Abstract
Background Physical therapist students are increasingly engaging in international clinical education (ICE). The growth of international engagement has been accompanied by appeals to ensure that these experiences are conducted in an ethical manner. Although detailed guidelines have been developed to guide global health training in general, they do not specifically address all aspects relevant to ICE in physical therapist education.
Objective The purpose of this study was to systematically develop recommendations for the implementation of ICE in physical therapist education to promote ethical practice.
Methods An initial virtual focus group of 5 physical therapist faculty with expertise in ICE provided input to review and revise global health training guidelines previously developed by non–physical therapists. The revised guidelines were distributed to a pool of 19 physical therapist faculty with ICE experience for additional review and revision through 3 online Delphi survey rounds.
Results The participants accepted 31 of the original guidelines with or without revisions, rejected 2 guidelines, and developed 10 new guidelines or subguidelines. Most notably, they rejected a guideline related to students pursuing training outside of a structured program, stressing that ICE should never be done outside of a formal program.
Limitations The primary limitation is that the study included only faculty from sending institutions and thus lacked the voices of the host institutions, students, partner organizations, or funders.
Conclusions This study systematically produced guidelines for ICE in physical therapist education using a range of ICE experts from sending institutions. The recommendations may be used by educators and other decision makers to optimally design new ICE opportunities or to improve existing ones. Additional validation should be done to ensure relevance for all stakeholders.
Clinicians, faculty, and students across the health professions are increasingly engaging in various educational and professional activities outside of their home countries.1–10 These include clinicians and faculty serving with organizations, such as Health Volunteers Overseas, which has a steadily growing number of volunteer placements (Nancy Kelly, MHS; written communication; June 2013). Faculty also are doing collaborative research,1,2 professional development,3,4 and exchanges5,6 with international colleagues. Additionally, students are participating in a wide range of learning opportunities in foreign settings, including international service learning (ISL)7,8 and international clinical education (ICE).9,10
Educators have expressed support for more international educational opportunities11–14 and have documented their potential benefits.15–22 Thompson and colleagues' literature review15 summarized positive impacts on medical students' and residents' knowledge, skills, and attitudes; they also noted that international experiences may influence participants' willingness to work in resource-limited settings. From the nursing literature, Sloan and colleagues16 documented improvements in nursing expertise and cultural competence from international clinical placements. The physical therapy literature contains numerous accounts of the benefits from international experiences, including the fostering of cultural competence,17–21 the expansion of participants' worldview,7,10,13,20–22 and improvement in clinical decision making and clinical skills.7,10,21
Although the evidence suggests that the international learning opportunities offer benefits, the growth of them has been accompanied by appeals to attend more to ensuring that these experiences are conducted in an ethical manner.23–29 Specifically, these authors highlighted that benefits must be maximized and risks minimized for all stakeholders, including the host institutions, host communities, patients, and students. They also highlighted various potential or existing problems, including that power imbalances between partners in higher income and lower income countries create potential for exploitation23,26,27 and that lack of preparation and adequate supervision put the students23,26,29 and patients23,26–29 at risk.
Although there are no studies that have systematically documented ethical violations related to ICE inside or outside of physical therapy, some evidence of problems exists. For example, in a qualitative study of medical trainees who had participated in international health electives, participants labeled the experiences as “unsustained short-term contributions that lacked clear educational objectives and failed to address local community needs.”28(p683) Another study revealed that sending institutions did not adequately implement risk management (eg, requiring international health insurance) for physical therapist students involved in international service learning.29 Authors have offered many suggestions to address the potential for or existence of ethical problems, including increased focus on sustainability,23–26 reciprocity between senders and hosts,23–27 appropriate student supervision,24,26 increased attention to risk management,29 and program evaluation.23–27
Because of these types of ethical concerns, Crump and Sugarman30 led the formation of the Working Group on Ethics Guidelines for Global Health Training (WEIGHT). Through consulting with global health and ethics leaders, Crump and Sugarman formed an international group of 13 experts in ethics and global health training. In addition to being chosen due to their relevant expertise, the group members were selected to represent a spectrum of perspectives and geographic locations. A literature review related to ethics and global health training was shared with the group prior to convening. Then, through a moderated workshop format, WEIGHT developed a set of ethics and best practice guidelines for global health training (eAppendix 1). These 33 recommendations address the host and sending institutions, trainees, and sponsors and are germane across the health sciences.
Although the WEIGHT guidelines30 have application to many health professions, they do not specifically address all aspects relevant to international educational opportunities in the physical therapy profession. Some resources have been developed to guide international educational activities specific to physical therapist education. They include conceptual models for ISL29 and ICE31; however, neither model provides the detailed assistance that the WEIGHT guidelines30 (eAppendix 1) do.
In this study, we used the WEIGHT guidelines30 as a starting point to systematically develop recommendations for the implementation of ICE in physical therapist education. Clinical education is a critical component of a physical therapist curriculum, and students earn clinical education credit for ICE.31 Participants in a prior study suggested that ICE requires a more formal structure than ISL.31 Additionally, it appears that ICE is being adopted by physical therapist education programs at a higher frequency than ISL.10 Therefore, the purpose of this study was to systematically develop guidelines for the implementation of ICE in physical therapist education.
Method
The study was conducted in 2 phases. A focus group method was used in the first phase, and the Delphi technique was used in the second phase. A consultant with expertise in both methods provided guidance throughout study design and implementation to ensure methodological rigor.
Focus groups are used to facilitate input around a particular topic from a particular group of informants. The advantage of a focus group is that a researcher can solicit ideas and opinions from a group of experts as they build upon one another's thoughts and reflections. A disadvantage of a focus group is that certain members may dominate the group and silence others.32 One way to mitigate this negative is to ensure anonymity. During the virtual focus group portion of this study, each participant was identified verbally by the moderator and on the screen by an assigned number only.
The Delphi technique has been used to obtain face and content validity from a panel of experts to reach consensus about an issue or determine whether the survey items reflect the concepts being measured.33 This method is based on the premise that the collective and anonymous consensus of identified experts in the field related to the topic or problem being examined results in broader knowledge of the topic.34
In the Delphi method, there is currently no set number of experts that is considered ideal to gain consensus. Yet, the literature suggests that the number and choice of identified experts should provide a broad and diverse level of knowledge about the issue under consideration and will vary depending on the objectives and issues of the study.35,36 Using a survey tool, the Delphi technique assesses consensus by analysis of the percentage of the “yes” and “no” responses to the questions posed.33
There is no universally agreed-upon percentage of agreement for consensus. However, the literature suggests that a threshold in the range of 70% to 80% is reasonable, and it is recommended that this level be set prior to the data analysis.34,35 In the current study, we set the level of consensus at 80% prior to initiation.
Some experts also argue that adding the element of anonymity in the process reduces the likelihood of “group bias or group think scenarios.”36(p97) Participants also were unaware of the identities of each other in phase 2.
Panel of Respondents
Participants had to be faculty from US-based physical therapist education programs who had current experience with placing physical therapist students in international settings for completion of clinical education. We deemed that faculty meeting these criteria possessed the relevant expertise to contribute to this study's aim. Participants were recruited in 4 ways. First, we sent recruitment e-mails to participants from a previous ICE study.21,31 Second, we posted an announcement on the listservs of 2 American Physical Therapy Association (APTA) sections (Education Section, Section on Health Policy and Administration) and a special interest group (Global Health Special Interest Group). Third, we recruited participants via written and verbal announcements at the Global Health Special Interest Group's business meeting and Global Health Reception at APTA's Combined Sections Meeting (CSM) in February 2013. Lastly, we sought to use snowball sampling, asking volunteers to suggest other possible participants with ICE expertise.
A total of 20 participants agreed to participate in the study. Two individuals were recruited at CSM 2013, one of whom was from the prior study.21,31 Of the other previous study participants, 6 responded to e-mail solicitation. A total of 12 new volunteers responded to the listserv postings. No participants were recruited via snowball sampling. All participants signed an informed consent statement.
In the informed consent statement, participants were asked to commit to one or both of the following phases: (1) a preliminary focus group that would convene via a virtual conference to vet the appropriateness of the proposed guidelines and (2) a larger group that would participate in the Delphi rounds to review iterations of the guidelines until consensus would be achieved.36 Although most participants offered to be in both groups, 1 individual chose only phase 1, and 2 people elected only phase 2. In total, 18 individuals volunteered for phase 1 (14 volunteered in time to be considered for phase 1, and 4 provided consents after we had already selected participants), and 19 individuals agreed to participate in phase 2.
From those individuals who agreed to participate in phase 1, we purposively selected a group of 6 experts who represented a range of university types (2 public, 2 faith-affiliated private, 2 non–faith-affiliated private) and who offered ICE opportunities of varying length in an assortment of countries (Table). Unfortunately, a chosen participant from a non–faith-affiliated university ultimately was unable to connect to the virtual focus group due to technical problems.
Participant Demographics, University Type, and Country Categories of International Clinical Education Sites by Study Phase
Phase 2 included all 19 participants who volunteered. Collectively, the 20 participants in both phases of this study reflected diversity in faculty roles, years of academic experience, years of ICE experience, university type, and duration and country category of ICE opportunities (Table).
The Delphi Instrument
We began by using the guidelines for global health training (eAppendix 1) developed by WEIGHT.30 These recommendations were used and revised with the original lead authors' permission (John A. Crump, MD, and Jeremy Sugarman, MD; written communication; February 2013).
Focus Group
The focus group convened virtually on a predetermined date via Blackboard Collaborate online collaboration platform (Blackboard Inc, Washington, DC). The research assistant conducted a trial session with each of the 6 planned participants, the consultant, and us prior to the designated date. As previously noted, despite this trial, 1 of the 6 participants encountered technical difficulties on the day of the virtual conference and was unable to participate. All participants were provided with a copy of the article that included the WEIGHT guidelines30 and a conceptual model of ICE in physical therapist education31 in advance of the focus group.
The consultant served as the focus group facilitator and followed a predetermined script (eAppendix 2). The WEIGHT guidelines30 were presented individually in a slide show that all participants could view. One researcher (C.M.P.) typed notes directly on the slides as the group members offered input and reached consensus; this procedure allowed the group members to confirm agreement with what was being written. The other researcher (J.D.B.) and the research assistant took notes on their own computers; the entire session was recorded.
The facilitator asked the participants to agree or disagree with the relevance of each guideline. They indicated their approval or disapproval electronically by selecting symbols (green check for “yes” and red X for “no”) and were able to contribute thoughts or suggestions by raising an electronic hand and engaging their microphone. The group worked through the entire set of guidelines and then reviewed the items to ensure clarity and 100% consensus. The focus group lasted approximately 2.5 hours.
After the focus group, we revised the original WEIGHT guidelines30 based on the participants' suggested changes. Additional nonsubstantive edits were made to better align terminology with physical therapist education terminology. For example, “trainees” was replaced with “students.” The revised guidelines were sent to all 5 members of the focus group for member checking. Two members responded; both expressed agreement and offered no changes.
Delphi Surveys
We then prepared the revised guidelines in the form of an online survey using the Qualtrics platform (Qualtrics Inc, Provo, Utah). The research assistant provided support in the management of the online survey tool, collection of the survey results, and e-mailing the survey link to participants. After being sent an e-mail with a link to the survey, participants had 5 days to complete the review of the guidelines. The survey began with an introduction (eAppendix 3). Next, participants were asked to indicate acceptance of each guideline as written, acceptance with suggested modification, or rejection. Those recommending modification or rejection were able to provide constructive comments or explanations. Additionally, they were asked to provide suggestions for additional guidelines if they thought they were needed.
We analyzed the survey results. We accepted those items where 80% or more of the participants indicated acceptance as written; we did not send these guidelines to the group again. When fewer than 80% of the responding participants agreed to a guideline as written, we revised it based on the panelists' comments. We also added new guidelines when suggested by the participants. We sent a second survey and then a third survey that included changes from the previous iteration, and participants were given 5 days to respond to each survey. Each survey had a revised introduction (eAppendix 3).
During the time period that the participants were completing the second round of surveys, we noted that some items in the round 1 survey had 20 responses instead of 19. Because responses were anonymous, it was not clear which one of the participants appeared to have duplicated his or her survey; also no 2 surveys came from the same Internet Protocol (IP) address (which is a unique identifier of each computer). An e-mail was sent to all participants; 1 person responded that she had started the first few questions of the survey but did not submit it and then began again later. However, this explanation did not account for the inconsistencies noted, as items further into the survey had 20 responses.
Therefore, we reanalyzed the data from the first round. We determined that there were 3 items that would not have reached the 80% threshold had one of the responses not been valid. Therefore, we added those guidelines to the third round of the survey for reconsideration by the group.
Role of the Funding Source
This work was funded through a research grant from the Texas Physical Therapy Foundation.
Results
After the focus group, 7 of the 33 original WEIGHT guidelines30 were accepted as written without any changes. Five guidelines were accepted with minor wording revisions. Nineteen guidelines were accepted after major revisions; 4 of these original guidelines were expanded into 8, and another 2 guidelines were collapsed into 1 guideline. Two of the original guidelines were rejected, and 3 additional guidelines were created as a result of the focus group.
After the first round of Delphi surveys, only 11 of the 37 post-focus group guidelines were accepted as written; the other 26 guidelines were accepted but with recommended revisions. No guidelines were rejected. We made revisions based on the collective recommendations. The second round of Delphi surveys yielded 80% consensus on all but 2 of the guidelines and 2 additional topic areas that were suggested by the expert panel.
Based on the recommendations, we added 2 subguidelines within the first guideline for the host and sending institutions to address the noted deficits, and the 2 items needing revision were modified accordingly. Round 3 of the Delphi survey yielded 80% consensus for all items, including the additional ones. The final round also confirmed that 3 items in question after round 1 indeed reached consensus.
Lastly, we made 2 minor edits. One small change was made to create consistency across the guidelines (by replacing “optimal” with “enhanced” in student guideline 9), and a minor edit was done to improve readability (by adding parentheses around “verbal and nonverbal” in host and sending institutions guideline 4). We considered other edits to further enhance readability but ultimately resisted other changes out of concern for altering the participants' voices.
The Appendix summarizes the final guidelines produced from the study. eAppendix 1 allows a comparison between the original WEIGHT guidelines30 and the final guidelines produced by the participants. Although most of the WEIGHT guidelines30 were accepted with little or no revision, the participants recommended some key changes. The focus group rejected 2 guidelines. First, they stressed that ICE should always be part of a structured program and so eliminated WEIGHT student guideline 14 (shown in eAppendix 1). They also rejected WEIGHT sponsor guideline 5 (shown in eAppendix 1), which tasked sponsors to be part of the selection of appropriate trainees.
Finding the use of the term “sponsors” to be too vague for the purpose of ICE, the participants recommended creating separate guidelines for “partner organizations” and for “funders.” In addition to incorporating the existing 8 sponsor guidelines into the newly created partner organization guidelines, the participants suggested 2 new guidelines (numbers 9 and 10) related to declaring conflicts of interest and maintaining predefined periodic communication. They also created 3 guidelines for funders (numbers 1, 2, and 3) related to formal written agreements, an option to request and analyze program evaluation data, and conflicts of interest.
A few final new guidelines and subguidelines were created to address the participants' key concerns. These concerns included addressing student safety and emergency care (new host and sending institution subguidelines 1f and 1g), donations (new host and sending institution guideline 11), and students' commitment to the internship (new student guideline 3).
Discussion
The goal of the study was to develop a list of recommended guidelines for ICE in physical therapist education to guide current and future educators involved in ICE. The results of the study revealed a significant overlap with the original global health training guidelines.30 However, the participants' deletions and additions highlight that revisions were indicated to better capture ICE in physical therapist education. Most notably, the focus group participants rejected original trainee guideline 14 (shown in eAppendix 1) related to circumstances when a student may seek global health training outside of a well-structured program. They stressed that ICE should never be done outside of a formal program. This assumption was in alignment with previous research31 indicating that faculty expects ICE to be well designed and meet the same standards as domestic clinical education. Similarly, the Commission on Accreditation in Physical Therapy Education (CAPTE) has stated that they have equivalent standards for domestic clinical education and ICE.37
This study was developed, in part, to provide guidance should CAPTE decide to create accreditation standards specific to ICE. We are not aware of such plans, nor are we promoting CAPTE guidelines. However, if accreditation standards related to ICE are proposed in the future, the results of this study should inform the creation of the standards. At this point, we advocate voluntary adoption of the guidelines by physical therapist educators involved in ICE.
Additionally, we support ongoing dialogue to identify how to further strengthen these guidelines. For example, ongoing efforts must continue to heed ensuring student safety (eg, use of US State Department travel warnings and registration system) and detailing what is meant by “cultural competence.”
Although the results of this study are most applicable to ICE in physical therapist education, these revisions of the original WEIGHT guidelines30 may inform future individuals who are seeking to develop or revise ethics guidelines for their purposes. For example, during the Delphi rounds, the participants added explicit guidelines related to declaration of conflicts of interest by partner organizations and funders. No similar language is found in the original WEIGHT guidelines.30 In retrospect, however, we note that similar wording was not suggested for host and sending institutions, which may have been an oversight on the part of the participants.
The above potential oversight highlights that the study design could have been improved. Once a guideline reached consensus, we did not include it in future surveys in an effort to minimize time demands on the participants to read and complete additional surveys. By not being able to see all guidelines, however, the participants may have lost the big picture and missed opportunities to identify holes or inconsistencies.
Additionally, the study did not include the voices of host institutions, students, partner organizations, or funders. Voices from nursing38 and occupational therapy39–42 call for careful consideration of all constituent voices. Kubolk et al38 conducted a literature review of all nursing manuscripts that addressed international field placement projects. They noted the consistent lack of input from the host communities as a gap in the accounts. The occupational therapy literature notes a similar gap39,40 and has begun to publish accounts that include various stakeholders' perspectives.41,42 The current study lays an excellent foundation for delineating guidelines relevant to international physical therapist practice from the lens of the sending institutions. Future investigations are planned to seek validation from representatives of the host institutions and partner organizations, as well as non–US-based sending institutions.
Conclusions
Although the guidelines will continue to evolve, this project has systematically produced a first set of recommendations for ICE in physical therapist education using a range of ICE experts from US sending institutions. They may be used by educators and other decision makers to optimally design new ICE opportunities or to improve existing ones for the benefit of all stakeholders. These guidelines explicitly address ethical concerns related to international learning experiences documented inside and outside of the physical therapy literature.21–25 We are hopeful that the results of this study contribute to the advancement of ethical practice in ICE in physical therapist education.
Appendix.
Final Proposed Guidelines for International Clinical Education in Physical Therapist Education
Footnotes
Both authors provided concept/idea/research design, writing, and data collection and analysis. Dr Pechak provided project management, fund procurement, and clerical support.
The authors thank Dr John Crump and Dr Jeremy Sugarman for granting permission to revise the original WEIGHT guidelines for our purposes and for their leadership in addressing ethical issues in global health training. They also gratefully acknowledge the Texas Physical Therapy Foundation for funding this study, Dr Genevieve Pinto-Zipp for assisting as the methodology consultant, and research assistant and The University of Texas at El Paso student Liliana Jimenez for her excellent support with study implementation and manuscript preparation.
This study was approved by the Institutional Review Board of The University of Texas at El Paso.
- Received June 11, 2013.
- Accepted December 4, 2013.
- © 2014 American Physical Therapy Association
References
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