Characteristics of US-Licensed Foreign-Educated Physical Therapists
- M.W. Cornwall, PT, PhD, FAPTA, Department of Physical Therapy and Athletic Training, Northern Arizona University, PO Box 15105, Flagstaff, AZ 86011 (USA).
- M.T. Keehn, PT, DPT, MHPE, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois.
- M. Lane, PT, MPT, Federation of State Boards of Physical Therapy, Alexandria, Virginia.
- Address all correspondence to Dr Cornwall at: mark.cornwall{at}nau.edu.
Abstract
Background Foreign-educated physical therapists are often viewed as one possible solution to the current shortage of physical therapists, yet there is very little research regarding these individuals.
Objective The purpose of this study was to describe those physical therapists who are licensed in the United States but who were educated in another country. This description includes their country of education, their employment patterns, and the reasons they decided to emigrate and work as a physical therapist in the United States.
Design A cross-sectional survey was conducted.
Methods An electronic survey was sent to all physical therapists currently licensed in the United States who had been educated in another country. Those who had been licensed within the last 5 years are reported.
Results The results of the survey indicated that the typical foreign-educated physical therapist is female, aged 32.2 years, and was born and trained in either the Philippines or India. A majority of foreign-educated physical therapists obtained their first license in New York, Michigan, Illinois, Texas, or Florida. The most common reasons cited as to why a particular jurisdiction was chosen for initial employment were “recruiter recommendation,” “family, spouse, partner, or friends,” “ease of the licensure process,” and “ability to secure a visa sponsor.” A majority of foreign-educated physical therapists in this study initially worked in a skilled nursing facility, a long-term care or extended care facility, or a home health setting.
Limitations Only those foreign-educated physical therapists licensed within the last 5 years are reported.
Conclusions This study is the first to report on foreign-educated physical therapists in the United States. The findings of this study will provide important and useful information to others dealing with physical therapy professional and workforce issues.
The United States is currently experiencing a shortage of physical therapists,1,2 and growth in employment is predicted to grow 36% between 2012 and 2022 according to the Bureau of Labor Statistics.3 The increasing demand for physical therapists in the United States has been attributed to several factors, including an aging population, the need to address mobility problems related to chronic diseases, new treatments and techniques that are expanding the scope of physical therapist services, and widespread interest in health promotion.3 In addition, expanded health care coverage under the Affordable Care Act will likely increase the demand for qualified physical therapists.1–3
Immigration of foreign-educated health professionals has been identified as one component of the workforce supply picture and a potential solution to workforce shortages, primarily in medicine and nursing.4–8 Based on information from the Federation of State Boards of Physical Therapy (FSBPT), foreign-educated physical therapists account for 4.2% of all licensed therapists in the United States (written communication, July 2015). Despite this relatively low percentage, very little is known with regard to where they were initially educated and where they choose to reside and work, as well as the settings in which they choose to work. As such, whether foreign-educated physical therapists do or might contribute to addressing workforce distribution challenges in the United States is not known. A 2014 study by Pittman et al2 reported on immigration patterns of pharmacists, physical therapists, occupational therapists, speech-language pathologists, and medical and clinical laboratory technicians, using several proxy data sources. Despite the authors' efforts, the immigration picture for these professions, including basic demographic information, employment location, practice settings, and the reasons for their immigration, remains very incomplete.
Research on foreign-educated nurses and physicians may provide a basis for understanding the foreign-educated physical therapist workforce and their overall impact. Studies in nursing have focused on issues such as the basic demographic composition of the internationally educated nurse and where these nurses work and live compared with nurses who were trained in the United States.8–11 Foreign-educated physicians are known to play a significant role in meeting needs in specific specialties and settings.12 Foreign-educated medical graduates provide 24.6% of all office visits to physicians. In addition, they were more likely to be serving patients who are identified as non-Hispanic black, Hispanic or Latino, and Asian or Pacific Islander compared with US medical graduates.12 Other studies have looked at the reasons for nurses immigrating and the challenges and obstacles encountered during the process of immigration, credentialing, and obtaining employment.9,13,14 Clearly, insufficient information exists in order to understand the characteristics of foreign-educated physical therapists, how they contribute to the current workforce, or how they might be able to contribute to meeting current and future physical therapist workforce needs in the United States. If foreign-educated physical therapists could contribute to meeting the current and future needs for physical therapist services in the United States, immigration policies, requirements, and processes for foreign-educated physical therapists to obtain licensure in the United States could be further examined in order to remove unnecessary barriers.
The purpose of this study was to provide the first comprehensive description of foreign-educated physical therapists who were initially licensed to practice physical therapy in the United States during the last 5 years in order to gain a better understanding of current immigration patterns, the current process of obtaining licensure, and where they are employed. The description of these individuals from this study includes country of education, employment and career patterns, factors surrounding the decision to immigrate, and the reasons for selecting a particular jurisdiction for employment. This information will assist current and future efforts by both professional and regulatory agencies in addressing immigration of foreign-educated physical therapists and projected physical therapist workforce shortages.
Method
Survey Instrument Development
An electronic survey by Qualtrics (Provo, Utah) was used to gather information about foreign-educated physical therapists and was funded by the FSBPT. The initial questions for the survey were developed by the authors and shared with 3 additional physical therapists knowledgeable about the issues related to the licensure of foreign-educated physical therapists in the United States. The survey questions were then modified based on the feedback from these individuals. The data collected by the survey included information concerning the demographics of the foreign-educated physical therapist, where they were initially educated, the length of time they had been licensed in the United States, and where they were initially employed in the United States.
Following the modification of the survey, it was pilot tested with 107 individuals identified by the FSBPT as licensed physical therapists who had been educated outside of the United States. The results from this pilot study were used to make further modifications to the survey questions to improve its clarity and minimize data entry errors. The final questions used in this survey are presented in the Appendix.
Administration of the Survey
The revised survey was sent electronically to all physical therapists who were licensed as of January 1, 2014, and who were identified by the FSBPT as having trained outside of the United States. The survey's introduction described the study's purpose, emphasized that the results would be reported in the aggregate, promised anonymity of individual responses, and stated that participation was voluntary. Four weekly reminders were sent to all individuals who had not yet completed the survey. Of the 9,334 email addresses provided for foreign-educated physical therapists, 498 (5.3%) were determined to be incorrect or no longer valid. Of the remaining 8,836 valid email addresses, 1,978 individuals (22.4%) consented to participate and completed at least a portion of the survey.
Data Analysis
Educational preparation is evaluated by all jurisdictions in the United States in order to obtain a license to practice physical therapy. For those jurisdictions that require licensure candidates to demonstrate that their educational preparation is equivalent to that obtained by those who graduated from a program that is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE), this evaluation is performed using the Coursework Evaluation Tool developed by the FSBPT. For this study, only those individuals who had been licensed to practice physical therapy in the United States within the 5-year period preceding January 1, 2014, were analyzed. Therefore, the number of respondents included in the analysis was 553. This time frame for analysis was chosen because it corresponded to the release of the fifth edition of the Coursework Evaluation Tool. In 2009, the criteria used to judge educational equivalency were significantly changed. As such, looking at those licensed within the last 5 years would ensure that the respondents to the survey had all followed the most current regulatory process for becoming licensed in the United States and that their initial physical therapy training was equivalent to that of the United States.
We used IBM SPSS statistical software, version 21 (Armonk, New York), to analyze the results of the survey. Descriptive statistics were used to characterize the demographics of the respondents. Based on the results of the pilot survey, we anticipated that the majority of respondents would have received their initial physical therapy education in either the Philippines or India. Respondents for the final survey were separated into 9 groups based on the country or region in which they received their initial education in physical therapy: Africa, Asia, Canada, Europe, India, Middle East, Pacific Islands, Philippines, and South America. These countries or regions were determined, in part, from the results of the pilot study and allowed for comparisons of respondents from different geographic areas. The countries included in each of these areas are shown in eTable 1. Comparative statistics were used to determine if significant differences or patterns existed on each question between the country or region of the respondents' physical therapy education.
The criterion for determining statistical significance was set at an alpha level of .05 for all comparisons. Because of the large number of statistical comparisons, a Bonferroni correction was used to reduce the study's overall type II error rate.
Role of the Funding Source
The work described in this report was supported by the Federation of State Boards of Physical Therapy.
Results
Age, Sex, and Country of Education
The majority of respondents to the survey indicated that they received their initial physical therapy education in the Philippines (49.4%), followed by India (31.2%), Europe (6.3%), the Middle East (3.6%), Asia (2.7%), Canada (1.8%), Africa (1.6%), South America (1.4%), and the Pacific Islands (1.3%) (Fig. 1). A large percentage of the respondents to the survey were female (60%), and this pattern remained true for all countries and regions, with the exception of those educated in Africa, Asia, Middle East, and South America, where there were more male respondents than female respondents (eFig. 1).
Distribution of countries and regions of professional education for foreign-educated therapists licensed to practice physical therapy in the United States within the last 5 years.
The mean age of the respondents to the survey was 32.2 years (SD=4.9, range=23–52). The youngest therapists were educated in India (29.0 years), followed by Canada and Europe (31.7 years), Middle East (32.5 years), South America (32.9 years), Asia (33.4 years), Philippines (34.0 years), Pacific Islands (34.3 years), and Africa (39.0 years).
The mean age of the respondents when they were first licensed to practice physical therapy in the United States was 27.3 years (SD=4.5, range=19–49). The mean ages of respondents at the time they were licensed to practice physical therapy in the United States, separated by sex and country or region of education, are shown in eTable 2. The results of a 2-way analysis of variance showed that there was a significant main effect (P=.000) of sex, with female respondents being younger (mean age=26.8 years) than male respondents (mean age=28.3 years). In addition, there was a significant main effect (P=.001) of country or region of education. Those educated in India were the youngest (mean age=25.1 years), which was significantly younger (P<.05) than all other countries or regions with the exceptions of Canada and South America. Those educated in Africa were the oldest (mean age=34.1 tears) and were significantly older (P<.05) than those educated in Europe, India, and the Philippines. Finally, there was not a significant interaction effect of age (P=.05) between the country or region of education and the sex of the respondents (eTab. 2).
Licensure
The vast majority (92.1%) of the survey respondents had practiced physical therapy prior to immigrating to the United States. On average, they had practiced 5.5 years (SD=4.1) prior to immigrating to the United States. The average total number of years that the respondents to the survey had been a physical therapist, regardless of where, was 7.2 years (SD=4.7). The length of time respondents had practiced physical therapy grouped by country or region of education is shown in eFigure 2. Those educated in India had practiced the least total number of years (4.6 years) and the shortest number of years prior to coming to the United States, whereas those from Africa had practiced the greatest total number of years (15.1) and for the longest amount of time (11.1 years) prior to coming to the United States. Although the most common country where respondents practiced before coming to the United States was in the country where they obtained their initial education, 4.4% of them worked in a country other than where they received their physical therapy education.
Educational Preparation
Regardless of where they were educated, 30.9% of the respondents felt that their preparation exceeded or far exceeded what was needed for them to practice physical therapy in the United States. An additional 55.1% of the respondents felt that their education was adequate for what was needed to practice in the United States. Fourteen percent of the respondents felt that their initial physical therapy education fell short or far short of what was needed to practice physical therapy in the United States. Figure 2 shows the self-reported degree to which respondents felt their initial physical therapy education prepared them for practice in the United States. The therapists who felt they were least prepared (ie, short or far short of what was needed) by their initial education were those educated in Asia (53.4%), followed by the Middle East (25.0%), Canada (20.0%), India (18.4%), Europe (17.1%), South America (12.5%), and the Philippines (8.7%). None of the therapists educated in Africa or the Pacific Islands felt that their education fell short or far short of what was needed to practice physical therapy in the United States. In particular, 85.8% of those educated in the Pacific Islands felt that their education exceeded or far exceeded what was needed to practice physical therapy in the United States (Fig. 2).
Percentage of male and female foreign-educated physical therapists separated by country or region of professional education.
Despite the very large percentage (86.0%) of foreign-educated physical therapists who felt that their entry-level physical therapy education was adequate or exceeded or far exceeded what was needed to practice physical therapy in the United States, only 55.4% of the respondents reported passing the National Physical Therapy Examination (NPTE) on the first attempt. Another 19.4% required 2 attempts to pass the NPTE, and 20.6% of them required 3 to 5 attempts to pass the NPTE. Fewer than 4.6% of the respondents to our survey indicated that they required more than 5 attempts.
English language proficiency.
English language proficiency (ELP) is a requirement for licensure in most US jurisdictions. Although there are several tests of ELP, the most commonly used test is the Test of English as a Foreign Language (TOEFL). The TOEFL was used by 67.8% of the respondents to the survey. Another 17.0% used the Test of Spoken English (TSE), and 11.8% used the Test of Written English (TWE). Fewer than 4% of the respondents used one of the other tests available to assess ELP.
Reasons for immigrating.
Fifty-one percent of the respondents indicated that they had always planned to move to the United States and practice physical therapy. The reasons given for immigrating to the United States and practicing physical therapy are shown in eTable 3. Table 1 contains the reasons given for immigrating separated by country or region. Across all respondents, advanced training or education (22.4%) and higher wages or benefits (26.0%) were identified as the top reasons for coming to the United States. These reasons, however, were different based on the country or region of education. For example, seeking advanced training or education was cited by a greater percentage of respondents who were educated in the Philippines (24.4%), India (23.5%), and the Middle East (23.1%), whereas a very low percentage or none of the therapists educated in the Pacific Islands (0.0%), Africa (5.0%), and Asia (7.1%) indicated that this was an important reason for immigrating to the United States. Seeking adventure or experiencing a new culture was cited more frequently by those educated in Africa (25.0%) and the Pacific Islands (22.2%). On the other hand, better working conditions were cited most frequently by those educated in Asia (21.4%). Immigrating to be with family or spouse was a top reason cited by therapists educated in the Pacific Islands (66.7%), Canada (54.5%), and Europe (26.2%). The possibility of higher wages and benefits was cited as a primary reason for immigrating to the United States by those educated in the Philippines (30.3%), Africa (30.0%), Asia (28.6%), and India (21.2%). Being able to practice physical therapy at a higher level was cited most frequently as a reason for immigration to the United States by those educated in Asia (25.0%) and the Middle East (20.5%). Finally, very few of the foreign-educated physical therapists who responded to this survey felt that improved personal safety was a primary reason why they immigrated to the United States to work as a physical therapist (Tab. 1).
Reasons Cited for Initially Coming to the United States, Reasons for Selecting a Particular Jurisdiction, and the Physical Therapist Practice Settings Chosen by Foreign-Educated Physical Therapistsa
Employment
Figure 3 shows the distribution of where those who responded to the survey were initially employed to practice physical therapy in the United States. Of the foreign-educated physical therapists who responded to this question and had been licensed in the United States for 5 years or less, 62.1% were initially employed in 1 of 5 jurisdictions: Florida (6.9%), Illinois (10.3%), Michigan (5.1%), New York (32.7%), and Texas (7.1%). With regard to the country or region of education, New York was the most common jurisdiction for initial employment of those educated in Asia (78.6%), Middle East (64.3%), Pacific Islands (57.1%), India (54.2%), South America (37.5%), Europe (27.3%), and Philippines (18.1%). On the other hand, those educated in Africa were more likely to take their first job as a physical therapist in Illinois (28.6%), and those educated in Canada were more likely to initially work in Texas (30.0%).
Jurisdiction of initial practice as a physical therapist for foreign-educated physical therapists.
The zip code reported by respondents for their initial employment as a physical therapist in the United States was used to determine whether that employment was in a metropolitan or nonmetropolitan area. A metropolitan area was classified as any zip code in a county with a population over 250,000. The result of that analysis showed that 71.1% of all respondents were first employed in a metropolitan area. When the respondents were separated based on the country or region of education, the majority of therapists again took their first employment in the United States as a physical therapist in a metropolitan area. The exceptions were those therapists educated in the Pacific Islands. These individuals were split evenly between metropolitan and nonmetropolitan areas for their first employment in the United States (eFig. 3).
Reasons for Selecting a Particular Jurisdiction
Table 1 shows the frequencies of reasons that respondents cited for selecting a particular jurisdiction for their initial employment in the United States. The frequencies of reasons separated by country or region are shown in Table 2. When all respondents are considered, recruiter recommendation (17.3%) was cited most frequently as a primary reason for selecting a particular jurisdiction, followed by being with family, spouse, partner, or friends (16.5%); ease of the licensure process (14.1%); the ability to secure a visa sponsor (13.8%); its geographic location (11.4%); and cost of living (7.0%). Fewer than 5% of respondents cited educational opportunities (3.9%) as a primary reason for selecting a particular jurisdiction for their initial employment in the United States (Tab. 1).
Reasons Cited by Foreign-Educated Physical Therapists for Selecting a US Jurisdiction for Initial licensure in the United Statesa
With regard to differences among countries or regions, although recruiter recommendation was cited the most frequently by all respondents, those educated in the Philippines cited this reason much more often than those educated in other countries or regions. Being with family, spouse, partner, or friends was a common reason for many therapists. Geographical location was cited 20% of the time or more by those educated in the Pacific Islands and Canada. Meeting educational requirements and ease of the licensure process for the selection of a particular jurisdiction were cited most frequently by those educated in India (22.0% and 22.5%, respectively) (Tab. 2).
Practice Setting
Table 1 shows the percentages of foreign-educated physical therapists who initially worked in a specific physical therapist practice setting. Upon becoming licensed to practice physical therapy in the United States, 39.2% of them worked in a nursing or residential care facility (skilled nursing facility [SNF], long-term care center [LTC], extended care facility [ECF], or assisted-living facility), 25.1% of them worked in an ambulatory care facility (physical therapist–owned outpatient clinic, non-physical therapist–owned outpatient clinic, or hospital outpatient department), and 20.4% of them worked in a home health setting. Only 10.5% of them reported initially working in a hospital inpatient setting (Tab. 1). Because respondents may have held more than one job, the above percentages do not add to 100%.
Table 3 shows the initial practice settings chosen by foreign-educated physical therapists, separated by country or region. At least one-third of those educated in Africa (33.3%), Asia (33.4%), Europe (34.3%), and South America (40.0%) reported having their first job as a physical therapist in either an inpatient or outpatient hospital setting. On the other hand, a physical therapist–owned or non-physical therapist–owned outpatient clinic was reported by fewer than one-third of the respondents, except for those educated in Asia (50.0%) and the Pacific Islands (50.0%). Thirty percent or more of those educated in the Pacific Islands (50.0%), India (34.5%), Philippines (34.1%), Middle East (31.3%), and Canada (31.3%) reported working in an SNF, LTC, or ECF for their first job as a physical therapist in the United States (Tabs. 1 and 2).
Physical Therapist Practice Settings for Foreign-Educated Physical Therapists' Initial Employment in the United Statesa
Discussion
This article reports on the results of an electronic survey of foreign-educated physical therapists currently licensed in the United States. The response rate for 6 well-regarded information system journals was reported by Sivo and associates15 to be between 22% and 59.4%. The response rate for the present survey falls within this range. The fact that this survey was sent to the entire population of foreign-educated physical therapists, rather than a sample, we believe that our response rate of 22.4% is sufficient to draw reasonable and reliable conclusions from the data.16 Significant differences were not found when respondents were compared with nonrespondents on the characteristic of country of education. No other data on nonrespondents are available for comparison.
When responses were broken down by country, some of the resulting frequency cells had 10 or fewer responses. Even when countries were grouped for analysis, some of these groups (Africa, Asia, Pacific Islands) had fewer than 10 respondents; therefore, the results for these groups should be interpreted with some caution. The grouping of countries was intended to provide analysis based on educational similarity and geographic proximity and to make the data more usable. Arguably, only the Philippines and India have a significantly high number of respondents to justify individual groupings, but given that there are significant differences in education, physical therapist practice, and the health care system among the remaining 29 countries, aggregating the data across all of those countries was not felt to be valid and would result in valuable information being lost. In future research, other approaches to grouping may provide additional insight.
To our knowledge, the results of this study provide the first description of the demographic, licensure, and employment characteristics of foreign-educated physical therapists who entered practice in the United States within the past 5 years. As this is one of the first studies of foreign-educated physical therapists in the United States, little or no published information exists for comparison with the results of our survey. Instead, we will compare our results with what is known about the internationally educated nurse and the foreign-educated medical graduate. Medical physicians who were educated outside of the United States represent 25.8% of the total physician workforce in the United States. For nursing, this percentage is estimated to be 5.4%.4 As such, the percentage of foreign-educated physical therapists in the United States (4.2%) is much smaller than medicine, but is very similar to that of nursing.
The high percentage of individuals educated in the Philippines (49.7%) found in the current study is consistent with that reported by Spetz and associates for nursing.8 They reported that 50% of foreign-educated nurses emigrated from the Philippines, followed by Canada (12%), India (9%), and the United Kingdom (6%). In contrast, however, we found that therapists educated in India represented a greater percentage compared with that of nursing and that those educated in Canada represented a smaller percentage compared with nursing.
It was clear from the responses to the survey that a majority of foreign-educated physical therapists felt that the initial professional education they received was adequate (55.1%) or exceeded (25.0%) or far exceeded (5.9%) what was needed to practice physical therapy in the United States. However, there were therapists from every country or region except Africa and the Pacific Islands who felt their education fell short or far short from what was needed for practice in the United States—even though all of these therapists at one point were found, through a review of their education by the licensing jurisdiction, to have substantially equivalent educational preparation.
The reasons for this finding may be related to differences in didactic or clinical preparation, or there may be deficiencies due to the specific features of the US health care system. Information from the FSBPT indicates that only about 25% of applications of foreign-educated physical therapists reviewed in the credentialing process are found to have an education that is equivalent to that of a US-trained physical therapist (written communication, June, 2015). Furthermore, even among those who are found by a credentialing agency to have an equivalent education, the mean first-time pass rate on the NPTE between 2009 and 2014 was 32.0% (SD=6.0). This finding is in comparison with a mean first-time passing rate of 88.7% (SD=1.4%) for graduates from programs accredited by CAPTE. The above first-time passing rate for all foreign-educated physical therapists is much lower than the self-reported passing rate obtained in the current study. A lack of specific accreditation requirements in some countries raises the possibility of significant differences in educational preparation even within the same country, which should be explored in future research.
Further research is needed to investigate the several reasons for the discrepancy in passing rates and to look closer at the several factors that best contribute to licensure preparation and clinical practice competence, including ways to best determine educational preparation and equivalency.
In addition, for those individuals who felt that their initial professional education exceeded or far exceeded what was needed to practice physical therapy in the United States, only 34.0% cited seeking advanced education or training as a reason for coming the United States. Instead, 46.1% of these individuals cited following a spouse or other family member as a reason for coming to the United States. It appears, therefore, that foreign-educated physical therapists may come to the United States to obtain advanced education or training, but it is not because they felt that their initial education was inadequate. Rather, it was the desire to go beyond what they had received in their home country. Future research should be conducted to further explore the many reasons that therapists felt that they were either sufficiently or insufficiently prepared for practice in the United States and how that influenced their decision to come to the United States.
The current study showed that a majority of foreign-educated physical therapists are initially licensed in just 1 of 5 different jurisdictions (Fig. 3). In a study by Spetz et al,8 foreign-educated nurses tended to emigrate to 1 of 4 different states: California, New York, Texas, or Florida. Although New York and Florida also were frequently cited as places of initial licensure and employment by foreign-educated physical therapists, California and Texas were not as common as that reported for nursing. In addition, Michigan, Indiana, and Illinois had a significant number of foreign-educated physical therapists taking initial employment, although this was not the case for nursing.8
English language proficiency is generally believed to be important for safe and effective practice of physical therapy, and a majority (84.3%) of US jurisdictions currently require verification of ELP.16 Based on this survey, the TOEFL is the most commonly used test to demonstrate ELP for foreign-educated physical therapists. Of the 5 jurisdictions where foreign-educated physical therapists were frequently licensed first, 2 of them (New York and Florida) did not have any requirement for ELP. In addition, 3 of the 5 common jurisdictions (New York, Illinois, and Michigan) did not require the foreign-educated physical therapist's entry-level education to be equivalent to that established by CAPTE, but they did have a review of their educational credentials.16 The results of the current study illustrate that foreign-educated physical therapists seek initial licensure in specific jurisdictions for a wide range of reasons. Thus, further research is warranted to better understand these reasons and the role that regulatory requirements for licensure play in that decision.
For those therapists who were licensed in the United States within the past 5 years, the jurisdiction's licensure process and the ability to meet the educational requirements were 2 important reasons identified by many respondents for choosing where to become licensed in the United States. These 2 factors, along with the requirement for ELP testing prior to licensure, are within a jurisdiction's control and could be modified, if desired. As jurisdictions change their licensure process and requirements, the future effect on where foreign-educated physical therapists choose to become licensed should be investigated to determine the effect of those changes. Foreign-educated physical therapists also identified the ability to secure a visa and recruiter recommendation as important reasons for choosing a jurisdiction in which to seek initial licensure. These 2 factors are indicators of employment availability that are not within a jurisdiction's control. These findings are important for regulatory agencies, employers, and state governments to consider if they want to encourage foreign-educated physical therapists to seek licensure and employment in their jurisdiction.
Spetz and associates8 reported as many as 93% of foreign-educated nurses were employed in an urban area, especially those nurses from the Philippines, India, and the United Kingdom. The current study showed a similar finding in that a majority of foreign-educated physical therapists were initially employed in a metropolitan area and that there was little difference based on the country or region of their initial professional education. Further research should be conducted, however, looking at the reasons for these therapists seeking initial employment in a metropolitan area rather than a nonmetropolitan area. Such information could help to encourage more therapists working in nonmetropolitan areas, which are frequently underserved. Given that rural and underserved areas may require incentives to recruit physical therapists, an improved understanding of the migration of physical therapists over the course of their careers would be helpful in setting policy and in determining if incentives would be of value.
The current study indicated that the majority of foreign-educated physical therapists licensed from 2009 to 2014 were initially employed in a nursing or residential care facility (SNF/LTC/ECF), a home health setting, or in an ambulatory facility (outpatient). This finding is in contrast to that reported for the nursing profession, where 70.3% of internationally educated nurses are employed in a hospital and only 11.7% are employed in a nursing home.11 Furthermore, vacancy rates for nurses in these settings have been reported to be greater than 10%.17–19 Of interest, however, is the fact that the vacancy rate for physical therapists in SNFs is 12.1%,18 which is slightly higher than that for outpatient settings (11.2%)19 and hospitals (10.0%).18
The Bureau of Labor Statistics20 indicates that only 7.0% of all licensed physical therapists are employed in a nursing or residential care facility. In comparison, 39.2% of foreign-educated physical therapists in the current study were initially employed in these settings. Nationally, 51.2% of all US physical therapists are employed in an ambulatory facility compared with 24.3% of foreign-educated physical therapists. For hospital-based inpatient settings, 28.4% of all physical therapists are employed in such a setting compared with only 10.5% of foreign-educated physical therapists. Finally, 11.4% of physical therapists nationally are employed in a home health setting, whereas 20.4% of foreign-educated physical therapists are employed in such a setting. Additional research is needed looking at employment patterns following initial job placement and the reasons why foreign-educated physical therapists select the particular practice settings reported in this survey. Such analysis also should include a comparison of trends in vacancy rates within specific settings.
A potential limitation of the study is the fact that only those who became licensed to practice physical therapy in the United States within the last 5 years were analyzed. Although this potential limitation resulted in a somewhat incomplete picture of the foreign-educated physical therapists licensed and practicing in the United States, it does allow a description of those whose education was evaluated under the same criteria and found to be substantially equivalent to that of US-educated therapists. This information also provides good baseline information regarding foreign-educated physical therapists so that future trends can be studied.
In conclusion, to our knowledge, these findings are the first to report on foreign-educated physical therapists in the United States and cover those who had been licensed within the 5 years prior to January 1, 2014. The results of that analysis describe the demographic, licensure, and employment patterns of these foreign-educated physical therapists. The results of this study provide a great deal of baseline information regarding foreign-educated physical therapists, including where they are predominantly located and the typical practice setting where they work. Although additional information is needed and desired, such information will allow organizations or individuals to better address issues of workforce distribution and licensure. In addition, this information can be utilized by regulatory agencies to address possible procedure or policy changes that could best determine educational preparation and minimal clinical competence prior to licensure and to facilitate a foreign-educated physical therapist immigrating to the United States and working in a particular jurisdiction, thus helping to address workforce shortages and disparate distribution, while ensuring public safety.
Appendix.
Survey Questions Used in the Study of Foreign-Educated Physical Therapists in the United Statesa
a The survey questionnaire may not be used or reproduced without written permission from the authors.
Footnotes
All authors provided concept/idea/research design. Dr Cornwall and Dr Keehn provided writing and data analysis. Dr Cornwall provided data collection and fund procurement. Dr Cornwall and Mr Lane provided project management. Mr Lane provided participants. Dr Keehn and Mr Lane provided consultation (including review of manuscript before submission).
The Northern Arizona University Human Subjects Committee reviewed and approved the study protocol.
The work described in this report was supported by the Federation of State Boards of Physical Therapy.
- Received December 11, 2014.
- Accepted August 9, 2015.
- © 2016 American Physical Therapy Association