. This multimethod analysis is relatively common and acceptable for qualitative investigations. (27) For this investigation, inductive analysis included searching for themes and patterns in the data. (27) Inductive analysis starts with specific statements from people and builds toward the creation of patterns and themes emerging directly from the cases under investigation rather than predetermining them prior to data collection. (27)

Conversely, deductive analysis requires defining at the outset of the investigation an explicit construct that provides the general basis for understanding specific cases in the investigation. (27) Data are analyzed, and themes that either support or refute previous theories are developed. From the outset, adult learning theory, specifically, lifelong learning as an adult education behavior, guided the investigation. As several authors have noted, lifelong learning skills are critical to professional development. (7,11,12,14,31,32) For the purposes of this investigation, CE was considered one component of lifelong learning behaviors, as this theoretical framework adequately addressed the scope of the investigation. As investigations such as the present study are added to the literature base, we anticipate that future investigations will be grounded in a variety of different and well-supported theoretical orientations.

A constant comparative process of data analysis was used. Data analysis was ongoing and progressed both inductively and deductively throughout the investigation. Each data set was compared with all other data sets, and themes were identified, tested, verified, and reverified. (27,33)

Results

Although multiple themes emerged from the data, the 4 that related to our analysis include: negotiating and managing the variables associated with CE, providing and promoting learning opportunities that meet physical therapists' CE needs, identifying the elements of employment environments that foster CE, and perceived implications of mandating CE.

Negotiating and Managing the Variables Associated With CE

Throughout the course of the interviews, participants readily identified variables that they currently faced or could potentially encounter when engaging in CE. For some, these variables were barriers to engaging in CE; for others, these variables were instrumental in facilitating the CE process. The summation of these variables represents a core set of items that participants negotiate and manage when participating in CE. The participants' responses indicated that the items in the core set were largely similar whether the participants were engaging in voluntary or mandatory CE.

Monetary impact of CE. Discussions concerning the monetary cost of CE incited an array of responses, often emotionally charged. The vast majority of participants indicated that they strongly considered and were cognizant of the financial cost of CE. Describing the monetary impact on CE decisions, participants noted, "If you have to pay out of pocket [for CE], it's the money" (1); and "[CE is a] financial burden ... I think it is because they're [CE courses] very expensive ... " (13). Participants stated that "Lowering the cost [of CE]" (2) and "Giving them ]therapists] time off and paying for it [CE]" (7) were appropriate measures for assisting physical therapists with the monetary impact of CE.

Although some participants were influenced by having to pay for CE, others received financial assistance from their employers, and this assistance eliminated or reduced the need to personally negotiate the financial cost of CE. Highlighting the current benefit of employer assistance but demonstrating concern that this benefit may not remain permanent, one participant said, "We haven't had to worry about that [money] too much here because what we have chosen to go to has fortunately been covered [by the employer]. We can't guarantee that's going to be the case, so, it's kind of scary to know that courses aren't cheap, and you're going to have to be forking some money out of your pocket" (22). Similarly, some participants believed that because CE is now mandatory for physical therapists in Illinois, employers would view monetary support for CE as a potential area for budgetary reduction, turning a previous facilitator into a future barrier. Emphasizing this point, one therapist stated,

   The hospital's been real generous with providing [CE money]. I have
   some concerns. They cut back this year and basically have said that
   they're not paying for our licensure anymore, which is a perk that
   they gave us in the past. And, because they say, "You have to have
   your license to practice anyway, so we're not going to pay for it,"
   I'm afraid with the mandatory thing that they're going to say,
   "Well, you have to have this course to remain in practice." So,
   that will probably be the next thing cut (18).

Interestingly, many participants perceived monetary support for CE from their employer as a direct reflection of the value and importance placed on CE by the employer and emphasized that monetary support for CE was an equitable and appropriate means through which employers can promote CE. "There is a monetary amount and it's fair" (23) and "They would allot money for you to go [to CE] which was pretty fair" (22) were typical responses. Describing strong departmental support, 1 therapist stated, "[I feel supported], I think we get $1,000 every year [for CE]" (4). Conversely, limited or lack of employer funding for CE often caused therapists to feel that their CE efforts were not supported. Describing limited financial assistance, one participant noted, "I do not feel supported with my continuing education. Examples of that would be financial backing. In the current budget, we were told continuing education dollars have been cut. It was the first thing cut" (21).

Geographic influence on CE participation. Although monetary concerns were the primary interest for the majority of participants, the location of the CE activity was of concern for several, with the need to negotiate travel distance being most pronounced for participants living in more rural settings. Referencing this geographic concern, one therapist from a rural community stated, "It [travel distance] is a barrier for us" (17). A second therapist stated, "I wouldn't go over probably 100 miles away [to attend a CE activity]" (19). A third therapist commented,

   It [travel distance] is [a barrier] for us, because we've got a
   bigger staff now, and the hospital is still willing to pay for a
   big chunk of continuing ed., but they ask us to try to stay as
   northern as we can [referring to an area of the state that is in
   closer proximity to her place of employment] (18).

Although less affected by travel distance, therapists from more metropolitan areas were cognizant of the concerns of their cohorts located in more rural areas. One therapist from a more populated area said, "There just isn't a problem with that [here] .... For small towns I can see it [travel distance] being a big problem (5)." Similarly, a second participant from an urban area stated,

   Yes [travel distance could be a barrier]. I think [I am] probably
   fortunate that I live in a large city that has people [CE
   providers] coming regularly through, but I certainly had courses
   only offered in other cities--that makes it more difficult (8).

Balancing the time demands of CE with personal and work commitments. The most challenging variable for some participants to negotiate was the time aspect associated with engaging in CE activities. In particular, therapists with dependent care responsibilities described the need to balance CE with personal responsibilities outside of work. Believing their normal work schedules and current family commitments were sufficiently demanding, these therapists believed that mandatory CE encroached further on their already limited time. Continuing education, although generally acknowledged as being necessary and important, placed unwanted demands on their schedules.

In terms of negotiating family commitments with continued learning, participants stated,

   I think it's the weekend ones [referring to CE courses[ that take
   me away from my family. I think that's the hardest one, and
   depending on what happens, the cost is probably going to be number
   two (22).

   It's [time away from family is] going to definitely be a barrier.
   I'm pregnant, so I think there's going to be a time when I'm not
   going to be able to fly here real soon, and I'm not going to be
   able to be away from home, and I'm not going to want to be away
   from home--which will present its own challenges (15).

   Before I used to pick the courses that were far away and get travel
   money. But now leaving my family makes the distance important as
   well. I'm more inclined to look for things locally where I don't
   have to go overnight somewhere (10).

Reiterating the challenge of successfully managing the competing demands of family and work, a fourth participant noted,

   I think probably as you settle into a different type of a life, you
   get other things that become a priority. As much as I like my job,
   my job is my job. My family is my life, and it's not that I don't
   love my profession and. like what I do, but I'm at a point in my
   life where I feel like there's other things that are more important
   so I quit taking my work home with me at night. I leave my job at
   work and go home to my family and spend what little time I have
   with them. That changes how you view your free time. Now we're
   coming across something [mandatory CE] that's really going to, in
   some ways, impede my free time (10).

Given instances of staff shortages, participants realized that time away from work for CE could pose a problem for the department. They believed, however, that employers who allowed and, in some instances, encouraged time away from work to attend CE activities demonstrated a strong commitment to learning and viewed this measure as one way to help balance work and personal demands. As one therapist stated, "They encourage you to take time off with the continuing ed." (13). A second participant said, "We have 3 days of continuing ed. that is not taken off our vacation time or sick time, which is really nice" (5). A third participant commented, "It's compensated if you go to a weekend course. If it's a Saturday/Sunday course, you are compensated with a day off the week before and a day off the week after" (3).

Providing and Promoting Learning Opportunities That Meet Physical Therapists' CE Needs

In addition to engaging in dialog related to negotiating and managing a core set of variables associated with CE, participants readily discussed the need to find learning opportunities that met their current educational needs and preferences. Their responses indicated that an array of learning opportunities were necessary. They were seeking CE activities that fit their schedules given changing personal and work demands.

Identifying alternative ways to reach the target audience. Imperative to the promotion of CE were increased CE options and formats that paralleled the participants' educational preferences and needs. Participant preferences included increased variety and locations of courses, courses offered during the work week, shortened CE sessions, increased home-based CE options, and courses brought to places of employment.

Consistent with the theme described above, for several therapists, limiting time away from family was the primary vehicle for facilitating CE. Participants spoke of needing a balance between work and personal commitments and were largely in favor of courses brought to their places of employment. For them, this option limited travel distance and allowed for courses to he offered at times other than the traditional weekend format. Describing this situation, one participant stated,

   I think variety [of CE options is important]. I guess, really, the
   issue is figuring out what are the challenges for that particular
   group [of therapists] and trying to find a balance between them. I
   think things at home in the evenings, where maybe you're not giving
   up weekends. That I know at my old job was something that a lot of,
   particularly persons with children, were appreciative of. We would
   do a series of speakers who would do a Thursday evening from 6 to 9
   for 4 weeks. That format a lot of those folks really enjoyed (14).

Additionally, participants stated that control over the pacing of CE was important. Because of the flexibility, most participants appeared to favor Internet and self-study opportunities. One participant, believing these options would facilitate CE, stated, "[I] would like to do things on my own, rather than having everything crammed in 1 weekend or a short 1-day course" (19). Also in favor of the Internet option, a second participant stated, "I think they [Internet options] will be especially [preferred] now that most people do have a computer. You can do it on your own time and at your own pace; I think that will be pretty effective" (13). Interestingly, although participants were generally in favor of Internet activities, few reported first-hand experience using the Internet for CE.

Need for adequate courses in diverse topic areas clearly identifying the target audience. Participants were acutely interested in finding CE topics that met their individual needs. Several participants, particularly those in small- and medium-size hospitals, reported treating a variety of patients and, therefore, favored a wide range of CE topics with a more generalized focus. One participant noted, "Well, since I [treat] a high variety of patients, I tend to do a wide variety [of CE], so I'm always interested in new treatment techniques... " (2). A second participant referred to therapists at her hospital as "jacks of all trades" (3) and therefore also was in favor of varied and more basic CE topics.

In contrast, physical therapists with several years of clinical experience or those with a specialized and fairly limited clinical focus believed that there was a lack of advanced courses on specific topic areas. Emphasizing quality and appropriateness of CE activities, participants remarked,

   After doing this for 26 years, I'm very particular about what I'll
   spend my time and money for to go to a course. I consider myself...
   I'm so specialized, and I read "all the literature that I can in my
   area, so, I believe that I might be frustrated by having to waste
   my time if there's not a course, and I still have to get some CEUs
   [continuing education units] (6).

   What I find difficult is finding courses that have advanced stuff
   in them because I've been around for quite awhile. You can go to
   the basic stuff for so long. A lot of the courses if you look at
   them are basic (20).

   I think that's [lack of quality courses] definitely an issue. I
   think there's some excellent content, but I don't think there's
   that much (14).

Although many times the call for advanced courses was from clinicians, a departmental manager emphasized a systematic department need by commenting,

   In particular, we have a very strong wound care [focus], both
   population and staff, and so we are always looking for an advanced
   wound care course because my staff know the basics. They're looking
   for the next level of wound care (9).

Although most participants stated that they believed they were well informed about available CE offerings, many believed that the course descriptions were sometimes insufficient or misleading. In their opinion, course brochures did not adequately convey course content, leaving therapists with little information with which to make an informed decision about the quality of a course. As one participant described,

   I think the continuing education people do a good job of marketing,
   or sending stuff past my nose... [it's] the quality of those
   courses, as far as not being able to judge from the information I'm
   being given, whether it is a quality course that I would want to
   attend or not (20).

A second participant wanted CE providers to "Add more information on specifically what you're really going to be getting when you're there. Be cause like the Medicare course--I may not have gone if [I had more specific information before attending] ..." (4).

Identifying the Elements of Employment Environments That Foster CE

The most striking finding of this investigation was the departmental influence on participants' views of CE. Although some participants equated departmental support for CE with the resources (monetary support and release time from work) that their employers were able to provide, these forms of support were not sufficient for creating employment environments that fostered CE. The departments that appeared to foster CE had 3 common characteristics. In these, regular discussion and planning of CE occurred, the manager was actively involved in CE, and CE was a component of annual performance evaluations. These individual and organizational elements that characterized an environment supportive of CE were present at 4 (2 large-size hospitals, 1 medium-size hospital, and 1 small-size hospital) of the 6 hospitals. Conversely, individual and organizational support did not appear to be present at 1 medium-size hospital and 1 small-size hospital.

Employer discussion, promotion, and planning of CE and delineation of a departmental CE plan. In the employment environments that fostered CE, clinicians and managers collaborated to systematically promote CE. Examples of support for CE included encouraging therapists to return to school for advanced degrees, circulating flyers and posting CE opportunities for both local and national events, and coordinating multidisciplinary meetings and in-service activities over the lunch hour.

Examples of participant descriptions of learning opportunities included the following:

   Every student is required to do an in-service which can be very
   helpful. It's pretty much every lunch hour there's something. There
   is either an in-service or there are grand rounds. There's always
   something. There are case studies. There isn't a lack of learning
   opportunities (5).

   We always have continuing ed. flyers being routed. If we find one
   that we think is interesting that we would like to attend, we keep
   it and talk to the coordinator about it (3).

   I think they actually do a fairly good job, because we are always
   routing information if any of us get information on courses. It's
   always being routed so we can see a wide variety of what's being
   offered (2).

The presence of a well-defined departmental plan for CE or a formal statement of departmental goals for CE also fostered CE at the workplace. Referencing the departmental goals for CE, one manager stated,

   What we do is, annually we have to do a staff development plan ....
   They [the staff] know whatever the annual goals are, or whatever we
   set up. I take those out, and I put it in a 1-page grid format, and
   then that goes to the education department, and at the end of the
   year, I have to turn in those things completed (1).

A second therapist described her department's plan for CE as follows:

   So, periodically, through the year in our meetings, we look at the
   educational plan . and we all ]have] a copy of the educational
   plan and what the goals were for the year from an educational
   standpoint for the whole department (16).

Conversely, in departments that did not appear to systematically foster CE, both managers and clinicians discussed CE primarily as it related to the traditional CE format and appeared to rarely promote additional learning opportunities. Reflecting on the departmental role in CE, one manager noted,

   I don't think it's been established, and I think that all we've
   done . only the courses we're familiar with as a group are the
   ones that you'd travel to and go. And I think that brings up a good
   possibility that there are other options out there (23).

The participant went on to reflect,

   I think we have to work on our in-service things. We pretty much
   have, I don't even think it is on paper, a standing rule. If you go
   to a course, you have to do an in-service. [It's a] very, very
   loose [rule] ... as a department, we'll have to really look at our
   in-servicing ... I think that would probably be where we could
   benefit and change and be positive (23).

Although the majority of clinicians in departments with a more nonsystematic approach to CE did not reflect on ways in which their departments could better support CE, one clinician, believing that her department was apathetic toward CE, commented,

   I think it [the department] encourages it [CE] with the fact that
   they say you can go and I think they will pay for a course. I guess
   from my administrative standpoint they appear to, course wise,
   support going to courses, but I think they're missing the boat on a
   lot of other nonspending of money that they could be doing to be
   more effective (20).

Elaborating more on the apparent ambiguity of a departmental focus on CE, the participant went on to comment,

   It's [CE is] a very individual thing that there doesn't seem to be
   any kind of a focus as far as the department is going to do this
   and these are all the different parts of this focus, and I'm going
   to take this part and go learn about it and then bring that back,
   and then we'll all put it together and get someplace. I don't see
   that at all (20).

Further illustrating the ambiguity regarding CE with the lack of a well-defined departmental plan for CE, some participants commented,

   I don't know. I shouldn't say. I thought it was so much a year per
   person but maybe that's how they divided it once they got the lump
   sum. I'm not sure (22).

   It's [CE is] not stressed as far as you need to do this as a
   therapist. There are some people who never go on CE courses at all,
   and I just think, as a department, that weakens your system (21).

   I don't think it's encouraged. I believe we have a budget (17).

   I just don't think a lot of staff here view that [CE] as being
   important. I doubt it ... it's not a high priority here. There's a
   lot of other things going on (19).

Role of the physical therapist manager. Clinicians were clearly cognizant of the views and actions of the physical therapist manager in relation to CE. In environments in which CE was viewed as being supported, the manager appeared to play an instrumental role. In environments in which CE was not systematically addressed or supported, clinicians rarely reflected on or mentioned the role of their managers in relation to CE.

Physical therapists reported feeling encouraged at their workplace to participate in CE if their managers approached them with CE opportunities that could help strengthen their clinical skills. Describing ways in which support was delivered, one participant noted, "It's strongly encouraged by our director. She's very supportive of myself going back to school and others. So, it's definitely encouraged throughout the department" (8). A second therapist commented,

   There's always things put in our mailbox [on] continuing ed.
   courses.... There are things posted on bulletin boards. Our
   supervisor will approach us with certain ideas, "You know, we may
   need this aspect in our facility that we haven't really touched
   base with; would you be interested in starting this program or
   going to this course?" (4).

Likewise, viewing the manager as a facilitator of CE, one participant commented,

   [She] is to introduce this idea ... she's then provided us with the
   educational backup and then, on top of that, has brought the
   appropriate paperwork and resources into the department . all sort
   of been happening hand in hand so that as we've learned more, she's
   provided more. She's encouraged us. She has brought stuff to us
   which has made life easier ... [we have a] common educational
   goal . we pooled money and that way we've been able to send more
   people and bring more people in on continuing education because
   we've used the pool of money and sent the appropriate people, etc.
   We set up an educational plan for the year ... (16).

A second participant echoed this sentiment, noting, "Our manager is bringing in continuing education into our department, and she really encourages courses that we're interested in and those that [she] feel[s] will contribute to our department growing" (15).

From some of the managers' comments, it was clear that they personally invested themselves in their role as promoters of CE. Describing her managerial role in CE, one manager noted,

   I certainly would be crushed if they [the clinicians] didn't [view
   the department as supportive of CE]. I have
   to balance people's needs to see patients and people have to be
   productive. I can't say we'll all sit around and have interesting
   discussions all day, but I try to trade off. We have weekly case
   presentations which right now everybody has agreed to focus on what
   kinds of outcome measures are being used on patients . so we do
   case presentations every week . research seminars . doing
   literature searches (7).

A second manager summarized her role in departmental promotion of CE by noting,

   We spend a lot of work time that a lot of places don't give. And
   we've done a lot to pool things together . to me, the biggest
   thing is not only these things we've done on weekends, but then
   it's this weekly, "let's keep going through it and going through
   it".... It [CE] just doesn't happen [on its own] (14).

Participants appeared to invite interactions with their managers in discussions of CE and believed that discussions related to personal and departmental CE needs were positive. Although a manager's ability to promote CE was partially constrained by budget and facility resources, not all managers appeared to focus equally on the promotion of CE, with some electing not to focus on CE, some assuming a more apathetic approach, and others choosing to make CE a priority.

CE as a component of annual performance evaluations. A primary strategy used to foster CE in employment environments was the inclusion of CE in annual performance evaluations. Several clinicians specifically mentioned that they were expected to engage in CE and reported CE participation as a component of their annual performance evaluations. Participants' comments included the following:

   I think, at least in this institution, it's [CE is] expected. It's
   part of your performance review that you do [go to CE] and that you
   come back and present (12).

   When you have your annual reviews every year we usually go over
   goals. Mine, for example, was to have another continuing ed. course
   within this year, by a certain date. That's a goal that's laid out
   there. I'm hoping to achieve it. My supervisor's gone over that
   with every single eval (4).

   Everyone is required to take at least one CE course per year so
   that helps you quite a bit. We do reviews on a mid-year and then at
   the yearly basis ... (11).

   In your annual evaluation and review that's [CE is] also
   considered, too, if you have been attending those and you need to
   attend them. Even at your annual review they say maybe you should
   attend more (13).

Physical therapist managers also discussed the inclusion of a CE requirement on annual performance appraisals. One manager volunteered,

   I think they [the clinicians] pretty much have their own annual
   appraisals that we do, and we always make continuing education a
   part of that goal. We try to seek out what area they need more
   improvement, or new program development issues (1).

A second manager stated, "We already have a performance requirement to attend 1 continuing ed. course every year" (7).

Perceived Implications of Mandating CE

Although participants were unsure of the long-term ramifications of mandatory CE because they had not completed a mandatory CE cycle at the time of data collection, many appeared to have a sense of how they and their departments would address the issue. Participants working in employment environments already fostering CE expressed little concern over mandatory CE requirements. Feeling confident that their current CE accountability standards were sufficient to meet the state requirements, several commented,

   We pretty much have done it ICE]. I guess it's been the practice of
   this place so I don't think it's been hard to think that we have to
   do it (1).

   I'm not worrying about it [the mandate] really. I believe everybody
   here does exceed the expectations already (7).

   I think we would be able to jump on the bandwagon without any
   problems (6).

   I don't think it's a huge concern because most people here do take
   advantage of it [CE]. I've always used what I can here in taking
   courses and I've gone above and beyond .... so I don't think it
   will change. I don't think it will actually change too many people
   in our department (8).

   I personally think we're going to be absolutely fine based on what
   our process has been all along. We, in part, use continuing ed. as
   a retention tool (9).

For these participants, the set of variables that they negotiated and managed was seemingly identical to their levels of CE involvement before and after the mandate.

Conversely, participants working in employment environments that did not foster CE expressed more concern over mandatory CE requirements. For these participants, the primary concern stemmed largely from the potential lack of financial resources to cover an increasing number of people requesting monetary assistance for CE. Acknowledging that mandatory CE would necessitate that all physical therapists in the department participate in CE but expressing uncertainty with regard to how the increased financial demand would be addressed, one manager noted,

   One of the negative things, I think, is the financial aspect of
   where our department is going to come up with this extra money....
   We never had enough money for everyone to go to a course, but we
   knew that we never had to worry about that because not everybody
   would go (23).

Reiterating the fact that not all physical therapists at her facility had participated in CE in the past, a second participant noted, "I think what has happened is there's been a few [individuals] who really take advantage of the [CE] money. If they want to allocate it [CE money] to a lot of individuals, it would mean cutting people's [money]" (21).

Discussion

The purposes of this investigation were to examine the perceptions of physical therapy clinicians and managers concerning the barriers to and facilitators of CE, given the recent state mandate, and to identify how clinicians and managers perceived the role of their departments in the CE process. A portion of the findings from this investigation support the existing body of literature related to CE; however, because of the qualitative method used, the participants' accounts provide more detailed perspectives and insights into the variables relating to CE participation than were available from previous investigations. Additionally, the findings relating to the departmental role in the CE process contribute new information regarding the potential organizational impact on physical therapy CE and mandatory CE. Of note, all clinicians participating in this investigation volunteered to be interviewed. Although it is impossible to determine whether willingness to participate may have influenced the results, it did not appear that participants had a personal agenda to fulfill. Instead, they seemed to be interested in sharing their personal perspectives concerning mandatory CE.

For several participants, particularly those practicing in small- and medium-size hospitals in more rural areas, the cost of CE and the travel distance to CE activities were obstacles to CE participation. This finding is consistent with previous investigations that identified cost, registration fee, and travel distance as important considerations for physical therapists with regard to CE. (25,34,35) Also, as in other investigations, (15,35,36) time away from family to attend CE activities was problematic for some participants and was most pronounced for those with dependent care responsibilities. Participants in this investigation did not minimize the importance of CE, but some believed that it was less relevant than family commitments and provided detailed descriptions of how their outlook toward CE changed after they had children.

Although participants believed that they were well informed about CE offerings, their reports of attending courses in which the presented information was inconsistent with the advertised objectives suggest that they believed that course advertisements were sometimes insufficient or misleading. This finding is similar to a previous survey in which 37.9% of the respondents reported attending CE activities that did not meet the advertised objectives. (37) Additionally, participants with a focused area of practice, several years of experience, or both expressed frustration with the traditional CE weekend format, which they perceived provided little to no new information. Although not specifically referencing practice setting or years of experience, Karp (25) found that 87% of respondents viewed the lack of availability of pertinent courses as a barrier to CE participation.

Participants were looking for CE options that fit their schedules and were largely in favor of CE offerings during the work week and increased CE activities at their places of employment. Researchers have reported that physical therapists and other health care professionals have difficulty finding CE activities that fit their schedules and that are conveniently located. (34,35,37,38) Participants also appeared to be interested in home study through the use of the Internet, commenting that personal control of the pacing of the CE activity was important. Participants' interest in the use of the Internet for CE is inconsistent with research. (22,25) The trend toward this appeal is likely attributable to advances in and increased comfort with the use of technology over the past decade.

Previous investigators (25,34,35) found that physical therapists prefer CE topics related to orthopedic or musculoskeletal management. Participants in this investigation believed that a wide variety of topics, ranging from more general to highly specific, were necessary to optimally promote CE. Although many of the participants voiced an interest in orthopedic topics, this topic was not favored more than others. This finding could be attributable, in part, to the diversity of the practice settings of the participants.

Prior investigations regarding physical therapy CE and mandatory CE largely used survey methods and often focused on the barriers to or facilitators of CE; although the results of this investigation do not refute those findings, the qualitative nature of this investigation encouraged a more in-depth examination of physical therapists' perceptions relating to CE. Although one of the stated purposes of the investigation was to examine the barriers to and facilitators of CE, given the recent state mandate, as the interviews progressed, it became evident to the investigators that categorizing a variable as either a barrier to or a facilitator of CE may be too simple of an explanation of the impact of the variable on CE participation. The findings highlight the importance of examining each variable with regard to its role as both a barrier and a facilitator. For example, cost was a barrier to CE participation for some participants, but the ability and willingness of the employer to defray the cost of CE were also facilitators for those same participants. With regard to the mandate, nearly all of the participants appeared to negotiate and manage a core set of variables that were largely similar whether CE participation was voluntary or mandatory. The one exception to this finding was an apparent increased focus on the financial aspects associated with mandatory CE for participants practicing in departments in which CE had not traditionally been supported.

Identifying the elements of employment environments that relate to successful CE engagement and the role of departmental managers in that effort provides a unique contribution to the existing literature. By interviewing both clinicians and managers from hospitals of various sizes in Illinois, we were able to compare and contrast participant responses with regard to how CE was addressed at the workplace. Each physical therapy department as a collective whole seemed to espouse a "departmental attitude" toward CE. Both clinicians and managers at 4 of the 6 hospitals provided accounts of concrete and diverse ways in which CE was fostered; conversely, clinicians and managers at 2 of the 6 hospitals described a more apathetic, sometimes viewed as unsupportive, environment for CE.

Although several participants acknowledged the potential difficulty for employers in covering all of the monetary costs associated with CE and mandatory CE, there appeared to be a level of expectation that employers, at a minimum, acknowledge the problems associated with a lack of financial assistance and provide support when possible. Ironically, it was the hospitals with the greatest resources for CE (increased departmental budget, courses in close proximity, resource libraries, and hospital-wide activities) that regularly discussed, promoted, and used multiple vehicles to foster CE; these included regularly scheduled lunch-hour in-service activities, journal clubs, and study groups. The hospitals with fewer resources (less departmental funding, geographic disadvantages, difficult access to library holdings, and fewer hospital-based activities) discussed, promoted, and implemented few, if any, of these lower-cost, resourceful ways to promote CE.

The presence of a well-defined departmental education plan was a second necessary element in creating employment environments supportive of CE. A clearly articulated departmental educational plan drafted through collective efforts from both managers and clinicians appeared to eliminate ambiguity over CE expectations and provided an important educational framework for the department. These departmental plans often identified common educational goals for clinicians and established specific performance requirements. These performance expectations appeared to be welcomed by participants.

Another variable in creating an environment that positively fosters CE is an actively involved physical therapist manager. In nearly all instances, clinicians' views toward CE and mandatory CE paralleled those of their managers. If a manager expected regular CE involvement, then the therapists under his or her management appeared to place a similar emphasis on CE. Clinicians appreciated and welcomed encouragement by their managers to become involved in the creation and execution of all aspects of CE. Participants readily identified their perceptions of how their departmental managers did or did not support CE. Similarly, managers viewed as being supportive of CE were readily able to discuss how they promoted CE in the department and appeared to take personal responsibility for facilitating an environment supportive of CE. Managers viewed as being less supportive did not readily address how CE was promoted and nearly always discussed CE solely in terms of financial assistance to attend weekend courses. It is unknown whether or not the managers in this investigation were cognizant of the full impact of their actions regarding CE, but the responses of the clinicians indicated that their managers were highly influential in shaping their views toward CE.

The final element significantly fostering CE was the inclusion of a CE component on annual employee performance evaluations. Linking expectations for engaging in CE to a performance evaluation, which was generally used to dictate pay increases and potential promotions, appeared to increase the level of importance placed on the need to engage in lifelong learning and professional advancement. Explicitly defining expectations and assessing accountability for involvement in CE appeared to assist in fostering an environment supportive of CE. Conversely, the absence of such explicit accountability appeared to perpetuate feelings of ambiguity over the level of departmental support for CE.

Previous research findings on the departmental role in the CE process are limited; however, a specific set of guidelines addressing the departmental role in physical therapy CE has been published. (39) In this publication, study leave and funding are described as essential for meeting patient and professional needs. Although not specific to physical therapy, other scholars also have addressed the need for employer involvement in the facilitation of learning. (32,40,41) The findings of this investigation strongly suggest that there are characteristics inherent in employment environments that foster CE and that although financial support is desired, it is not sufficient for fostering CE. Managers working collaboratively with clinicians to discuss and promote a well-defined departmental CE plan and delineating expectations for engagement in CE, as assessed on annual evaluations, are instrumental in creating employment environments that foster CE.

The results of this investigation further suggest that clinicians employed in environments that foster CE are less apprehensive about the recent transition to mandatory CE, because they believe that they are supported in their current efforts which, in most cases, are sufficiently rigorous to meet the mandatory CE requirements for physical therapists in Illinois. Clinicians with less support for CE in their employment environments appear to be focusing on the barriers to meeting the mandatory CE requirements and are less likely to identify resourceful ways in which to meet the mandatory CE requirements.

The findings of this investigation that are most closely linked to the principles of lifelong learning involve the influence of departmental support on participants' views toward CE and mandatory CE. Although lifelong learning often is perceived as a personal endeavor, scholars have described the significant role of organizations in the lifelong learning process. (11,32) As Miller (11) noted, people are influenced by internal and external concerns and generally work within an organizational framework. The sizes of organizations may vary, but the need for viable and informed members does not. Therefore, lifelong learning occurs not only for people but also for their organizations. (11) Senge32 specifically described organizational success in relation to viable and informed employees who value learning. As he stated, "organizations learn only through individuals who learn. Individual learning does not guarantee organizational learning. But without it no organizational learning occurs. (32(p139)) Supporting the premise of organizational involvement in lifelong learning, one manager acknowledged the potential difficulty of engaging in CE given money and time shortages but stated, "We make it work because we value continuing education that much. That's part of what we sell as an organization. That's not what every organization sells" (9).

In summary, participants at 4 of the 6 hospitals described ways in which their employment environments and, more specifically, departmental management supported and systematically addressed lifelong learning. In most cases, participants did not specifically use the term "lifelong learning"; however, their statements reflected the need for and measures taken to support ongoing engagement in CE.

Conclusion

The findings of this investigation suggest that physical therapist clinicians and managers need to identify and address the core set of variables relating to engagement in CE. Because the presence or absence of a particular variable can render it as either a barrier to or a facilitator of CE, collaborative efforts between clinicians and managers should be used to try to maximize the variables that promote CE participation and minimize the variables that are obstacles to CE participation. The findings of this investigation also suggest that a variety of CE opportunities and CE topics are necessary to meet the educational needs of all physical therapists. Clinical education providers and physical therapists, as stakeholders in the CE process, should recognize and address the unique challenges associated with the locations of CE activities and the need to balance CE with personal commitments.

Most importantly, the findings of this investigation strongly suggest that employment environments appear to be influential in how physical therapists perceive CE. A physical therapist manager who promotes and maximally uses institution-wide resources to promote CE is essential, as clinicians are keenly aware of the measures that their managers use to promote CE. Additionally, departmental CE plans outlining CE expectations and annual evaluations to ensure CE engagement accountability are helpful in establishing an environment that fosters CE. Finally, the results of this investigation suggest that viewing CE as a lifelong learning activity, synergistically addressed by the individual and the organization, decreases apprehension regarding compliance with recently mandated CE requirements.

Invited Commentary

Gerard P Brennan 

Austin and Graber (1) explore the concept of continuing education (CE) in physical therapy as a behavior consistent with lifelong learning and professional development that enables physical therapists and physical therapist managers to meet the challenges of a complex health care system. Continuing education is identified as a key component to negotiating this dynamic process. Lifelong learning is defined as being grounded in personal development that is specific to the individual and the situation (eg, heath care, physical therapy). The aim of this study was to describe the perceptions of physical therapists and managers related to the barriers and resources of CE and the influence of the work environment on CE.

The relationship between CE and patient care was not explored in this study) The investigators' observations of the perceptions of the physical therapists do not appear to articulate a clear and strong linkage between CE as lifelong learning and the process of patient care. As the profession of physical therapy evolves to rely more consistently on principles of evidence-based practice, this necessitates that the delivery of care should link to the evidence in conjunction with the patients' values, and not necessarily to the physical therapists' perceptions and values.

If our collective goal as a profession is to deliver care that is evidence-based, as the American Physical Therapy Association's Vision 2020 statement (2) suggests, CE should be viewed as an important opportunity to change practice behavior in a way that will improve the quality of patient care for specific clinical conditions. Quality of care improves when inappropriate variation in the treatment process is eliminated, and continuous improvement is documented by consistently tracking clinical outcomes. (3) Physical therapists' perceptions about CE are not as important as the linkage between CE and the delivery of care to the patient.

The authors (1) state that to remain current in the field, CE is of "unquestionable importance." The importance of CE, however, does need to be questioned, especially if it is perceived in the serf-serving context proposed in this article. For example, therapists perceived that the CE program met their "individual" educational needs and preferences in terms of personal schedule and topics of interest. The results of the study never once portray the therapists' concern that CE somehow relates to patient care and the delivery of care in terms of clinical outcomes or costs. Perhaps, the relationship of CE to patient care is assumed and "unquestionable" to the authors, but it ought not be. Moreover, anyone who provides financial resources for CE can legitimately question its importance. Without linking the effects of CE to the clinical outcomes of patients and the practice behavior of therapists, there is little foundation upon which therapists are able to request financial support from their employer to sustain an investment in CE. To be sustainable, the CE needs to benefit the patient and be congruent with the goals of the organization or employer.

The purpose of CE needs to address patient care by improving clinical outcomes and changing practice behavior toward the consistent delivery of evidence-based interventions. (4) When approached from this perspective, CE has the potential to change practice behavior in a manner that can result in improved clinical outcomes for patients. (5-8) Typically, improving clinical outcomes relies on evidence-based practice and reducing the variability of practice behavior. Physical therapists and managers need to target specific CE goals that are directed at clinical conditions of patients most frequently treated in the department. In addition, departments need an ongoing assessment of outcomes to determine the effectiveness of any CE opportunity in improving quality. This approach helps managers articulate a business case to improve the quality of care and facilitates the request for financial support from the employer to sustain a strategic plan for CE, because it relates specifically to improving the quality of care for patients. The observations of therapists and managers in this study (1) do not demonstrate an understanding of these factors that would facilitate a sustainable effort toward CE. If CE is a component of lifelong learning in physical therapy, then it needs to meet the needs of patients first, and hopefully that will be consistent with the interests of therapists and employers. The goals for CE need to be congruent and integrated with the goals of patient care, therapist, and employer.

GP Brennan, PT, PhD, is Director for Clinical Quality and Outcomes, Intermountain Healthcare, Rehabilitation Agency, 5848 South 300 East, Murray, Utah 84107. Address all correspondence to Dr Brennan at: [e-mail].

DOI: 10.2522/ptj.20060053.ic

References

(1) Austin TM, Graber KC. Variables influencing physical therapists' perceptions of continuing education. Phys Ther. 2007;87: 1023-1036.

(2) Vision 2020. American Physical Therapy Association Web site. Available at: http://www. apta.org/AM/Template.cfm?Section=Vision_ 20201&Template=/TaggedPage/TaggedPage Display.cfm&TPLID=285&ContentID=32061.

(3) Brennan GP, Fritz JM, Hunter SJ. Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy. Phys Ther. 2006;86:1251-1262.

(4) Cantillon P, Jones R. Does continuing medical education in general practice make a difference? BMJ. 1999;318:1276-1279.

(5) Davis D, Thomson M, Oxman AD, Haynes RB. Evidence for the effectiveness of CE: a review of 50 randomized controlled trials. JAMA. 1992;268:1111-1117.

(6) Davis D, Thomson M, Oxman AD, Haynes B. Changing physician performance: a systematic review of the effect of continuing education strategies. JAMA. 1995;274:700-705.

(7) Davis D, O'Brien M, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999; 282:867-874.

(8) Thomson O'Brien MA, Freemantle N, Oxman AD, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(2): CD003030.

Author Response

Tricia M Austin, Kim C Graber

We thank Brennan for his commentary and insightful perspectives concerning the significant relationship between continuing education (CE) for physical therapists and quality of patient care. We appreciate the opportunity to respond.

We concur that linking CE to the delivery of patient care is essential and agree that CE should be viewed as an opportunity to change practice in ways that will improve the quality of patient care. Brennan infers, however, that physical therapists' perceptions toward CE are less critical than examining the linkage between CE and the delivery of patient care. From our perspective, both are worthy of investigation. Arguably, each is important in its own right, and each contributes to an improved understanding of the CE process.

Adult education and CE have been described as "a human endeavor, a social practice of human interaction that depends significantly upon its practitioners' assumptions, values, and experiences to shape practical actions, actions themselves that are profoundly affected by the larger socio-cultural-economic-political conditions in which they take place." (1)(p17) We acknowledge that the end goal should focus on linking CE with patient outcomes, but this was not the purpose of the present investigation. Rather, recognizing that CE, as a human endeavor, is affected by physical therapists' perceptions, we focused our efforts on: (1) identifying the variables that physical therapists negotiate when engaging in CE and (2) investigating the workplace influence on CE.

We state "the need to remain current in the field and engage in life long learning has unquestionable importance" (2(p1024)) and acknowledge that opinions among professionals on the role and effectiveness of CE differ. We have not, however, equated CE with having unquestionable importance and agree that CE that is not based on evidence and does not ultimately address improvements in patient outcomes can and should be questioned. We do not believe that we suggested otherwise at any point in our article.

Physical therapists, as consumers and implementers of CE findings, have a critical role to play in the CE process. If CE is going improve patient outcomes, physical therapists must assess the merits of CE and select CE activities that have the potential to offer the most success. (3-5) Understanding the variables associated with physical therapists' engagement in CE does not minimize the importance of linking CE and patient outcomes, but, in our view, enhances the likelihood that this link can occur. Findings from the present investigation strongly suggest that employment environments appear to be influential in how physical therapists perceive CE. Therefore, employers, in conjunction with physical therapists, appear well positioned to actively bring patient outcomes to the forefront of CE discussions.

Brennan expressed concern that our results "never once portray the therapists' concern that CE somehow relates to patient care." This was not discussed, as it was neither the purpose nor a finding of the present investigation. (2) In an upcoming article (6) focusing on physical therapists' perceptions of the role and effectiveness of CE, physical therapists acknowledge the importance of incorporating evidence-based findings into CE opportunities. Furthermore, they report attending CE out of a sense of professional obligation, noting the importance of the quality of care and desiring the fastest outcomes for their patients.

We believe the current article provides valuable insight regarding the variables associated with engaging in CE and the elements of the employment environments that foster CE. Considering these findings, employers, physical therapists, and researchers must continually assess the merits of CE, promote CE activities that aim to improve quality of patient care, and assess patient outcomes.

DOI: 10.2522/ptj.20060053.ar

References

(1) Wilson AL, Hayes ER, eds. Handbook of Adult and Continuing Education. New ed. San Francisco, Calif: Jossey-Bass Inc Publishers; 2000.

(2) Austin TM, Graber KC. Variables influencing physical therapists' perceptions of continuing education. Phys Ther. 2007; 87:1023-1036.

(3) Davis D, O'Brien M, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999; 282:867-874.

(4) O'Brien M. Keeping up-to date: continuing education, practice improvement strategies, and evidence-based physiotherapy practice. Physiother Theory Pract. 2001; 17:187-199.

(5) Thomson O'Brien MA, Freemantle N, Oxman AD, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001;(2): CD003030.

(6) Austin TM, Graber KC. Physical therapists' perspectives on the role and effectiveness of continuing education. J Allied Health. In press.

Both authors provided concept/idea/ research design and writing. Dr Austin provided data collection and analysis and project management.

This study was approved by the University of Illinois at Urbana-Champaign Institutional Review Board.

A portion of the data were presented at the Combined Sections Meeting of the American Physical Therapy Association; February 1-5, 2006; San Diego, Calif.

This article was received February 22, 2006, and was accepted March 15, 2007.

DOI: 10.2522/ptj.20060053

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TM Austin, PT, PhD, ATC, is Assistant Professor, Department of Physical Therapy, Doisy College of Health Sciences, Saint Louis University, 3437 Caroline St, St Louis, MO 63104 (USA). Address all correspondence to Dr Austin at: [e-mail].

KC Graber, EdD, is Associate Professor, Department of Kinesiology and Community Health, University of Illinois at UrbanaChampaign, Urbana, III, and University of Illinois Distinguished Teacher/Scholar.

[Austin TM, Graber KC. Variables influencing physical therapists' perceptions of continuing education. Phys Ther. 2007;87: 1023-1036.]