Ebook Teaching and learning in physical therapy – From classroom to clinic (2/E): Part 1

Part 1 book “Teaching and learning in physical therapy – From classroom to clinic” has contents: Filters - individual factors that influence us as teachers and learners; reflection and questions - developing self- awareness and critical thinking for continuous improvement in practice, communication and conflict negotiation - facilitating collaboration and empowering patients, family members, and peers,… and other contents.

Margaret M Plack, PT, DPT, EdD

Professor of Physical Therapy

School of Medicine and Health Sciences The George Washington University

Washington, DC

Maryanne Driscoll, PhD

Educational Psychologist and Associate Professor

School of Health Sciences Touro College New York, New York

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Names: Plack, Margaret M., author | Driscoll, Maryanne, author.

Title: Teaching and learning in physical therapy : from classroom to clinic /

Margaret M Plack, Maryanne Driscoll.

Description: Second edition | Thorofare, NJ : Slack Incorporated, [2017] |

Includes bibliographical references and index.

Identifiers: LCCN 2016055499 (print) | LCCN 2016056009 (ebook) | ISBN

9781630910686 (paperback) | ISBN 9781630910693 (epub) | ISBN 9781630910709

(Web)

Subjects: | MESH: Physical Therapy Modalities education | Learning | Teaching

Classification: LCC RM706 (print) | LCC RM706 (ebook) | NLM WB 18 | DDC

615.8/2071 dc23

LC record available at https://lccn.loc.gov/2016055499

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Instructors: Teaching and Learning in Physical Therapy: From Classroom to Clinic, Second Edition Instructor’s Manual is also available from SLACK Incorporated Don’t miss this important companion to Teaching and Learning in Physical Therapy: From Classroom to Clinic,

Second Edition To obtain the Instructor’s Manual, please visit http://www.efacultylounge.com

In memory of my best friend from the womb! I have never met a stronger, more kind- hearted woman, mother, daughter, aunt, sister- in- law, sister, and friend! To my twin sister, my soul sister, Kathy, who taught me more than she will ever know.

To my family, particularly my husband and soul mate, Tom, thank you This would not have happened without all of the love and support that you have shown me throughout the years

Margaret M Plack, PT, DPT, EdD

I dedicate this book to my family, immediate and extended, for their love and support Chuck, Meg, Mike, Chad, and Nicole, educators in their own right, demonstrate daily the importance of being creative and seeking the best way to reach and teach individuals in their charge

Maryanne Driscoll, PhD

Dedication v

Acknowl edgments ix

About the Authors xi

Contributing Authors xiii

Foreword by Michael Pagliarulo, PT, MA, EdD, BA, BS xv

Introduction xvii

Section I Who Are We as Teachers and Learners? 1

Chapter 1 Filters: Individual Factors That Influence Us as Teachers and Learners 3

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Chapter 2 Reflection and Questions: Developing Self- Awareness and Critical Thinking for Continuous Improvement in Practice 29

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Chapter 3 Communication and Conflict Negotiation: Facilitating Collaboration and Empowering Patients, Family Members, and Peers 57

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Chapter 4 The Brain: Translating Current Concepts in Brain Science to Inform the Practice of Teaching and Learning 91

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Section II Designing, Implementing, and Assessing Effective Instruction 127

Chapter 5 Systematic Effective Instruction 1: Keys to Designing Effective Pre sen ta tions 129

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Chapter 6 Systematic Effective Instruction 2: Going Beyond the Basics to Facilitate Higher- Order and Critical Thinking 189

Elizabeth Ruckert, PT, DPT, NCS, GCS and Margaret M Plack, PT, DPT, EdD Chapter 7 Systematic Effective Instruction 3: Adapting Instruction for Varied Audiences and Formats 219

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Chapter 8 Motor Learning: Optimizing Conditions for Teaching and Learning Movement 239

Joyce R Maring, PT, DPT, EdD and Susan Joy Leach, PT, PhD, NCS, CEEAA Chapter 9 Patient Education: Facilitating Be hav ior Change 269

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Section III From Classroom to Clinic and Beyond 315

Chapter 10 Communities of Practice: Learning and Professional Identity Development in the Clinical Setting 317

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD Chapter 11 The Learning Triad: Optimizing Supports and Minimizing Barriers to Learning in the Clinical Setting 337

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD

Chapter 12 Teaching and Learning in the Clinical Setting: Striving for Excellence in Clinical Practice 357

Aaron B Rindflesch, PT, PhD, NCS; Heidi J Dunfee, PT, DScPT; and Margaret M Plack, PT, DPT, EdD

Chapter 13 Harnessing Technology: Enhancing Learning in the Clinic and the Classroom 393

Laurie J Posey, EdD and Laurie B Lyons, MA Financial Disclosures 421

Instructors: Teaching and Learning in Physical Therapy: From Classroom to Clinic, Second Edition Instructor’s Manual is also available from SLACK Incorporated Don’t miss this important companion to Teaching and Learning in Physical Therapy: From Classroom to Clinic,

Second Edition To obtain the Instructor’s Manual, please visit http://www.efacultylounge.com

As with the first edition, countless individuals need to be acknowledged for their ongoing role in helping us learn

To the many students, faculty, and clinicians with whom we have interacted, thank you for your insights and for what you have taught us over the years The teaching- learning experience truly is a two- way street, and at times we won der

if we gain more than we give! It is a true honor and privilege to work with students, faculty, and clinicians who value teaching and learning and view it as integral to the quality of care they provide To our contributors, we thank you for your insights and for helping us continue to refine our own teaching philosophies

In this, our second edition, there are 2 additional individuals in par tic u lar we would like to acknowledge: Kristen Wolf and Linda Cotton Kristen is a doctor of physical therapy student at The George Washington University in Washington DC She has been a dedicated research assistant over the past year, gathering articles, creating annotated biblio graphies, referencing chapters, designing figures, and, most importantly, providing some exceptional insight into the pro cess Linda Cotton is a graphic designer who is a multimedia specialist and member of the health sciences instructional design team at The George Washington University Linda’s keen eye for and skill in designing figures has truly enhanced this edition The work of these women has been invaluable; they have been perceptive, patient, per sis-tent, and fun individuals with whom to work! To both of you: THANK YOU!

Margaret M Plack, PT, DPT, EdD, is a professor in the Doctor of Physical Therapy (DPT) Program at The George

Washington University School of Medicine and Health Sciences, Washington, DC She received her baccalaureate degree in Physical Therapy and her master’s degree in Physical Therapy with a specialization in developmental dis-abilities from New York University, NY Once joining the academic community, she went on to obtain her EdD in adult education from the Department of Organ ization and Leadership at Teachers College, Columbia University, NY, and followed with her post- professional DPT degree from Nova Southeastern University, Fort Lauderdale, FL With

Dr. Driscoll, she coauthored and taught a course titled “Teaching in Physical Therapy Practice” in several entry- level and post- professional DPT programs Currently, Dr. Plack pres ents annually at a faculty development workshop for new faculty with Dr. Driscoll She has been involved in ongoing research related to adult learning princi ples, educational outcomes, and reflective practice  Dr. Plack has more than 40 publications on teaching and learning and has provided more than 135 educational pre sen ta tions and workshops in physical therapy education, medical education, and higher education venues both nationally and internationally on topics to be discussed in this text She has received a number of

awards for her research related to the scholarship of teaching, including the Stanford Award from the Journal of Physical

Therapy Education (2005 and 2007), the Emerald Literati Network from the Journal of Workplace Learning (2010), and

the J Warren Perry Distinguished Author Award from the Journal of Allied Health (2013) She also received the Award

for Leadership in Education from the Education Section of the American Physical Therapy Association in 2011

Maryanne Driscoll, PhD, is an educational psychologist and associate professor in the DPT program at Touro

College, New York, NY Dr.  Driscoll received her PhD in educational psy chol ogy from Teachers College, Columbia University, NY She consults with schools and hospitals throughout the metropolitan New York region on effective instruction With Dr.  Plack, she coauthored and taught a course titled “Teaching in Physical Therapy Practice” for

2 post- professional DPT programs, and also teaches similar content in 2 professional DPT programs Dr. Driscoll has implemented the strategies to be used in this text in a number of teaching and learning venues, including the American Physical Therapy Association’s Combined Sections Meetings and Annual Conferences and vari ous other conferences

on medical education She has been involved in ongoing research related to adult learning princi ples and educational outcomes and has published several manuscripts on topics related to this text

Heidi J Dunfee, PT, DScPT (Chapter 12)

Operations Man ag er—Education

Mayo School of Continuous Professional Development

Rochester, MN

Susan Joy Leach, PT, PhD, NCS, CEEAA (Chapter 8)

Assistant Professor

Program in Physical Therapy

School of Medicine and Health Sciences

The George Washington University

Washington, DC

Laurie B Lyons, MA (Chapter 13)

Director of Instructional Technology for the Health Sciences

School of Medicine and Health Sciences

The George Washington University

Washington, DC

Joyce R Maring, PT, DPT, EdD (Chapter 8)

Associate Professor

Program Director and Chair

Program in Physical Therapy

Department of Physical Therapy and Health Care Sciences

School of Medicine and Health Sciences

The George Washington University

Washington, DC

Laurie J Posey, EdD (Chapter 13)

Assistant Professor and Instructional Designer

School of Nursing

The George Washington University

Washington, DC

Aaron B Rindflesch, PT, PhD, NCS (Chapter 12)

Assistant Professor of Physical Therapy

Director of Clinical Education and Assistant Program Director

Mayo School of Health Sciences

Rochester, MN

Elizabeth Ruckert, PT, DPT, NCS, GCS (Chapter 6)

Assistant Professor

Director of the Neurologic Residency with MedStar Hospital

Program in Physical Therapy

School of Medicine and Health Sciences

The George Washington University

Washington, DC

Have you ever experienced one of the following scenarios?

• You are a faculty member with 15 years of full-time experience in a physical therapist education program, and now must teach in a content area that is outside of your comfort zone You have spent a great deal of time ensuring the content you intend to present is contemporary and evidence-based, but have spent little time considering how to deliver the material beyond your PowerPoint slides

• You are a physical therapist with 10 years of clinical experience with some experience as a part-time lab assistant in the local physical therapist education program, and have just accepted a full-time, tenure-eligible academic position in that program You are not only expected to teach in that course where you were a part-time assistant, but be the primary instructor in 3 other courses You have questions about how to design and deliver content in those areas

• You are an experienced physical therapist clinician and just received your board certification as a Geriatric Certified Specialist You have been asked to provide a lecture and lab to the second year students in the local physical therapist assistant education program on the normal changes in the aging process of older adults You have been informed that the student body varies from a recent high school graduate, a mother in her 30s with 2 children, and a 42-year-old male who is changing his career path You are thinking about how to engage this diverse audience

• You recently began your first clinical position after graduating with your DPT and were asked to conduct an in-service

to a select group of hospital personnel (orthopedic surgeons, radiologists, physical therapists, and occupational pists) on the benefits and use of ultrasound for imaging in rehabilitation You are considering what to include and how

thera-to conduct this session

• You have just completed the first year of your physical therapist education program and are about to begin your first full-time clinical experience You have done very well in your courses and are wondering how you can continue to excel in your clinical experience

If you can identify with one or more of the above scenarios, reading this text is exactly where you should be! The ment of a new endeavor can quickly change to a less than expected outcome if all the factors of the new experience are not considered, and steps are not taken to make this an effective experience This text has been designed to address the knowledge, skills, and attitudes to provide effective instruction by a variety of individuals, to diverse learners, in a wide range of scenarios

excite-When the authors invited me to submit a Foreword on this second edition of their text, I was honored and delighted to accept As an experienced faculty member, I have personally benefited from the expertise and talents of this team having attended 2 sessions on designing and implementing Systematic Effective Instruction (short and long versions) that they have presented over several years at the Combined Sections Meeting of the American Physical Therapy Association The knowledge and skills that I learned from these presentations and this text certainly were instrumental in improving new and ongoing instructional activities I have had to conduct I would like to offer some highlights of this text that likewise could assist others who conduct any instructional activity

First, as the subtitle of the text implies, From Classroom to Clinic, teaching and learning occur throughout the

con-tinuum of education and practice in the profession of physical therapy Although this may seem exclusive to the academic arena, this applies to nearly every instance when a patient or client is seen by a physical therapists or physical therapist assistant These factors serve as fundamental tenets of this text: a) characteristics and outcomes of the learners are just

as important as the skills of the teachers, and b) practitioners constantly teach knowledge and skills to their learners, the patients/clients they treat

Similarly, the benefits of the text apply to the student as well as the teacher Students in physical therapy education must learn how to effectively instruct patients and clients to learn about their conditions and accurately perform activities just

as the physical therapists and physical therapist assistant, which they will become, must do In addition, a new chapter in this edition specifically addresses the transition from the classroom to full-time clinical experience and how the student can excel in this very different environment (see Chapter 12)

The format of the chapters emulates the principles and practices of active learning, a fundamental factor of effective teaching and learning Content is replete with questions and applications that enhance learning, including Stop and Reflect, Critical Thinking Clinical Scenarios, and Key Points to Remember The material becomes vivid and more mean-ingful rather than appear as a series of PowerPoint slides filled with information

The chapters on systematic effective instruction, which include a new one on facilitating higher-order and critical thinking in the classroom and clinic, serve as the core for excellence in instructional design and delivery Designing any instructional activity should “begin with the end in mind” (see Chapter 5) What are the expected outcomes for the learner throughout the instructional session These are absolutely essential to provide an effective teaching/learning experience

Indeed, the authors include these in the list of “non-negotiable” attributes of systematic effective instruction: needs ment, motivational hook, learning objectives, content booster and active learning strategies, and summary (see Chapter 7) I can attest to these as providing the basis for excellence in instruction having used these principles and practices to enhance a variety of educational arenas from a single classroom session to an entire course I have also had the pleasure of seeing this in action as a learner in instructional sessions provided by the authors on the topic The room was filled with individuals who were engaged and enthusiastic in the learning process, and eager to incorporate these practices in their work

assess-Active learning strategies, such as those above, require time, therefore, the authors contend that content for any tional activity should be limited to the “needs to know” category Data from sources noted by the authors indicate that lectures provide the lowest retention rate of material presented as compared to other strategies, such as demonstrations, discussions, practice, and teaching others (see Table 5-4) The delivery of instruction for any audience should limit time spent using the classical lecture approach and maximize use of strategies to engage the learner and enhance retention Although the lecture method of instructional delivery still predominates in physical therapy education, increased use of technology is fostering other more engaging strategies, such as blended learning and the “flipped classroom.” The final chapter of the text addresses this expanding area to move instruction beyond the classroom and clinic

instruc-Teaching and learning are pervasive in physical therapy education and practice This text is an excellent resource to understand learners and design and deliver effective instruction It should be in the personal library for any novice or experienced physical therapy educator or clinician The same applies to students in physical therapy education as they learn how to instruct their patients, clients, and others I commend the authors for their excellent work in this area and look forward to their continued contributions to our profession

Michael A Pagliarulo, PT, MA, EdD, BA, BS

Professor EmeritusDepartment of Physical Therapy

Ithaca CollegeIthaca, NY

“Learning and teaching are not inherently linked Much learning takes place without teaching, and indeed much teaching takes place without learning.”

—Etienne Wenger, Communities of Practices: Learning, Meaning, and Identity.

“Teaching, in my estimation, is a vastly over- rated function.”

—Carl Rogers, Freedom to Learn.

Teaching is a significant component of any clinical practice In physical therapy, we teach patients, families, colleagues, students, community members, and other professionals, and as we teach we learn Teaching and learning are both formal and informal, and happen on a daily basis (Figure I-1) Teaching and learning are dynamic skills that require both knowl-edge and practice to perfect

STOP AND REFLECTWhat comes to mind when you think about Teaching and Learning in Physical Therapy Practice ?

When we prepared the first edition of this text, a colleague asked us why we deci ded on the title Teaching and Learning

in Physical Therapy She asked, “ Isn’t it a book for educators; isn’t it really about teaching? So why ‘learning’ ”? We believed,

and continue to believe, that teaching and learning are inseparable Our goal in this second edition is to continue to help the reader make that link between teaching and learning In any teaching- learning situation, the goal is to ensure that learners learn Whether we are in the formal setting of the classroom or the more informal community of practice of the clinic, learning is critical to professional development and to quality patient care In physical therapy, learning is a lifelong pro cess, as is teaching In practice, what was learned becomes more impor tant than what or how something was taught

We would agree that teaching without learning is relatively unimportant and vastly overvalued!

To be effective educators and clinicians, it is impor tant to understand who we are as learners; to explore how we learn, how we think, and how we approach our prob lem solving We must identify our strengths and the areas where we strug gle

We need to recognize the assumptions that we bring to the teaching- learning situation and what influences our decision making Most of all, we want to be certain our teaching is linked to learning For a long time, lit er a ture suggested that good teachers were born and not made Not true! Teaching and learning are skills that, like other physical therapy skills, must be learned and perfected

In physical therapy, knowledge is being generated at such an enormous rate that much of what we learn today may very

well be obsolete within a few years Unless we are helping our learners to understand how to learn, to critically think, and

to prob lem solve, we are only truly preparing them for today and not for the future Even when working with patients, it is not enough to teach them a skill, we need to help them learn to prob lem solve challenges that they may face once they leave the clinical setting Our learners need to be prepared to leverage their resources and to use their communities of practice for purposes of lifelong learning As clinicians and educators, we have moved from being teachers with all of the answers

to being facilitators of learning, from being the “Sage on the Stage” to being the “Guide on the Side.” We no longer view our learners as blank slates or passive recipients of knowledge; rather, they bring their own knowledge and experiences and are active participants in the learning pro cess, in negotiating meaning, in developing identities, and in creating new knowledge Learning is not simply an accumulation of facts; it is a pro cess of adapting information and transforming it into something useful

Learning is about making connections and linking them to prior experiences so that we can modify what we know Learning is a dynamic and complex pro cess, and each new connection influences how we approach all future situations

As clinicians and educators, our role is to identify and acknowledge the experiences that our learners bring to the learning situation, which includes the clinical setting, and to help them make those connections and transform their knowledge and prob lem- solving abilities It is impor tant to recognize as educators that we, too, bring our own knowledge, experi-ences, and assumptions to the teaching- learning situation and that we, too, learn and change with each experience Even

as authors of this text, we brought our personal histories and research to our writing, and we continue to learn from the

pro cess For us, teaching and learning are inseparable, which is why we use the term teaching- learning experience

through-out this text Not only are they inseparable, but they are integral to physical therapy practice Teaching and learning do not just happen in the classroom, they continue to happen every day in both the classroom and the clinic while interacting with patients, families, peers, and community members

In this text, we explore what it takes to be an effective teacher and learner in physical therapy, and we provide you with multiple opportunities to apply, adapt, and practice the skills required to ensure excellence in teaching and learning

A IM AND A UDIENCE

This text is designed for anyone interested in enhancing his or her skills as a learner, clinician, and educator in cal therapy Whether you are a student, clinician, first- time presenter, or faculty member, or whether you are a teaching student, peer, or patient, you will find this book useful This text offers a systematic approach to designing, implementing, and evaluating effective teaching- learning experiences We offer practical strategies throughout that can be adapted to

physi-STOP AND REFLECT

Consider the opening quotes:

• Why would we title this book Teaching and Learning in Physical Therapy:

From Classroom to Clinic?

• Why, too, would we begin a book on teaching and learning with these quotes,

which suggest that teaching is relatively unimportant and vastly overvalued?

a variety of teaching and learning situations The concepts discussed are relevant for any health care provider; although, given our experiences in physical therapy, the examples and activities relate specifically to physical therapy practice.

ers We use the terms personal filters or lenses to describe some of the factors that may impact how we teach and how we

learn We refine our understanding of the factors that shape our values, beliefs, and worldviews including our past ences, culture, gender, generational differences, levels of expertise, and current social roles (ie, family, work, community) and further develop our pre sen ta tion of the characteristics of the adult learner These filters certainly influence us as indi-viduals and may impact any teaching- learning situation in which we are involved This chapter highlights the importance

experi-of recognizing how designing effective instruction requires us to know our learners and therefore gain an appreciation experi-of the dynamic interaction of all of these filters

In Chapter  2, “Reflection and Questions: Developing Self- Awareness and Critical Thinking for Continuous Improvement in Practice,” we explore the reflective pro cess (what it is, why it is impor tant and how to facilitate it) In this edition, we focus on reflection as the basis for critical thinking, self- assessment, and clinical decision making We describe reflection as the basis for lifelong learning and the development of therapeutic relationships and expertise in practice We emphasize the art of questioning, which goes way beyond the types of questions asked to include the environment and the ways in which they are asked Although asking questions might seem intuitive for some, the challenge lies in whether

we are asking the right questions at the right time and in the right way to facilitate reflection and critical thinking in ourselves and in others This chapter highlights how we can use questions and the reflective pro cess to better understand our learners and ourselves

Chapter  3, “Communication and Conflict Negotiation: Facilitating Collaboration and Empowering Patients, Family Members, and Peers,” is new to this edition In this chapter, we address the pivotal role that communication plays in all aspects of physical therapy practice and how communication underpins the quality of care we provide Building on concepts from Chapter 1, we discuss how communication can be misconstrued and provide strategies to minimize com-munication errors, whether working one- on- one with a patient or working in teams We describe some of the potential barriers to communication and some strategies for effective communication We discuss challenging patient scenarios, such as delivering bad news, apologizing for errors, or working with terminally ill patients, and offer vari ous frameworks

to help optimize communication in those scenarios We discuss communication in teams and its unique challenges, as well as evidence- based strategies to optimize team communication such as SBAR (situation, background, assessment, recommendation), call outs, and hand- offs We offer strategies for providing effective feedback and, fi nally, we discuss the inevitable: conflict Many shy away from conflict Here, we discuss vari ous sources of conflict, conflict styles, and strate-gies to effectively manage conflict through communication

In Chapter  4, “The Brain: Translating Current Concepts in Brain Science to Inform the Practice of Teaching and Learning,” we continue to refine our understanding of brain function and its implications for teaching and learning Since our first edition was published, neuroscience and cognitive psy chol ogy have greatly enhanced our understanding of the complexity of the human brain In this edition, we continue to draw from these fields and add to our pre sen ta tion on learning, memory formation, and memory retrieval In this edition, we provide numerous strategies to enhance learning and retention, which you may find helpful, particularly for the struggling student We have also added a section on how vari ous practice strategies and factors such as sleep, exercise, and individual perspectives affect learning We continue to acknowledge how brain research is truly in its infancy and how we are grateful to the neuroscientists and cognitive psy-chologists who work to unlock the complex function of our brain

In Section II of this text we examine the design, implementation, and assessment of effective instruction In Chapter

5, “Systematic Effective Instruction 1: Keys to Designing Effective Pre sen ta tions,” we pres ent a comprehensive, systematic approach to instruction that includes assessing the needs of your learners, gaining their attention, and effectively present-ing content to achieve the established objectives We discuss motivational hooks, content boosters, formative assessments, practice opportunities, summaries, and summative assessments In this edition, we enhance our pre sen ta tion on active

is a necessary part of the learning pro cess The ultimate goal in developing critical thinkers is to prepare clinicians for the challenges of clinical practice; however, perhaps of even greater importance is our goal of preparing patients to be able to think through the challenges and prob lems that they will face at home and in the community Here, we build on concepts presented in previous chapters (integrating reflection, questions, feedback, dialogue, and active and collaborative learning)

to refine our learners’ thinking in dif fer ent environments We discuss scaffolding techniques and provide strategies for creating learning activities that facilitate higher- order thinking both for individuals and for groups of learners, including mind maps, infographics, priming activities, and au then tic environments Recognizing that critical thinking is impor tant not only for our students but also for our patients, we apply these concepts to clinical practice and to classroom teach-ing throughout this chapter

In Chapter 7, “Systematic Effective Instruction 3: Adapting Instruction for Varied Audiences and Formats,” we continue

to build on the princi ples presented in the previous chapters The goal of this chapter is to help you to adapt a pre sen ta tion for dif fer ent formats and dif fer ent audiences Here, we discuss the non- negotiables of systematic effective instruction and demonstrate how these concepts can be adapted and applied to a variety of formats common to physical therapy, including continuing education programs, platform pre sen ta tions, panel discussions, health and wellness fairs, and the like We also prob lem solve challenging issues often encountered in preparing for and providing pre sen ta tions

In Chapter  8, “Motor Learning: Optimizing Conditions for Teaching and Learning Movement,” we transition from teaching through pre sen ta tions, to designing environments and conditions that encourage learning through active engage-ment and practice We describe how theories of motor control and motor learning inform practice We examine vari ous types of movement, task characteristics, and movement taxonomies; conditions of practice, types of practice, and practice schedules; and vari ous forms of feedback We discuss humans as information pro cessors and link to concepts such as attention, interference, response alternatives, and accuracy demands We integrate and apply these concepts to optimize learning given the individual, the task, and the environment In this edition, we also discuss the importance of dual tasks and divided attention in helping our patients learn to move and function in their environment Fi nally, the chapter ends with a discussion of teaching and learning differences across the lifespan

In Chapter 9, “Patient Education: Facilitating Be hav ior Change,” we focus on the importance of our patients as ers and our role in optimizing their learning Adding to the filters discussed in Chapter 1, we examine concepts of health beliefs, explanatory models, motivation, and readiness to learn as components of understanding our patients as learners

learn-We describe the importance of negotiating shared meaning and maintaining our patients at the center of the decision- making pro cess We emphasize our role in facilitating be hav ior change, examine the stages of change, and suggest strate-gies to help move our patient along the continuum of be hav ior change We discuss potential facilitators and barriers to

be hav ior change and identify strategies to facilitate adherence in our patients We apply the same non- negotiable concepts

of systematic effective instruction to educating our patients Given the prevalence of low literacy in the United States, we also offer you strategies to assess your patient’s literacy level and to design effective patient educational materials Fi nally,

we offer strategies to facilitate the long- term maintenance of be hav ior change in your patients In this edition, we also provide evidence- based resources to facilitate learning and optimize adherence and retention, and we discuss concepts such as psychologically informed practice, motivational interviewing, Teach- Back Method, and Ask Me 3 The goal of this chapter is to help us empower our patients to become partners in their own health

In Section III, we move from the classroom to the clinic and beyond We focus on how learning takes place in the clinical setting, we provide strategies to optimize the clinical learning experience, and we discuss the use of technol-ogy in enhancing learning for students, clinicians, and patients In Chapter 10, “Communities of Practice: Learning and Professional Identity Development in the Clinical Setting,” we explore the concepts of apprenticeship learning and empha-size the development of professional be hav iors While focused on the affective domain, the concepts we pres ent here can

be generalized to all aspects of learning in the clinical environment We use quotes from interviews with students and clinicians to illustrate and reinforce the concepts discussed Through the quotes, students and clinical instructors provide their perspectives on how they developed their own professional identity

In Chapter  11, “Optimizing Supports and Minimizing Barriers to Learning in the Clinical Setting,” we pres ent the concept of a learning triad involving the learner, the instructor, and the clinical community We examine the role of mentorship within the physical therapy community of practice and how mentorship in physical therapy moves beyond the one- to- one relationship of the student and clinical instructor to include the entire learning triad We examine the role

of the learning triad in both supporting and potentially hindering learning We conclude with a framework for learning that optimizes the supports and minimizes the barriers to learning in the clinical setting As in the previous chapter, we use direct quotes from students and clinicians to illustrate, reinforce, and provide opportunities to apply the concepts that are discussed.

Chapter 12, “Teaching and Learning in the Clinical Setting: Striving for Excellence in Clinical Practice,” is new to this edition of the text Given that clinical education is a significant component of entry- level physical therapist education pro-grams, with students in many programs spending at least one- third of their curriculum time in full- time clinical educa-tion, this is an impor tant addition Here, we examine strategies to optimize the clinical learning experience for students

In this chapter, we build on and apply the concepts of systematic effective instruction to clinical education The concepts of completing a needs assessment, planning learning objectives, capitalizing on the characteristics of adult learners, design-ing learning experiences, engaging, and assessing learners are applied to clinical education The authors share successful tools and strategies from multiple students and clinical instructors with whom they have interacted over the years This chapter also includes several appendices with worksheets and tools that students and clinical instructors can use to opti-mize the learning opportunities available in the clinical setting

Section III and the text conclude with Chapter  13, “Harnessing Technology: Enhancing Learning in the Clinic and the Classroom.” This chapter has been substantially revised from the original text, with a greater focus on the “why” and

“what for” of e- Learning Emphasis is placed on how technology can be used to support all of those involved in teaching and learning in physical therapy— students, clinicians, patient educators, teachers, and lifelong learners Framed around the princi ples of systematic effective instruction, we discuss strategies to motivate and engage a diverse group of learn-ers using multiple modalities and the Universal Design for Learning We provide strategies and tools to address a wide range of challenges and needs in physical therapy education We also discuss factors to consider in using technology such

as copyright issues, challenges of vari ous device interfaces, and the importance of maintaining separate professional and personal identities on social media Although technologies evolve, the foundational princi ples and concepts we pres ent will remain relevant and will help you to navigate the ever- changing landscape

F ORMAT

The format of this edition remains unchanged Each chapter begins with a set of Chapter Objectives that clearly eate what you, the reader, will be prepared to do after completing the chapter, and concludes with a Summary of the major concepts presented in the chapter Embedded throughout each chapter are opportunities for you to “Stop and Reflect” and actively engage with the content as you pro cess the information presented Concepts are supported by research and clinical examples You will have multiple opportunities to apply and adapt these concepts to real world situations through “Critical Thinking Clinical Scenarios.” Fi nally, concepts are reinforced through frequent “Key Points to Remember.”

delin-I NSTRUCTOR ' S M ANUAL

The Instructor’s Manual includes numerous examples of in-class activities and assignments designed to apply and extend concepts presented in each chapter Examples of active learning strategies, such as gallery review, small group brainstorming, group problem-solving tasks, and reflective writing assignments are provided throughout

I Who Are We as Teachers

and Learners?

3

-1 Filters

Individual Factors That Influence

Us as Teachers and Learners

Margaret M Plack, PT, DPT, EdD and Maryanne Driscoll, PhD

Plack MM, Driscoll M.

Teaching and Learning in Physical Therapy: From Classroom to Clinic, Second Edition (pp 3-28) © 2017 SLACK Incorporated.

C HAPTER O BJECTIVES

After reading this chapter, the reader will be prepared to:

● Consider the influence of individual characteristics

and experiences on us as teachers and learners in the

classroom and clinic

● Describe the vari ous factors or filters that influence

who we are as teachers and learners

● Analyze how our cultural and generational experiences

influence our role as teachers and learners

● Examine how adult learning princi ples and learning

styles influence us as teachers and learners

● Recognize the influence of the dynamic interactions

of these individual factors on our role as teachers and

learners

● Consider the implications of these dynamic

interac-tions on designing effective teaching and learning

experiences in the classroom and clinic

Dewey is often considered to be the father of experiential

learning He believed that all learning is grounded in our

experiences and that our experiences very much influence

how, why, and what we learn.1,2 Our past experiences

influ-ence how we view and react to the world around us, both as

learners and as teachers Before we can begin to think about

how to facilitate learning in others, we must first develop a better understanding of who we are and what we each bring

to the learning situation The more we learn about ourselves and what might be influencing us as individuals and learn-ers, the better equipped we are to learn about others in our learning environment, including our patients and other learners In this chapter, we explore some of the factors that make us unique as individuals, teachers, and learners

We use the terms personal filters or lenses to describe

some of the factors that may impact how we teach and how

we learn These lenses overlay one another and bring to the forefront the complexity of the teaching- learning situation

We explore the factors that influence how we experience a learning situation, which include but are in no way limited

to our perceptions, culture, gender, past experiences, erational experiences, level of expertise, and current social roles (ie, family, work, community) While each of these filters has an influence on us as learners and as teachers, we cannot always know to what extent they impact any given learning situation Therefore, we discuss how critical it is

gen-to recognize and re spect the potential influences of each of these filters The goal of this chapter is for us to recognize that designing effective instruction requires an appreciation

of the dynamic interaction of all of these filters Getting to know our learners is like peeling away an onion; the more layers we peel away, the closer we are to truly understanding our learners and what may be influencing them

4  Chapter 1

P ERCEPTION

When you first looked at the picture in Figure  1-1, did

you see more than one image? If not, look more closely and

you will eventually see 2 dif fer ent images Generally, people

will immediately see one of the images in the picture and,

at times, strug gle to see the other Depending on how you

view the picture of the young woman or the older woman,

you will respond to the questions posed very differently

Two people can look at the very same picture and see 2 very

dif fer ent things, which will influence how they respond

and react

Unlike a simple optical illusion, the cartoon presented in Figure 1-2 can elicit an emotional response that is guided

by our own perceptions These perceptions are influenced

by our own personal experiences and cultural beliefs As a result of our perceptions, we begin to make assumptions and judgments about the world around us For example, depending on your past experiences, you may make dif fer-ent assumptions about what is happening in the cartoon One individual may view this as a very positive experience, seeing the woman as being positive and kind to the young boy, while another may view this as a negative experience, seeing the woman as being overbearing and patronizing without stopping to consider the young boy’s feelings

In his book titled The 7 Habits of Highly Effective People,

Covey3 discusses the concept of internal maps These maps determine how we view the world and are based on own value system and beliefs He describes people as having the following 2 sets of internal maps: (1) our realities or how

STOP AND REFLECT

Look at Figure 1-1 What do you see?

● Would you describe the person as being young

or old?

● What type of job, if any, does the person have?

● Would you describe the person as being

attrac-tive or unattracattrac-tive?

Figure 1-1 Ambiguous woman.

STOP AND REFLECT

Look at Figure 1-2

● What is your reaction?

● What do you think is going on?

● What do you think each person is thinking and feeling?

Figure 1-2 Picture of a person in a wheelchair.

things are and (2) our values or how we think things should

be We often accept these maps without question because

they grew out of our own personal experiences in life This

is how we perceive the world As a result of our own

percep-tions of the world, we make assumppercep-tions and we assume the

way that we view the world is real ity These assumptions

also influence the judgments we make and how we act in

certain situations

As humans, we make assumptions about people all the

time As physical therapists, it is a significant part of what

we do As physical therapists, we are data gatherers! The

minute a patient walks into the room, we begin to collect

data on that person and, based on the data we collect, we

begin to make assumptions about that person For example,

if a patient walks into the room limping and grimacing, we

immediately begin to assume that he or she is in pain We

often use hypotheses to guide our clinical decision- making

pro cess We make hypotheses and then test those

eses, and, based on the outcome, we revise those

hypoth-eses Assumptions are like hypotheses, except people are

not always aware of their assumptions and therefore do

not always stop to test their assumptions Very often, our

assumptions are accurate, just like our hypotheses;

how-ever, there are times when they are not Making

assump-tions is not really a prob lem until we begin to act on our

assumptions without first checking the accuracy of them

There are always at least 2 people in any teaching- learning situation, each with their own perceptions And, whenever you are interacting with 1 or more people, the following 2 things are always happening si mul ta neously:

1 The intended be hav ior of the person saying or doing something (ie, the intention)

2 The impact of that be hav ior or comment on the person

on the receiving end (ie, the impact)The intent and the impact do not always match As noted earlier, our personal perceptions are often very strong and often color the way we view the entire world; they are very much a part of what we bring to the teaching- learning situ-ation Our personal perceptions influence both intention and impact For example, if the student in the previous clinical scenario perceived that the CI lacked expertise, it may have colored or influenced how that student reacted

to the examination and to any feedback that the instructor may have offered

Another example might be the experience of intending

to help someone and having the person on the receiving end react negatively to your actions In the illustration presented in Figure  1-2, the intent of the woman may very well have been to show kindness and offer assistance, while the young boy, wanting to be in de pen dent, may have experienced her kindness as unwanted and unnecessary Intention and impact are essential components of any com-munication and may influence how learners react to the teaching- learning situation Examples of how intention and impact may be easily mismatched are provided in Table 1-1

TABLE 1-1

EXAMPLES OF MISMATCHED INTENTION AND IMPACT

To be humorous Sarcasm, flip, glib, silly, making fun of

To be fair Rigid, unyielding, inflexible, unfair

To be flexible Wishy- washy, unfair, favoritism, weak, indecisive

To understand someone’s thinking (ie, asking why?) Insubordinate, rude, challenging, confrontational

CRITICAL THINKING CLINICAL SCENARIO

A second- year physical therapy student recently

completed her first 4- week, full- time clinical

rota-tion In meeting with the director of clinical

educa-tion, she describes her clinical instructor (CI), who

had many years of experience, as being awful When

asked why, the student responds that the CI had

poor evaluation skills, rarely completed a full

exami-nation, and often made decisions simply based on a

few quick tests

Reflective Questions

1 What do you think is going on in this scenario?

2 How might the student s limited experience in physical therapy be influencing her perceptions

of the CI s skills?

3 How might the physical therapist s expertise be influencing her approach to the examination?

4 How might the perceptions of each differ?

5 What other explanations might there be for what may have happened in this scenario?

6  Chapter 1

It is impor tant to recognize that a mismatch can easily

occur and that, in any given situation, there are the

follow-ing 2 experts:

1 The person behaving is the expert on the intention of

the action

2 The person on the receiving end is the expert on the

impact of the action

To minimize the likelihood of these mismatches

becom-ing problematic, clear communication between teacher

and learner is essential If there is any chance that a

mis-match between teacher/practitioner and learner/patient has

occurred, it is impor tant to clarify the intent and describe

the impact to maintain an effective teacher- learner

rela-tionship

Here is one final example of this concept: A therapist

instructs a patient to perform 7 home exercises each day

over a 1- week period The therapist’s intention may have

been to provide the patient with numerous options,

know-ing that he or she will likely complete only some of the

exercises The therapist may have assumed that giving the

patient a choice would result in enhanced adherence, with

the patient completing at least a few exercises each day

However, this may have resulted in the patient feeling

over-whelmed by the excessive number of exercises provided

Unless the therapist both checked his or her assumptions

and clarified his or her intentions with the patient, a

mis-match may have occurred This mismis-match may have had a

negative influence on adherence and on the development of

an effective therapeutic relationship

As noted, it is critical to recognize the potential for

mis-matched communication in clinical practice, particularly

when engaging with a number of learners si mul ta neously

Clarifying the intent and checking the impact of the

com-munication is essential to developing and maintaining an

effective teacher- learner relationship The teacher must

continually clarify intentions, and the learner must be

made to feel comfortable enough to provide feedback

when-ever communication has had a negative impact

C ULTURAL D IFFERENCES

The United States population is becoming more and more diverse People from dif fer ent cultures often bring with them dif fer ent values, beliefs, and experiences If we do not appre-ciate these differences, they may become barriers to effective teaching and quality health care Dif fer ent cultures have dif-fer ent beliefs about illness, intervention, prevention, and health promotion We each tend to think our own beliefs are right and make most sense; however, we must suspend our own beliefs as we strive to understand our patients’ beliefs to provide effective instruction or health care This underscores the need to consider culture as another personal filter in any teaching- learning situation

Bennett writes the following4:The Golden Rule is typically used as a kind of tem-plate for be hav ior If I am unsure of how to treat you, I simply imagine how I myself would like to

be treated, and then act in accordance The positive value of this form of the Rule is virtually axiom-atic in US American culture, and so its under lying assumption frequently goes unstated: other people want to be treated as I do And under this assump-tion lies another more pernicious belief: all people are basically the same, and thus they really should want the same treatment ( whether they admit it or not) as I would

STOP AND REFLECT

● Do you believe that by treating every one as you want to be treated you will be meeting their needs and providing effective care?

● Can you think of a time when this might not have been true?

STOP AND REFLECT

Have your intentions ever been misunderstood?

If so:

● What were your intentions?

● What was the impact on the other person?

● How might this influence your assumptions and

actions in the future?

KEY POINTS TO REMEMBER

● There are 2 experts in every communicative interaction, described as follows:

○ The provider is the expert on the intent of the communication

○ The receiver is the expert on the impact of the communication

● Clarifying the intent and checking the impact of the communication are essential to developing and maintaining an effective teacher- learner relationship

Simply stated, the Golden Rule in this form

does not work because people are actually dif fer ent

from one another Not only are they individually

dif fer ent, but they are systematically dif fer ent in

terms of national culture, ethnic group,

socioeco-nomic status, age, gender, sexual orientation,

po liti cal allegiance, educational background, and

profession, to name a few possibilities

While it may seem obvious that knowledge of dif

fer-ent cultures is critical in teaching and in health care, the

pro cess of understanding dif fer ent cultures cannot be

oversimplified The danger in teaching others about

dif-fer ent cultures is the possibility of reinforcing ste reo types

Ste reo types are generalizations that individuals make about

people of other cultures Learning about cultures may, at

times, foster a simplistic view, whereby learners attempt

to fit people into categories learned Generalizations can

be a helpful entry point to understand more about your

learner or your patient For example, understanding that

an Orthodox Jewish man may prefer a male therapist may

facilitate patient assignments in a busy clinic However, if

a female therapist in the clinic has a strength in managing

this patient’s par tic u lar dysfunction, it would be impor tant

to have a conversation with the patient to ascertain his

indi-vidual perspective before simply assigning a male therapist

Generalizations are like hypotheses and assumptions; they

must be checked It is critical to check your assumptions

with each patient

Culture is a complex concept with no standard ogy The U.S Department of Health and Human Ser vices

terminol-Office of Minority Health focuses on culturally and

linguis-tically appropriate ser vices, which are described as being

“respectful of and responsive to the health beliefs, practices and needs of diverse patients.”8

It is impor tant to remember that there is often as much variability within cultures as there is across cultures Purnell6 and Purnell and Paulanka,7 suggest that subcul-tures exist within a culture where 2 individuals may have had very dif fer ent personal experiences and therefore view the world differently Subcultures are a result of vari ous factors, including age, generation, nationality, race, color, gender, socioeconomic status, marital status, occupation, physical characteristics, religious affiliation, sexual orienta-tion, and reason for migration For example, a 62- year- old Asian male business owner who emigrated from China at the age of 4 years may have a very dif fer ent view of Western health care practices than a 62- year- old Asian man who is a new immigrant from China

The following are 2 components to understanding tures: (1) learning the basic facts and characteristics of dif-fer ent cultures and (2) learning how to effectively engage

cul-in cross- cultural encounters Presentcul-ing the specifics about dif fer ent cultures is beyond the scope of this book; how-ever, there are numerous resources available, including textbooks, research articles, and the like.5,6,9-14 In addition, websites, health care provider brochures, and videos can be easily accessed to help you learn more about dif fer ent cul-tures, especially those most represented in your practice 14

Learning about dif fer ent cultures is not enough, ever It is impor tant to go beyond simply learning facts about dif fer ent cultures to developing skills and abilities

how-STOP AND REFLECT

● What does the quote from Bennett mean to

you?

● In what ways, if any, does this quote change

your perspective on culture as a filter in the

teaching- learning situation?

KEY POINT TO REMEMBER

● It is impor tant to remember that there is often

as much variability within cultures as there is across cultures!

CRITICAL THINKING CLINICAL SCENARIO

You have been reviewing the lit er a ture on cross-

cultural differences The lit er a ture suggests that in

dealing with pain, individuals from Italian and Jewish

descent tend to complain about their pain, whereas

Americans are often more stoic and those from Irish

descent tend to ignore pain.5-7 You are a health care

provider of Irish descent You were born and raised

in New Eng land and your family has lived there for

7 generations You have the following 3 patients:

1 of Jewish descent, 1 of Irish descent, and 1 of

Italian descent

Reflective Questions

1 How might your cultural background influence the type of pain questions you ask each of these patients?

2 How might your cultural characteristics impact your reaction to their reports of pain?

3 Knowing about the influence of culture on one s pain experience, how might you alter the questions you ask to better assess each patient s pain?

8  Chapter 1

in working effectively with individuals from dif fer ent

cul-tures.15-17 Cultural competence is the ability to work across

cultures; it is “a set of congruent be hav iors, attitudes, and

policies that come together in a system, agency, or among

professionals that enables effective work in cross- cultural

situations.”14 This implies that you have the ability to

func-tion effectively as an individual and as an organ izafunc-tion

within the context of the cultural beliefs, be hav iors, and

needs presented by consumers and their communities

Purnell6 suggests that certain types of knowledge and

skills are essential to being able to interact effectively across

cultures Adapted to the teaching- learning situation, to be

an effective instructor, it is impor tant to develop the

follow-ing knowledge and skills:

● Awareness of your own cultural beliefs and their

potential impact on the teaching- learning situation

● Awareness of, and re spect for, the needs and beliefs of

others

● Adapting your teaching to meet the needs of the learner

As Purnell6 describes, it is insufficient to simply be

aware of and re spect differences; you must also actively seek

knowledge about dif fer ent cultures and subcultures with

the goal of providing care that is congruent with the values,

needs, and beliefs of people from dif fer ent cultures and

subcultures Campinha- Bacote and Camphina-Bacote12,18

indicate that it is equally impor tant to actively engage in cross- cultural encounters that enable you to practice cul-turally appropriate interactions

Several stages or pro cesses for developing cultural petence or the ability to interact across cultures effectively have been presented in the lit er a ture Table  1-2 pres ents

com-3 such models

Inherent in each of these pro cesses is a self- exploration; consciously taking time to reflect upon your own char-acteristics and how they impact your worldview and the teaching- learning situation The ability to interact effec-tively across cultures and subcultures is a pro cess rather than an end point; even if you reach the point of cultural proficiency as described by Leavitt10 and others, care must

be taken to continually check your assumptions with each new patient

TABLE 1-2

PROCESSES OF DEVELOPING CULTURAL COMPETENCE

LEAVITT (2002)

MEDEROS AND WOLDEGUIORGUIS (2003) PURNELL (2005)Cultural destructiveness: Treating people in a dehu-

Cultural incapacity: Bias is pres ent and cross- cultural

encounters are in effec tive

Gaining knowledge of other cultural groups

Conscious incompetence: Being aware of sonal limitations of cultural knowledgeCultural blindness: Treating all people the same with

per-no regard for cultural differences

Engaging in cross- cultural encounters

Conscious competence: Learning about and dating one’s cultural knowledge and providing culturally specific interventions

vali-Cultural precompetence: Committing to

appropri-ate cross- cultural interactions and acknowledging

inadequacies

Unconscious competence: Automatically ing competent cross- cultural care

provid-Cultural competence: Respecting cultural

differ-ences; continuous self- assessment and adaptation

are pres ent

Cultural proficiency: High regard for cultural

differ-ences and seeks research and advancement of

effec-tive approaches to cross- cultural practices

Adapted from Leavitt RL Developing cultural competence in a multicultural world -part I PT Magazine 2002;10(12):36-48; Mederos F, Woldeguiorguis I Beyond cultural competence: what child protection managers need to know and do Child Welfare 2003;82(2):125-142; Purnell L The Purnell model for cultural competence J Multicult Nurs

Health 2005;11(2):7-15.

CRITICAL THINKING CLINICAL SCENARIO

You are starting a new position as a physical pist at an urban hospital serving a large Ca rib bean population Patient education will be a significant aspect of your role

thera-(continued)

Purnell6 and Purnell and Paulanka7 also provide a

model that can be used both as a framework to help you

with your own self- exploration and as a means to help you

learn more about your learners’ or patients’ cultures and

subcultures In this model, they pres ent 12 domains to

explore when attempting to better understand dif fer ent

cul-tures Some aspects of these domains include the following:

1 Heritage, including country of origin

2 Communication, including primary language, verbal

and nonverbal cues, touch, and awareness of space and

time

3 Family roles and practices, such as childrearing, status

of the el derly, and views of alternative lifestyles

4 Workforce issues, including autonomy and

accultura-tion

5 Biocultural ecol ogy, such as physical and metabolic

characteristics

6 High- risk be hav iors, such as the use of drugs, alcohol,

and tobacco; sedentary lifestyle; and safety practices

7 Nutrition, including food rituals and taboos

8 Pregnancy and childbearing practices, including birth

control and perinatal taboos and practices

9 Death rituals, including end- of- life care and burial

practices

10 Spirituality, including religious practices

11 Health care practices, such as health beliefs and

explan-atory models

12 Health care prac ti tion ers, including the status, use, and

perceptions of dif fer ent types of health care providers

The authors suggest that the practitioner can use these

12 domains to formulate questions in obtaining a patient’s

history This can also be a helpful framework for teachers

attempting to better understand their learners However, factors that are potentially influencing health go far beyond Purnell’s 12 domains Once again, this simply becomes a starting point for you to begin to think about the influence

of culture and subculture on teaching, learning, and health care A discussion of the social determinants of health and health disparities is beyond the scope of this text; whole texts have been written on these topics As health care pro-viders, it is critical that we are aware of and sensitive to issues surrounding gender, sexual orientation, socioeco-nomic status, race, ethnicity, education, and so on that may

be influencing both the health care and learning ments

environ-In practice, the first step to becoming facile in cross- cultural encounters is to understand what you bring to the interaction Self- awareness of your values, beliefs, and prac-tices provides the under pinnings of your knowledge about cultures and subcultures As you begin to recognize the dif fer ent aspects of your own values and beliefs and what has influenced your development, you can begin to explore how others differ In doing so, it is impor tant to recognize the potential impact of unconscious biases Engaging with others of diverse backgrounds provides you with opportu-nities to further enhance your knowledge of and skills with cross- cultural interactions It is through this knowledge and these experiences that you can begin to provide cultur-ally congruent interventions, both in teaching and patient care

As you move toward becoming self- aware and better able

to interact effectively across cultures on an unconscious level, it is critical to maintain a reflective stance, continually checking your assumptions and validating your actions Even at the stage where you feel comfortable with multiple cross- cultural encounters, reflection will help prevent you from overgeneralizing and stereotyping

STOP AND REFLECT

Reflect on the 12 domains in relation to you and your culture, and consider the following:

● What are your beliefs and/or experiences tive to each of these domains?

rela-● How might your beliefs differ from the beliefs of some of your peers?

● How might your beliefs influence your role as a health care provider?

● What types of questions might you pose to learn more about your patients or your stu-dents cultural or subcultural influences?

CRITICAL THINKING CLINICAL SCENARIO

(CONTINUED)

Reflective Questions

Considering the 3 dif fer ent pro cesses for developing

cultural competence in Table 1-2

1 Where along each of the pro cesses do you

cur-rently see yourself?

2 What do you think might be impor tant to

know about the Ca rib bean culture as it relates

to healthcare and, more specifically, physical

therapy?

3 How might you better prepare for your position

by moving yourself through these pro cesses?

10  Chapter 1

G ENERATIONAL D IFFERENCES

As noted previously, our past experiences very much

influence how we view life and how we interact with others

As health care providers, you will encounter individuals

from across the life span Not only are these individuals

influenced by their own family and cultural experiences,

but they are also influenced by their social, po liti cal, and

historical experiences (ie, generational diversity) You will

encounter individuals from many generations in the

class-room and clinic, and it has been proposed that each

genera-tion has its own set of values, ideas, and beliefs Individuals

from the same generation share defining moments in

his-tory; they share common music, tele vi sion shows, heroes,

and passions Generational commonalities often cut across

issues of race, ethnicity, and economics, and may shape how

individuals from a given generation think and how they

view the world around them.20-26

For the first time in history, you may find individuals

from the following 4 and possibly 5 generations working

and learning in the clinic and classroom together24:

● The silent generation (born 1925 to 1942)

● The baby boomer generation (born 1943 to 1960)

● Generation X (born 1961 to 1981)

● The millennials (born 1982 to 2002)

● Generation ? (born 2000 to pres ent date)

Generation ? is the newest generation These individuals

were born after 2000 and, at this point, are still

develop-ing an identity As a result, they have not yet received an

official name! Individuals from each of these 5 cohorts may

very well share similar world views because of their shared

sociopo liti cal and historic experiences It is impor tant

to remember, however, that just as there may be as much diversity within cultures as there is across cultures, there may be as much difference within generations as there is across generations

As a health care provider and as an educator, it is tant to understand how generational values and beliefs might impact the teaching- learning situation It is impor-tant to recognize and acknowledge our own biases as well as the biases that may exist between individuals from dif fer ent generations Table  1-3 provides some characteristics com-monly seen in individuals from dif fer ent generations If you notice, there are times when a certain characteristic may be considered both a strength and a challenge, depending on the context For example, Generation Xers are generally noted for their desire for work- life balance, which can be viewed as a great personal strength However, this same characteristic may pres ent a challenge at work, particularly

impor-if these individuals are being supervised by someone from the baby boomer generation who places a high priority on work in his or her life

STOP AND REFLECT

How might the following events influence the ues, attitudes, beliefs, and be hav iors of the people experiencing them? How might they influence an individual s learning preferences?

val-● The Great Depression

● The Women s Movement

● The assassination of Martin Luther King

● The Vietnam War

● The rise in the divorce rate

● The sale of the first personal computer

● The advent of the Internet

● The attacks on 9/11Can you think of other events that have shaped your environment across your life span? How have these events influenced your perception of yourself and of those around you?

KEY POINTS TO REMEMBER

● The ability to interact effectively across cultures

requires both culture- and subculture- specific

knowledge, as well as the development of skills

in engaging in cross- cultural encounters

● The ability to interact effectively across cultures

begins with the development of self- awareness

through reflection on your own values, beliefs,

cultural, and subcultural experiences and

prac-tices

● The more familiar you are with the vari ous

influ-ences on dif fer ent cultures and subcultures, the

better prepared you are to engage, ask

ques-tions, and learn more

● Because there is as much variability within a

culture as there is across cultures, checking your

assumptions is critical

CRITICAL THINKING CLINICAL SCENARIO

You work at a pro bono physical therapy clinic ing to raise funds to support the efforts of the clinic

try-A local community group agrees to give you some time at its next meeting to give a pre sen ta tion and

to provide it with information about physical therapy

(continued)

Given that multiple generations coexist, misperceptions

can occur For example, in the work environment, members

of the silent generation typically value loyalty; they place

work as a high priority in their lives and often work for

the same com pany for many years Generation Xers and

millennials, on the other hand, typically value work- life

balance and embrace change These individuals expect to

change jobs multiple times in their lives and may not easily

change their social schedules to accommodate the needs of

the work environment, which could easily be misperceived

as a lack of commitment by members of the silent

gen-eration Similar misperceptions can occur in the classroom

Millennials, for instance, may prefer teamwork and group

per for mance over the highly individualized and

competi-tive nature of the boomers Boomers may perceive this as

a lack of ambition and in de pen dence, whereas millennials

may perceive the competitiveness as a lack of cooperation

In planning any teaching- learning activity, generational

differences should be considered Incorporating

learn-ing preferences based on generational characteristics may

serve to engage the learner However, using techniques

that require learners to move out of their comfort zones

(eg, requiring baby boomers to use new technologies) may

also enhance learning Teaching the same material using

a variety of strategies will likely optimize learning for all

participants For example, if you are teaching a

multigen-erational community group about health and fitness you

might consider the following:

● Incorporate lectures, handouts, and time for discussion

and questions to engage members of the baby boomer

generation

● Provide a bulleted overview of the major concepts with

access to videos and self- paced CD ROMs to engage

members of Generation X on their own time

● Use an interactive game with an experiential

compo-nent that requires the learners to incorporate all of the

components of health and wellness in their daily lives

to engage members of the millennial generation

When planning patient education in the clinical setting for an individual learner, caution should be exercised in incorporating unfamiliar strategies (eg, CD ROMs for indi-viduals from the silent generation) Patients are already challenged by their own medical issues, and requiring your patients to use unfamiliar strategies may, at times, add to their stress and result in a less- effective teaching-learning situation

CRITICAL THINKING CLINICAL SCENARIO

In reviewing your patient s chart, you note that her birth date is 03/09/1996 She recently underwent an anterior cruciate ligament reconstruction, and you will be seeing her for the first time tomorrow

Reflective QuestionsConsidering the typical characteristics of her gen-eration:

1 How much information might you expect your patient to have about her injury and course of treatment before she comes for therapy? What

is the likely source of that information?

2 How involved will your patient likely want to be

in the decision- making pro cess?

3 How involved will her parents likely be in her course of rehabilitation?

4 What mode(s) of instruction will you consider using?

5 How might you consider communicating with your patient between sessions?

KEY POINTS TO REMEMBER

In understanding yourself and others, it is impor tant

● Recognize that there is likely as much diversity within generational cohorts as there is across generational cohorts

CRITICAL THINKING CLINICAL SCENARIO

(CONTINUED)

and about the clinic The group is an

intergenera-tional group, and you expect repre sen ta tion from all

5 generations in the audience

Reflective Question

1 What strategies would you use both in the

pre-sen ta tion and in providing information to

opti-mize learning for all members of this group?

14  Chapter 1

A NDRAGOGY AND

THE C HARACTERISTICS OF

THE A DULT L EARNER

Our first filter had to do with how we view life, how we

perceive the world, and what might have influenced our

values and beliefs Our perceptions are, in part, a result of

our cultural and subcultural experiences, which was our

second filter The third filter that we discussed is when we

were born or generational differences; the socio- political-

historical influences on our world view Another filter or

lens that must be considered in any teaching- learning

situ-ation, particularly in health care, is the influence of the

characteristics of the adult learner.27 As was discussed in

the introduction to this text, many—if not most—of our

learners are adults, namely patients, caregivers, students,

colleagues, and other professionals Even pediatric physical

therapists must work closely with parents and caregivers in

any teaching- learning situation

Adults bring a great deal of background and experience

to any learning situation, which must be both considered

and respected In 1973, Knowles, often referred to as the

father of adult learning, coauthored a book titled The

Adult Learner: The Definitive Classic in Adult Education

published and updated several times since and has become

the primary source of information for teachers of adult

learners It is the work of Knowles28 along with that of

Lindeman29 that spawned the field of adult education It

was here that the notion that perhaps children and adults

learn differently and that the goal of educating adults may

differ from that of educating children was developed

The term pedagogy generally refers to the study of

teach-ing; however, in educational theory, the term more

spe-cifically refers to the study of how children learn Pedagogy

traditionally had, at its core, the transmittal of knowledge

as the goal of education Central to this concept is the

teacher as expert The teacher has full responsibility for the learning situation, including making determinations about what is to be learned, how it will be learned, when it will be learned, and even if it has been learned The learner in this situation assumes a rather dependent role The content of the learning is primarily subject- directed and determined

by external factors (eg, grade school curriculum) There is generally a standardized curriculum and students pro gress

as a unit The goal of learning is often subject mastery for its own sake, and progression is dependent on success defined

by grades on examinations Children bring limited ence to the situation In transmitting knowledge, instruc-tors, using a pedagogical approach, tend to rely on lectures, drills, readings, quizzes, and rote memorization

“art and science of helping adults learn.” In the early part of the 20th Century, educators began to recognize that educa-tion was more than simply preparing for a life career or profession Learning does not end when your formal schooling finishes Rather, the goal of education, particu-larly for adults, is a lifelong pro cess of learning and prob lem solving based on life situations, rather than a pro cess driven

by the need to learn a par tic u lar subject Educators began experimenting with assumptions about the characteristics

of the adult learner and how he or she learns These assumptions formed the basis of the andragogical approach

○ As an adult, your readiness to learn is based on the extent to which you perceive your learning will help you perform tasks or deal with prob-lems you are confronting in your life Because adults learn best when their learning has immedi-ate application, instructional activities should be goal- directed and goals should be based on the learner’s current life situation and prob lems Goals should be functional and purposeful for the learn-

er and should meet a specific need determined by

STOP AND REFLECT

What is the difference between how and why

children learn vs how and why adults learn? Consider

the following:

● Their motivation to learn

● Their readiness to learn

● What they bring to the learning situation

● What is dif fer ent?

● What is the same?

STOP AND REFLECT

When you are most motivated to learn, what vates you?

moti-the learner/patient (ie, learner- centered/patient-

○ Adults are most responsive to internal motivations

(eg, self- esteem, quality of life), although external

motivation can also be a factor; adults want to be

successful; they are most motivated to learn

some-thing that they believe will help them perform

tasks or manage current life situations They want

to be active participants— not passive recipients—

so they want some owner ship over their learning

○ As an educator, you want to actively engage— not

simply transmit knowledge to— your adult

learn-ers To maximize internal motivation, you want to

be sure that learning centers around activities that

are valued by the learner

○ Adult learners should be given some ownership

of their learning by involving them in both the

design and prob lem solving

● Assumption #3: Adults have an in de pen dent self-

concept

○ Adult learners identify themselves as being in

charge of and responsible for their own lives;

without some control, adults feel out of control!

This is particularly impor tant in health care, when

oftentimes our patients are adult learners who feel

quite vulnerable as a result of their illness or loss

of function

○ As educators, our role is to give our learners some

responsibility and control The key is to figure out

what will work for each individual learner; what

will help him or her be as in de pen dent as pos

si-ble As educators, it is also impor tant to recognize

that adults often feel somewhat vulnerable in new

learning situations, so it is necessary to create a

safe environment where they feel comfortable

ask-ing questions and makask-ing mistakes

○ To help our adult learners maintain their self-

concept and sense of control, we want to give them

a voice throughout the learning pro cess!

● Assumption #4: Adults bring prior experiences to the

learning environment

○ Adults come to the learning situation with a great

deal of experience, which must be both considered

and respected The more the teacher can link new

learning to something the learner is familiar with,

the more likely the learner will both learn and

retain that information

○ As educators, we want to build on our learner’s prior experience In designing an exercise pro-gram, you can ask about the types of movement activities that your patient engages in and how

he or she learned that activity You can then draw analogies between what is currently being learned and what was previously learned For example, you could ask your patient to think about what strategies he or she used previously in perfecting his or her golf game, and then have him or her consider using similar strategies in refining his or her movement patterns after surgery

○ As educators, it is also impor tant to remember not all past experiences are positive We must recog-nize the potential influence of negative experiences

on the learning situation and how they may ally create barriers to learning For example, you may have a patient you are trying to motivate to engage in a more active lifestyle, but he or she has never participated in sports or exercise because of negative experience he or she had in gym class as a young child Similarly, in the classroom, you may have a learner who was criticized for asking ques-tions in a previous class, so he or she never raises his or her hand in your class Because of the poten-tial influence of negative experiences, educators must create a safe learning environment; one in which learners feel comfortable making mistakes, asking questions, and bringing their own experi-ences to bear without fear of embarrassment

actu-○ In working with adult learners, it is impor tant to

recognize, re spect, and build upon the experience

that they bring to the learning situation!

● Assumption #5: Adults are most ready to learn when topics are relevant (ie, related to their role [ family, social, work])

○ Adult learners want to know that what they are learning is relevant to them; they want to know how learning will occur, what learning is expected, why they are learning what they are learning, and who is teaching them (ie, teacher expertise)

○ As educators, the most critical place to start when designing any effective learning activity for adults

to ensure that the learning situation is relevant is

to understand your patients’ or learners’ needs Later in the text we will discuss the use of needs assessments, which will help you to identify the needs of your learners so that you can make your learning activities as relevant as pos si ble However, adults may not recognize what it is they need to know; they may not recognize that a prob lem exists, that they do not know something, or that they even need to learn something For example, a patient with diabetes may be focusing on following

16  Chapter 1

the diet and exercise program, but may not

recog-nize the importance of daily skin checks to prevent

potential skin breakdown It then becomes our

role as educators to help our learners to recognize

the relevance of what you are trying to teach

○ To optimize learning for adults, the topic must be

relevant to the learner.

Because adults have a need to know, an impor tant

start-ing point in designstart-ing effective adult learnstart-ing activities

in the classroom or clinic is to provide the learner with

answers to the following questions:

● What learning is expected?

● How will the learning occur?

● Why is he or she learning what he or she is learning?

● Who is teaching (ie, the expertise of the instructor)?

For example, in working with an adult learner in the

clinic, it is not sufficient to simply describe an exercise

program that you want him or her to follow You want to be

sure to make your expectations explicit, describe how you expect the learner to accomplish the task, and provide solid rationale for why you are asking the learner to do certain activities In doing so, it is also impor tant that the therapist displays both professionalism and confidence, and demon-strates expertise not only in the physical therapy interven-tions, but also in the pro cess of teaching

In summary, adults come to the learning situation with their own interests, immediate goals, values, experiences, and motivations, and are accustomed to being responsible for their own lives This should be incorporated into the decision- making pro cess in developing educational activi-ties To enhance their feeling of owner ship and control in the situation, it is impor tant to give adult learners’ choice Decisions that are made collaboratively are more likely to be followed For example, in working with a group of patients,

or even an individual patient, it is helpful to provide options from which they can choose so that each individual can determine the HEP that best meets his or her own immedi-ate personal goals and interests Linking exercises to activi-ties valued by the individual by collaboratively developing goals moves the learner from a passive recipient to an active participant in the rehabilitation pro cess, further reinforc-ing his or her in de pen dent self- concept It also fosters owner ship and internal motivation to achieve Inherent

in working collaboratively in the teaching- learning tion is the development of functional goals that meet the most- urgent personal needs of the learner Meeting these needs makes it immediately relevant and practical to the adult learner, which will enhance his or her motivation and likelihood of participation

situa-In working with the adult learner, we have developed the following acronym to help you remember what we need to

do to optimize the learning environment by maximizing learner engagement and motivation: COVER, which stands for Choice, Own ership, Voice, Experience, and Relevance!

CRITICAL THINKING CLINICAL SCENARIO

You are a third- year DPT student in the clinic and

you are asked to instruct a patient on a home

exer-cise program (HEP) Your patient is a 42- year- old man

who has returned to therapy for a recurrent shoulder

prob lem He is anxious to return to playing tennis

He had a previous HEP, but, given that his injury is

a recurrent prob lem, he does not believe that the

program was effective This is the first time that you

have ever in de pen dently instructed a patient on a

HEP To save time, you decide to develop the HEP

before the patient comes in for his session When

your patient arrives, you introduce yourself and

immediately begin to tell him what you want him

to do The patient reacts negatively and seems to

question every thing you are suggesting For each

exercise you give him, he suggests doing something

dif fer ent You describe what happened to your

clini-cal instructor (CI) She suggests that you review the

princi ples of adult learning

Reflective Questions

1 What characteristics of an adult learner does

this patient display?

2 Why might the patient be questioning the

exer-cises that you are suggesting?

3 Considering the assumptions under lying the

andragogical approach to learning, how might

this student have approached this teaching-

learning situation differently?

KEY POINT TO REMEMBER

In working with the adult learner, to optimize the learning situation consider the acronym COVER:Choice: Provide options; prioritize the learning based on the immediate needs of your learner.Ownership: Recognize that your learner brings

an in de pen dent self- concept to the learning situation and give your learner some owner-ship of and responsibility for the learning; engage your learner in the decision- making pro cess

Voice: Res pect and give voice to the needs, interests, goals, and values of your learner

(continued)

Although there are some distinctions between how

adults learn and how children learn, it is critical to

remem-ber that this is a continuum, not a dichotomy In fact, both

children and adults may learn best when their needs,

inter-ests, and experiences are taken into consideration While

adults have a strong desire to be self- directed, they too can

be quite dependent in a new learning situation Andragogy

and pedagogy are essentially 2 sets of assumptions, and

it is the role of the educator to determine whether to use

these assumptions, either in whole or in part, based on the

characteristics of the learner and the context of the learning

situation

The educator must make decisions about which

teach-ing strategies to use based on who the learners are, what

they need to know, and what past knowledge and

experi-ences they bring to the situation At times, a pedagogical

approach to teaching and learning may be very effective

with adults Certainly, in working with students who need

to acquire certain knowledge (eg, origins and insertions of

muscles), a pedagogical approach such as rote

memoriza-tion with its concomitant use of examinamemoriza-tions for

assess-ment purposes may be most effective Regardless, helping

your learner see the relevance of this information to his

or her future practice may enhance his or her readiness to

learn A pedagogical approach may also, at times, be an

effective strategy in working with patients For example,

if you are working with a patient who recently had a total

hip replacement, the use of rote memorization and

quiz-zing may be an effective strategy for helping him or her to

learn his or her total hip replacement precautions Si

mul-ta neously engaging patients in the collaborative pro cess of

designing an HEP may be an effective strategy to enhance

overall patient adherence In either case, however, helping

your learner to understand what is to be learned, why it is

impor tant, and how it is relevant, as well as actively

engag-ing your learner in the pro cess, will enhance your learner’s

motivation and potential success

Similarly, in working with students in the clinical or

classroom setting, the concepts within COVER are equally

impor tant Given the demands of professional curricula,

you may not be able to give your students a choice about

what they will learn; however, giving them choices in

assignments or activities, listening to their own personal

goals and interests, linking new knowledge to their prior

experiences, helping them to see the relevance of the rial being taught, and collaboratively developing goals may enhance motivation and self- directed learning

mate-In part, the decision to use one approach over the other depends on the learner’s experience and the context of the learning situation For example, if the teacher is presenting totally new content with which the learner has no prior experience, the teacher should expect the learner to be more dependent in his or her learning, and a pedagogical approach may be warranted (eg, learning to perform special tests in orthopedics) If the learner needs to accumulate a certain amount of baseline knowledge to perform a task, again, a pedagogical approach may be appropriate (eg, teaching a patient partial weight- bearing gait) However,

if the learner has had a fair amount of experience with the content and needs to master it and apply it to solve par tic-

u lar prob lems, giving the learner increasing amounts of responsibility and control over his or her own learning may

be most effective (eg, working collaboratively with a patient

to advance a learned exercise program)

A number of distinctions have been made between how children learn vs how adults learn One aspect of the learn-ing environment that is the same across the continuum is that all learners like to have FUN! Children and adults alike want to feel that the learning environment is enjoyable and safe They need to feel like they can make errors and ask questions, knowing that they will be respected both for what they know and what they do not know

KEY POINTS TO REMEMBER

● Pedagogy and andragogy are not dichotomous; rather, they are a set of assumptions that run along a continuum

● Assumptions are to be adopted in whole or in part, depending on the needs of the learner; flexibility is critical

● The challenge for any instructor is to recognize where along the continuum your learner is and to plan your teaching strategies accordingly

● Regardless of the assumptions used or where along the continuum your learners lie, all teach-ing situations should be learner- centered

● Choice is essential because in any group of learners you will find individuals along the con-tinuum from:

○ Those who are dependent to in de pen dent

○ Those who need a great deal of direction to little direction

(continued)

Experience: Recognize, re spect, and build upon

the prior experience of your learner and engage

him or her throughout the learning pro cess

Relevance: Make sure that the learning is

rel-evant to the learner; make the educational goals

learner- centered

KEY POINT TO REMEMBER (CONTINUED)