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Research Reports |
TM Long, PT, PhD, is Associate Professor, Director of Training, and Director, Division of Physical Therapy, Center for Child and Human Development, Georgetown University, Box 571485, 3300 Whitehaven St NW, Suite 3300, Washington, DC 20057-1485 (USA). She also is Lead Investigator, The Training Needs of Interdisciplinary Team Members in Assistive Technology
DF Perry, PhD, is Assistant Professor and Director, Department of Population, Family, and Reproductive Health, Women's and Children's Health Policy Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
Address all correspondence to Dr Long at: longt{at}georgetown.edu
Submitted December 1, 2006;
Accepted January 18, 2008
 | Abstract |
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Subjects and Methods: Three hundred eighty pediatric physical therapists responded to a survey questionnaire mailed to a random sample of members of the Section on Pediatrics of the American Physical Therapy Association. The survey was used to determine training needs of therapists in the area of AT, their confidence in delivering AT services, preferred methods of training, and challenges in becoming trained.
Results: The therapists reported having less-than-adequate training in AT and a lack of confidence in delivering AT services. They also reported that they would like accessible and affordable training that focuses on funding technology and services, knowledge of specific devices, and assessment and evaluation methods.
Discussion and Conclusion: The findings underscore the need to develop pre-service, in-service, and continuing education training opportunities in AT for providers working with children who have disabilities.
| Introduction |
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 TopAbstract Introduction MethodResultsDiscussionConclusionReferences |
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Despite significant advances in AT and legal mandates, these interventions often remain underutilized.9–12 Dusing et al12 found that 9% of children with special health care needs have an unmet need for mobility devices and that l7% of these children have an unmet need for communication aids or devices. Dusing and colleagues indicated that the children who lack insurance or have more severe limitations are more likely to report an unmet need.
There is little data on how many children could actually benefit from AT. Service providers report that not all the children who could benefit from AT are receiving it.13 Recently, Wilcox et al13 surveyed interdisciplinary team members, including 187 physical therapists who provided services for infants and toddlers, and found that the physical therapists felt that only 19.8% of the children for whom they provided services and who could benefit from AT are receiving it. They found that the respondents with more training in AT recommended AT more and reported greater use of AT by the children for whom they provided services. According to the National Early Intervention Longitudinal Study,14 only about 4% of infants and toddlers receiving early intervention services have AT and AT services listed on their IFSP. This figure is consistent with national statistics reported by the US Department of Education15,16 and has remained virtually unchanged over the past decade. In 1997, the Department of Education reported that 4.4% of IFSPs listed AT and AT services,15 and, in 1999, 3.8% of the IFSPs listed AT and AT services.16 Additionally, early intervention providers and part C coordinators are more likely to describe AT as those devices that are considered high tech, are not readily available, and more often fit the definition of durable medical equipment.17 There is a growing body of literature indicating that the successful use of AT by children is related to service providers’ experience, expertise, and attitudes regarding AT and AT services.17 However, Lesar18 found that the majority of early childhood professionals, including physical therapists, who responded to a survey on needs, concerns, and perceived barriers to the use of AT felt unprepared to recommend, provide, and use AT with young children.
As one of the first rehabilitative specialists to provide services to children with disabilities and special health care needs, pediatric physical therapists are in an ideal position to recommend and implement the appropriate use of AT. Physical therapists promote the attainment of functional skills, suggesting a logical connection for the use of AT as a modality to promote function. Although training in the area of AT has not been studied widely, there has been an assumption, primarily based on Lesar's work,18 that service providers, including physical therapists, feel they are inadequately prepared to provide AT and AT services to young children. Recent work on how confident early intervention providers, including physical therapists, feel in providing AT17 indicates that, based on responses to the Assistive Technology Confidence Scale (ATCS), early intervention providers, including physical therapists, are confident in AT assessment but feel ill-prepared to obtain and use AT resources and services. Thus, early intervention providers appear confident in their ability to identify a need for AT but not in AT implementation.
The American Physical Therapy Association (APTA) supports the training of physical therapists in AT in a variety of ways. The Guidelines for Pediatric Content in Professional Physical Therapist Education19 developed by APTA's Section on Pediatrics recommends that professional training programs should incorporate content that provides the professional (entry-level) physical therapist with the ability to determine the need for adaptive equipment and mobility devices, which—according to the federal definition—are considered AT. These guidelines are consistent with the scope of practice delineated in the Guide to Physical Therapist Practice.20 A Normative Model of Physical Therapist Professional Education: Version 200421 also recommends that components of AT, such as adaptive equipment and assistive devices, be covered within the curricula of professional preparation programs. Finally, according to the evaluative criteria from the Commission on Accreditation in Physical Therapy Education (CAPTE),22 the curriculum and content of a professional preparation program in physical therapy should provide the student with necessary knowledge and skills to examine an individual in the area of assistive and adaptive devices (criteria number: CC-5.30d) and provide intervention, including prescribing, applying, and, as appropriate, fabricating devices and equipment (criteria number: CC-5.39e). Like the terms "adaptive equipment" and "mobility devices," assistive and adaptive devices and equipment are considered components of the broader, federally mandated description of AT. Although supported by APTA, there is little indication that training in AT is taking place in a significant enough degree or depth to ensure knowledge and skill in this area in professionally trained physical therapists.23
Few recent studies have described the degree or depth of information on AT covered in physical therapist education programs. Brady et al23 found that many physical therapy professional preparation programs spend 20 hours or less on AT and AT services content. This content is primarily embedded into other courses and focuses mainly on positioning and mobility devices. Program administrators who completed the survey indicated that, although they are satisfied with the amount of time devoted to AT within their curriculum, they feel more content on AT would be beneficial. Additionally, faculty members ranked AT education as marginal to satisfactory in most content areas related to AT.23 Areas of AT education include understanding the potential of technological systems, evaluating systems, acquiring the system and finding a funding source, fabricating and modifying systems, and training in the use of the system.
Gitlow and Sanford24 reported that rural health care professionals (occupational therapists, physical therapists, and speech-language pathologists) have minimal or nonexistent training in the area of AT, although more than 50% reported having a moderate or significant need for information in this area. Additionally, the National Council on Disability, an independent federal agency that makes recommendations to the President and Congress that will enhance the quality of life for all Americans with disabilities and their families, reported that a barrier to individuals with disabilities receiving appropriate AT is the lack of expertise in AT found in service providers.25 The National Council on Disability recommended that the federal government fund and support training programs that build the capacity of service providers in the area of AT.25 Although there are indications that service providers are in need of more training in the area of AT and AT services, it is unclear how much more training physical therapists think they need and whether there are specific areas in which physical therapists think they need training.
In this article, we report on a national survey used to assess how well prepared pediatric physical therapists felt they were in the area of AT, in which areas they felt additional training in AT is needed, and their preferred training methods. Our specific research questions were:
This survey was conducted as part of a larger effort to improve services and support for children and youth with disabilities, funded by the National Institute on Disability and Rehabilitation Research. Identifying the areas of AT in which pediatric physical therapists perceive they need additional training will facilitate the development of targeted training and technical assistance.
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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The legal definition of AT (Fig. 1) was used as the operational definition of AT in the survey. This definition was provided in the survey booklet, and the respondents were directed to use the definition when responding.
Following a review of the literature, the survey instrument was developed by a team of physical therapists, occupational therapists, research psychologists, and Rehabilitation and Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professionals (ATPs). A focus group of 17 service providers (4 physical therapists, 5 occupational therapists, 3 speech-language pathologists, and 5 special educators) who also were certified Assistive Technology Professionals in the metropolitan Washington, DC, area reviewed the survey instrument. The questionnaire was pilot tested with a small group of pediatric physical therapists (n=20) following the focus group to determine readability of the questions, time required to complete the survey, and face validity. No changes were made to the survey instrument based on the results of the pilot testing. The survey tool demonstrated a high degree of internal consistency (Cronbach alpha=.90).
Sample
The APTA provided a mailing list of a random sample of those members who identified themselves as pediatric physical therapists (defined by membership in the Section on Pediatrics). This sample (n=1,000) represented approximately 20% of all pediatric service providers in the Section on Pediatrics. The survey instrument was sent to this group of pediatric physical therapists. Only physical therapists were surveyed because we were interested in those service providers who are in positions to evaluate and recommend AT in addition to providing the device and providing AT services. Postcards were sent to remind nonrespondents to complete the survey. A second mailing of the survey questionnaire was sent to those who still had not responded. A total of 380 questionnaires were returned, a response rate of 38%; this represents 8% of those therapists who provided services to children and were members of the Section on Pediatrics.
Table 1 describes the 380 pediatric physical therapists who responded to the survey. The sex and racial distribution is similar to that of the Section on Pediatrics but not to that of APTA as a whole. Overall, the APTA membership is approximately 65% female and 88.2% white, and the membership of the Section on Pediatrics is 92% female and 91% white. Thus, our sample reflects the Section on Pediatrics membership from which it was drawn but not the larger APTA membership (electronic communication with Marc Goldstein, EdD, November 27, 2006).
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Qualitative data analysis was based on a phenomenologic design. Methods were used to examine the responses to the 3 open-ended questions on the survey questionnaire, which asked about the respondent's biggest challenge in becoming trained to provide AT and AT services, helpful strategies for training, and most critical training need regarding AT and AT services. Responses were coded by 3 members of the research team. Initially, each coder independently reviewed a sample of responses and generated a list of preliminary codes. Members of the research team then met to compare these codes and developed a coding scheme. This process was repeated until the coding classifications demonstrated reliability across coders. All responses then were recoded by all 3 coders. Percentage of agreement across the coders ranged from 89% to 93%. The classifications used for coding the data are shown in Table 2.
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Table 3 shows that 33% to 59% of the respondents reported inadequate training in each of the 5 categories. The percentage of respondents receiving no training ranged from 7% to 18%. The topics rated the highest were: collaborating with other service providers and working with clients with disabilities and AT and AT services. The majority of the respondents reported inadequate or no training for the remainder of the categories. The majority of the respondents rated their training in legislation, regulation, and policy related to AT services as inadequate. A similar pattern was seen for the areas of service delivery systems regarding AT and AT services and working with families regarding AT and AT services.
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Likewise, practitioners who reported that a higher percentage of their professional responsibilities were related to AT and AT services (41% or greater) were more confident in their ability to perform a variety of tasks. For 10 of the 11 items, these differences were statistically significant (P<.05). For some of these tasks, rates of confidence were nearly twice as high in the service providers whose jobs required more work related to AT compared with those whose jobs required less work related to AT (eg, evaluating outcomes [52% versus 36%], matching a device to a client's need [36% versus 19%], and working with high-tech devices [26% versus 11%]). These findings underscore the high percentage of pediatric physical therapists who lacked confidence in these core competencies, even among a select group of service providers whose current job responsibilities were highly dependent on these skills.
In Which Training Topics Do Pediatric Physical Therapists Want Additional Training in to Enhance Their Appropriate Use of AT?
A list of 28 topics was presented to the respondents (Fig. 2). All of the potential training topics were rated on a 3-point scale, ranging from "somewhat useful" (1) to "very useful" (3). All training topics had a mean score of at least 2.15, indicating that all of the topics were felt to be useful. Of the 28 topics rated by the pediatric physical therapists, 7 were rated particularly high in terms of usefulness for future training. Three of those highly rated topics pertained to information on specific types of devices: positioning devices (
=2.83, SD=0.42), devices used for activities of daily living (=2.85, SD=0.39), and seating devices (=2.87, SD=0.36). Twenty-four respondents specified their interest in training in other types of devices, such as switches and toy adaptations. The other highly rated topics were evenly distributed across other domains: assessing the client for use of the device (=2.73, SD=0.46), provider knowledge of funding sources (=2.71, SD=0.51), provider skills in techniques to train others (=2.72, SD=0.51), and provider skills in decision making (=2.71, SD=0.51). In addition, respondents were asked to identify their 3 most critical training needs regarding AT and AT services. Sixty-two percent of the pediatric physical therapists indicated that keeping current with advancements in technology and service provision (32.5%), understanding funding for AT and AT services (16%), and advanced skill in the evaluation and assessment of AT needs (13.4%) were their 3 most critical needs.
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Two training methods were rated as more effective than the other 3: person-to-person techniques and group instruction received the highest mean scores (=2.8, SD=0.44 and =2.8, SD=0.45, respectively). The other techniques received somewhat lower ratings: classroom instruction (=2.2, SD=0.66), print resources (=2.2, SD=0.56), and online instruction (=2.0, SD=0.63).
Additional qualitative data were analyzed in comments provided by the pediatric physical therapists regarding training strategies that they would find helpful. Most therapists indicated that hands-on practicum or lab experiences would be the most helpful. Although group instruction in the form of continuing education or in-service was preferred, the physical therapists were not interested in attending an academic program or class for further instruction, nor were they interested in online courses. The therapists also indicated that person-to-person mentoring, especially client-specific training, would be the preferred training method.
What Are the Main Challenges to Becoming Better Trained in AT?
Qualitative data were gathered through an open-ended question that asked respondents to identify their biggest challenge in becoming trained in AT and AT services. Practitioners indicated that too few courses are offered and timing and locations of the training programs often are not convenient. The lack of funding available to attend training also was indicated as an obstacle. The pediatric physical therapists also felt that the training was of poor quality or biased by vendor sponsorship. Finally, therapists indicated that attending training in AT and AT services was difficult to justify to their employers, as the number and types of children served were not felt to be large enough to warrant the expense of attending a training event.
| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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To successfully promote AT use, physical therapists must possess the knowledge and skills to address the AT needs of the children for whom they provide services. The results of this national survey underscore the challenges faced by the therapists in the area of AT and AT services. A national sample of the members of the APTA Section on Pediatrics reported less than adequate training in AT and AT services and low levels of confidence in terms of providing these services. These therapists also identified methods of training and training topics that they felt would be the most useful in meeting the needs of their practice.
Overall, nearly half of pediatric physical therapists reported less than adequate training in all 5 areas related to AT and AT services tapped by the survey: knowledge about children with disabilities; pediatric service delivery systems; working with families; collaborating with other service providers; and legislation, regulation, and policy. Knowledge about service delivery systems and legislation, regulation, and policy related to AT and AT services were the 2 areas that the therapists felt the least prepared to address. Although the majority of the respondents reported confidence in recognizing the benefit of AT and AT services, in working with low-tech devices, and in assessment and evaluation, low confidence was reported for identifying sources of funding, identifying qualified suppliers of AT and AT services, and working with high-tech devices. These findings are consistent with those of Moore and Wilcox17 and Lamorey and Wilcox.27 Lamorey and Wilcox27 found that early intervention providers, including physical therapists, rated themselves as novices in the area of AT. These providers reported 5 problem areas that were consistent with those found in the current study. They reported a lack of training and on-site technical assistance in collaborating with families in the assessment process, involving families during intervention, assessing AT needs, selecting AT devices, and providing AT services.
In addition to lack of training in AT and AT services, it has been proposed that self-efficacy can affect a service provider's ability to perform certain tasks.17 Service providers who lack confidence in their knowledge and skill level are hesitant to recommend or suggest a strategy such as AT or AT services. There is scant research on the relationship between confidence and skill performance in physical therapists. Rea et al28 found that physical therapists’ confidence in their knowledge base of health promotion best predicted a therapist promoting health behaviors in their patient population. Like Rea and colleagues, Moore and Wilcox17 posited that, according to social-learning theory,29 self-efficacy is related to training and experience; thus, as experience or training increases, confidence in applying that knowledge also should increase. In the current study, this relationship held true. Pediatric physical therapists with 11 or more years of experience and those with a greater percentage of their job responsibilities related to AT and AT services were over-represented in the group of therapists who reported high confidence levels. Thus, for these therapists, on-the-job training and experience may be the most common method of increasing confidence levels, which is consistent with social-learning theory. Early interventionists also reported more self-efficacy in AT-related skills based on years of experience as measured by the Early Interventionist Self-Efficacy Scale.17
Conversely, practitioners with less experience and a smaller percentage of their job responsibilities devoted to AT and AT services reported less confidence. Although this is a logical pattern to emerge, it points to the need for further training and support in the area of AT and AT services. Therapists in this study indicated that they need more training in basic information on AT and AT services. The most critical training needs identified by the respondents were knowledge of devices, equipment, software, and so on and funding of the technology and services. These findings support those of Gitlow and Sanford.24 Their survey of physical therapists, occupational therapists, and speech-language pathologists in rural Maine indicated that service providers do not describe themselves as competent in the area of AT, and most of their sample indicated a need for knowledge in equipment, funding, and collaboration, all areas noted by the current sample of therapists.
The field of physical therapy recognizes that therapists need to be competent in the area of AT and AT services; however, therapists continue to indicate a need for more training in this area. Long and Brady23 indicated that physical therapist professional preparation programs embed information on AT and AT services into the curriculum. Limited hours, however, are devoted to this content area. Thus, it is reasonable that therapists would report the need for ongoing training. Additionally, AT is an area of rapid expansion, and therapists need ongoing training to keep up with these advancements. The findings from the current study underscore the need to develop comprehensive approaches to delivering preservice and in-service training in AT and AT services. Practitioners gave consistently high ratings to the usefulness of all 28 of the potential training topics presented in the survey. Pediatric physical therapists are particularly interested in receiving training in mobility, seating, and positioning devices as well as training in clinical decision-making skills, funding, and assessment. Training programs that incorporate person-to-person and group instruction activities in response to the survey respondents’ preferences for mentoring, supervision, and consultation with experts may be successful.
Keeping current with advancements in technology and service provision also was identified as an area of training need. Barriers such as limited access to training must be overcome by continued and more intensive training at the preservice level in educational curricula, as well as continuing education in the style of hands-on workshops offered more frequently and throughout the country. As AT and AT services become accepted as standard practice, the training should become more available, less specialized, and integrated into training curricula. Although it is unreasonable to expect that professional preparation programs can add courses on AT into the curriculum, creative use of activities that incorporate AT decision making across the curriculum would be helpful. There are resources such as the Assistive Technology Training Online Project30 that provide a variety of curricular enhancement activities that could be embedded into existing courses. There also are online training programs31 specifically designed for rehabilitation professionals that physical therapists may find helpful.
Options Available for Training in AT
The Tech Act programs are one source of training available to service providers. The Tech Act1 established grants to states to address the AT needs of individuals with disabilities. These programs, available in all states, provide training and technical assistance to service providers. According to Campbell et al,32 the Tech Act programs and the early intervention (part C) programs collaborate in 65% of the states. Thus, early intervention providers have a training and technical assistance source of which they may not be aware. This same collaborative relationship may be available with older children through the collaboration between the Tech Act and the school-aged population (part B). The Tech Act programs may need to be more proactive in reaching out to practitioners and providing training that is available, accessible, affordable, and client specific—all parameters that physical therapists feel are barriers to becoming trained and thus having confidence in the use of AT and delivering AT services.
Another potential source of training is through RESNA, a multidisciplinary association that promotes the development and implementation of AT and offers a variety of educational programming at various levels, including a certification program. The Fundamental Assistive Technology Program is for any professional interested in becoming a certified ATP. According to RESNA, 108 physical therapists have become credentialed ATPs, which is 7.23% of all credentialed ATPs.33
Limitations
The survey questionnaire was sent to 1,000 individuals, but only 380 therapists returned the completed instrument. Great efforts were made to increase the response rate, including multiple follow-up contacts with our sample. In addition, we do not have demographic data on nonresponders to determine whether the people who returned the survey questionnaire were representative of all of the pediatric physical therapists in APTA's Section on Pediatrics, nor do we know whether the sample was representative of all physical therapists. The majority of physical therapists are not members of APTA; thus, it unclear whether the results of this survey represent pediatric physical therapists who are not members of the Section on Pediatrics. Another source of possible error is our sample size. In a sample of nearly 400 individuals, relatively small differences in the scores on individual items are statistically significant. In addition, a large number of statistical analyses were performed on these data, meaning that some of the statistically significant differences may have occurred by chance. Another limitation is with the survey itself. Through focus group and pilot testing, we determined that the questions were easy to understand, written clearly, and tapped into the constructs we were interested in exploring; however, the survey has had limited psychometric testing.
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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| Footnotes |
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The survey and the study method were approved by the Georgetown University Medical Center Institutional Review Board.
Parts of this research were presented at the following: the American Public Health Association Annual Meeting, November 9–13, 2002, Philadelphia, Pa; the 2002 Association of University Centers on Developmental Disabilities Annual Conference, October 27–30, 2002, Washington, DC; the 2003 Association of University Centers on Developmental Disabilities Annual Conference, November 9–12, 2003, Washington, DC; the Combined Sections Meeting of the American Physical Therapy Association, February 4–8, 2004, Nashville, Tenn; The Consortium, State of the Science Conference, Georgetown University Center for Child and Human Development, March 18–19, 2004, Bethesda, Md; and the 15th International Congress of the World Confederation for Physical Therapy, June 2–6, 2007, Vancouver, British Columbia, Canada.
This project was funded by grant H133B001200 from the National Institute on Disability and Rehabilitation Research, US Department of Education.
* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606. 
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2202 (1999).508 (1986).1401, 1212, 1414 (2000).1210 (1990).
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