BACKGROUND

Women comprise more than 50% of a physical therapist's patient load1; yet, reproductive and urogenital system pathologies, as well as other "women's health" (WH) conditions such as post-breast cancer lymphedema or fibromyalgia, comprise a small focus of the American Physical Therapy Association's (APTA's) document, titled "A Normative Model of Physical Therapist Professional Education: Version 2004."2 This is a document that provides curricular accreditation standards for entry-level (professional) physical therapy (PT) programs across the country. Over the years, there has been progress toward greater inclusion of WH curricular content in entry-level PT programs. In 1985, the first survey of physical therapist educational programs and WH content conducted by Hulme et al3 reported that only 7 of 45 schools taught childbirth education or any other information on the obstetric client. In 2001, Jean Irion4 undertook another WH curricular study to determine content areas in the 185 Commission on Accreditation of Physical Therapy Education (CAPTE)-accredited entry-level PT programs in the United States at the time. Of the 79 WH topics included in the survey, 42 were identified as being covered by at least 70% of the programs that responded to the survey. The results of this study indicated a significant change since 1985 in the topic areas considered within the scope of WH.4,5 In 2005, LaPorta Krum and Smith6 reported on the topics that clinicians deemed important and essential for inclusion in entry-level PT programs. These research findings were consistent with unpublished dissertation survey research done by Boissonnault1 in 2001, which focused on faculty opinions of important WH content in entry-level PT curricula (Table 1).

Table 1. Women's Health Curricular Content Items Deemed Important to Include in Entry-Level Curriculaa

In 2002, the Section on Women's Health (SoWH), of APTA, in response to the Boissonnault,1 Irion,4 and LaPorta Krum and Smith6 convened a task force on WH curricular content in entry-level physical therapist education with a mission to "address the variation and amount of women's health physical therapy curricular content currently present in PT schools in the US through development of curricular content guidelines for first-professional physical therapy programs."7 This task force subsequently published a curricular guideline in 2005, titled "Section on Women's Health, APTA, Guidelines for Women's Health Content in Professional Physical Therapist Education."8 The Guideline was sent in DVD format to every US PT program and became a saleable item through the SoWH Web site. The SoWH education committee plan for this Guideline was to update it every 5 to 10 years, or as practice changes dictated. In 2011, the SoWH Board of Directors reconvened the Section's task force with the purpose of updating the Guideline. The new task force was called the "Women's Health Curricular Guideline Task Force," and in 2014, it completed a document titled "Guidelines for Women's Health Content in Professional Physical Therapist Education: 2014 Update."9 This updated Guideline is available on the Section's Web site in a format allowing document surfing and links between content areas.

The formatting of the 2 versions of this curricular guideline is very different and the content is somewhat different. The methodology used to reach consensus among committee members varied significantly between the 2 versions as well. Understanding the steps the 2 task forces undertook, and the subsequent guideline they produced may be instructive for other WH PT organizations, as well as APTA Sections trying to develop entry-level standards. Therefore, the purpose of this article is to compare and contrast the methodology, the survey tools, and the 2 curricular guidelines produced by the SoWH in 2005 and 2014.

METHODS: 2002-2005 AND 2011-2014

2002 Task Force Approach

The recorded minutes from the early task force meetings reflect that the group decided to utilize the aforementioned research published by LaPorta Krum and Smith,6 the dissertation survey research by Boissonnault,1 and the unpublished curricular study by Irion4 as the foundation for development of the curricular content areas of the 2005 Guideline.10 The group established a 75% cutoff score for items to be included or excluded from the LaPorta Krum and Smith6 study and the Boissonnault1 study and resolved the few differences between the cohorts of the 2 studies through consensus discussion. The Irion4 study, which focused on content that was currently being taught in entry-level PT programs, informed choices the group made as the task force discussed what to keep in the Guideline and what to exclude. Ultimately, the task force created a list of content areas to cover in the Guideline and began work on determination of the format and the content information.

2011 Task Force Approach

The minutes from the 2011 SoWH task force11 indicated that the members agreed to survey US entry-level PT programs about the WH content faculty believed should be included in their curricula. The task force also wanted to survey clinicians. Initially, the task force planned to utilize the LaPorta Krum and Smith6 survey tool, but it ultimately chose 2 different survey tools: one for clinicians and one for faculty. The faculty survey was sent to PT program directors with instructions to forward to the faculty member (adjunct or core) who taught the majority of WH content. The group distributed the clinician survey to all members of the SoWH, with a goal of surveying WH practitioners with regard to their expectations of the WH skill set and knowledge of newly graduated physical therapists. As work progressed, the task force moved toward a content area section of the survey similarly formatted to the patient-client management model and the interventions found in the Guide to Physical Therapist Practice, 2nd edition.12 The task force members were charged with developing content areas by system and utilized the 2005 SoWH curricular Guideline8 and Women's Health Physical Therapy Description of Specialty Practice13 as resources for these content areas. The reader is directed to the publication, titled "Survey on Curricular Content for Doctor of Physical Therapy Guidelines for Women's Health Content in Professional Physical Therapist Education: 2014 Update,"14 for more detail on the survey development and to the publication, titled "Technical Report on Using the Systems and Patient Management Model in Women's Health DPT Curricular Guidelines,"15 for detailed information on the 2014 Guideline formatting. The surveys were distributed electronically by APTA and the SoWH and analyzed by APTA research staff. After reviewing the data from the 2 surveys, the task force came to consensus on a soft 70% cutoff score for acceptance of content areas for the final 2014 Guideline. The cutoff score was based both on the work of the 2005 task force and on the actual results from the 2011 survey. The clinician and faculty survey results demonstrated a natural break below this cutoff score for items that should be left off the final Guideline. Items that received between 70% and 82% scores on either survey were each discussed by the task force for inclusion consensus.

Survey Tools

The LaPorta Krum and Smith6 clinician survey tool can be found in their 2005 publication in the Journal of Physical Therapist Education, and the Boissonnault16 faculty survey tool can be found in the appendix of her dissertation research of 2001 published in this journal for the first time. The LaPorta Krum and Smith6 clinician survey consisted of demographic questions, followed by questions on the type and location of the respondent's practice. The Boissonnault1,16 faculty survey also began with demographic questions and ended with questions on barriers to inclusion of WH PT content in the respondents' entry-level curricula. The main sections of both surveys requested the respondent to rank WH curricular content areas as essential components of entry-level curricula, important components of entry-level curricula, or unimportant components of entry-level curricula. The 2014 Guideline academic and clinician survey tools are found in the appendices of the article on the 2011 task force survey process.15 A comparison of the survey tools utilized by the 2 task forces demonstrates a shift toward use of the "Guide to Physical Therapist Practice, 2nd edition,"12 as a means of formatting both the 2011-2012 faculty and clinician surveys14 and, subsequently, the 2014 Guideline.9 Both the 2012 surveys15 and the 2005 Guideline8 utilized foundational and clinical science content categories, which are consistent with Normative Model formatting.2 Pieces of the demographic section of the LaPorta Krum and Smith6 clinician survey tool and pieces of section 3 of the Boissonnault1,16 faculty survey on needs of the faculty informed the structure of the demographic and pedagogy sections of the 2012 task force survey. Thus, there are similarities between the survey tools utilized by both task forces, but they were certainly not identical.

2005 and 2014 Guideline Format determination

In 2003 and 2004, the SoWH task force consulted with APTA Education Department on choices of format for the Guideline. APTA felt strongly that the SoWH curricular guidelines should mimic the Normative Model (APTA, 2004) format to assist with consistency among APTA and its components. The SoWH task force complied and combined the Normative Model format with a "systems" model for the final product. See Figure 1 for a copy of the Table of Contents from the 2005 Guideline.

Figure 1. Table of Contents for the 2005 SoWH Guidelines for WH Content in Professional Physical Therapist Education. From American Physical Therapy Association Section on Women's Health.

Both Guideline versions incorporated categories for "foundational" and "clinical" sciences, but the 2014 Guideline used these categories only as an addition to the "patient-client management model" espoused in the Guide to Physical Therapist Practice, 2nd edition,12 whereas the 2005 Guideline8 closely followed the Normative Model2 format.

Figure 1. Table of Contents for the 2005 SoWH Guidelines for WH Content in Professional Physical Therapist Education. From American Physical Therapy Association Section on Women's Health.

The 2014 version is organized by system, with commonly treated clinical pathologies as subcontent areas.14 See Figure 2 for a copy of the Table of Contents from the 2014 Guideline.9

Figure 2. Table of Contents from the 2014

Both the 2005 and 2014 versions of the SoWH curricular guidelines8,9 delineated between content that was already likely incorporated into entry-level PT curricula and content that would be designated as uniquely WH content. In the 2005 version, the task force accomplished this by creating an entire section titled "Content Likely Covered in Existing Professional Physical Therapist Curricula."8 The 2014 version utilized bolded text to denote content exclusive to WH PT and unlikely to be covered in the general curricular content.9

Figure 2. Table of Contents from the 2014

Because the 2005 version8 used the Normative Model2 formatting, terminal behavioral objectives and instructional objectives were included for most curricular items. In the 2014 version,9 all content within the Guideline was noted as either, "F" for "familiarity," "P" for "proficient," or "M" for "mastery." These designations denote a level of competence the entry-level student is expected to achieve. They are modeled after designations used in the APTA's Physical Therapist Clinical Performance Instrument to assess physical therapy students during clinical internship experiences.17 These competencies, in essence, replaced the objectives found in the earlier 2005 version.8 The results of the 2012 survey also informed the task force as to the depth of instruction for the content areas. The competency designations, therefore, also served to identify that depth. For example, an item listed as "F" (familiarity) would require more of a general introduction, whereas one that is listed as "M" (mastery) would require in-depth coverage in the curriculum.

Finally, but not insignificantly, the 2005 Guideline was published on DVD and did not have any interactive features.8 The 2014 Guideline is presented online and posted on the SoWH Web site, allowing the user to link to related conditions or content under other body systems.9 Because the "pages" are configured as independent documents, updating them should be relatively easy and allow for a more current, living document.

OUTCOMES

An analysis of differences in content within the 2 documents is somewhat difficult since the formatting is so different; however, one can see in Table 2 a side-by-side listing of the general content areas for both documents. Table 3 lists the specific areas where there is no overlap. One can see from viewing these 2 tables that most of the content within the 2 documents are similar.

Table 2. Content Areas From the 2005 and 2014 SoWH Women's Health Curricular Guidelines

Table 3. Areas Where Content Does Not Overlap Between Versions 2005 and 2014

DISCUSSION

Much has changed in health care and PT education since the formation of the first Guideline on WH curricular content in 2005.8 Increasing emphasis is being placed on individualizing medicine based on genomics, and discoveries continue on differential disease presentation and treatment responses between men and women. Adequate preparation for the next generation of physical therapists should include recognition of health differences among groups. An update of the recommendations for WH content in entry-level PT education is timely.

Significant changes in PT education and specialization have occurred between 2005 and 2014. In 2002, when the first SoWH entry-level WH curricular task force was formed, the advancement of entry-level education from the master's to the clinical doctorate was beginning, with 59 of 212 (27.8%) accredited programs offering the DPT degree. The progression to a DPT degree increased the number of credits and clinical internship hours, with an emphasis on improved critical thinking.18 In 2005, 88 of 205 (42.9%) accredited programs awarded the DPT, and in 2013, all but one of the accredited US programs did so.19 Prior to the surveys used for the 2014 guideline, no data had been gathered on curricular changes in WH content over this time period.

Specialization within physical therapy has been supported by the APTA House of delegates since 1976. The SoWH specialization was approved in 2006, with the first examination administered in 2009. Currently, there are more than 200 certified WH specialists. A key document related to the specialization process is the Description of Specialty Practice,13 which defines advanced practice in the area of WH PT. Creation of this document may also have assisted in clarifying content expectations for entry-level curricula in WH PT. Residency programs, requiring a minimum of 9 months and 1500 hours of study, are designed to advance expertise in a defined clinical specialty area.20 The first Women's Health Clinical Residency was accredited in 2007 at Duke University. Currently, there are 8 credentialed WH residencies.21

The Guide to Physical Therapist Practice, now in its 3rd edition, online,22 uses the patient-client management model to describe current professional practice and is used as a reference in creating clinical residencies and other PT curricular endeavors. The recognition and utilization of this model across a range of professional PT educational arenas support its use in the current WH curricular guideline, which is a change in format from the 2005 WH curricular document.8,9 It is hoped that the new format, in conjunction with its online administration, will make the information more accessible to the many clinicians who serve as adjunct/associated faculty as well as to veteran full-time PT faculty who teach this content.

The 2005 Normative Model-based format changed to a systems model in the 2014 Guideline.8,9 The foundational and clinical science information within the various systems has been expanded and made specific to the included diagnoses and dysfunctions. One effect of this change is clearer integration of patient management within each pathologic condition. Use of designations for the level of competence recommended for the student was possible due to the expanded information provided by the surveys. These designations will be helpful in designing teaching and testing strategies. In line with the structure of the Guide to Physical Therapist Practice,12 the expectation that students are familiar with the use of appropriate outcome measures to assist with client management is explicitly stated.

Polycystic ovary disease was the only specific content item included in the 2005 version that was not represented in the 2014 version.8,9 Instead of being singled out, this condition was included under general endocrine and reproductive disorders' clinical sciences and screening. Many new specific areas, such as chronic fatigue syndrome, chronic pain, gallbladder dysfunction related to pregnancy, thromboembolic events in the obstetric client, and sex and low back pain, were added to the 2014 version.9 This is likely a function of the change in format for the survey and the broader constituency of both faculty and WH practitioners who were polled in gathering the data. Overall, the basic content has remained relatively stable throughout the intervening 9 years. The new Guideline correlates with the advancement of the entry-level degree to a doctorate level and contains more explicit foundational, clinical science, and outcome measurement content. The Description of Specialty Practice13 and residency training have provided enhancement to advanced practice but have not reduced the recommendations for entry-level instruction.

CONCLUSION

With this update, the SoWH "Guidelines for Women's Health Content in Professional Physical Therapist Education" has been reorganized and expanded to better reflect the clinical doctoral level of first professional physical therapist education, to more explicitly place content items within the context of an entire curriculum, and to improve the navigation within the document to facilitate use by faculty and clinicians alike.9 It is anticipated that this document will continue to contribute to the consistency of current and future preparation of physical therapists who will, in turn, provide targeted care to female clients.

ACKNOWLEDGMENTS

The authors wish to thank task force members Kathleen Alcon, PT, MS, QCS, CLT, Andrea Branas, MPT, MSE, CLT, and Ann Dunbar, PT, DPT, MS, WCS, for their contributions to the survey design and creation of the Revised Guidelines. The authors also acknowledge the assistance the task force received from the Section on Women's Health and specifically from the Directors of Education Carrie Schwoerer, PT, OCS, and Darla Cathcart, DPT, WCS.

REFERENCES