968644

research-article2020
POI0010.1177/0309364620968644Prosthetics and Orthotics InternationalSpaulding et al.

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Special Issue: ISPO 50th Anniversary

Prosthetics and Orthotics International

Education in prosthetic and orthotic 2020, Vol. 44(6) 416­–426

© The International Society for
Prosthetics and Orthotics 2020
training: Looking back 50 years and Article reuse guidelines:
sagepub.com/journals-permissions
moving forward DOI: 10.1177/0309364620968644
https://doi.org/10.1177/0309364620968644
journals.sagepub.com/home/poi

Susan Ewers Spaulding1 , Sisary Kheng2, Susan Kapp1

and Carson Harte3

Abstract
There is a long history of prosthetic and orthotic services helping to mitigate the impact of physical impairment by restoring
function, and enabling and equipping the user. The training of health professionals who design, fit, and maintain prosthetic
and orthotic devices has evolved over the centuries, reflecting an increase in knowledge, technology, understanding,
and social attitudes in each era. Improvements in pedagogical thinking and biomechanical understanding, as well as the
advent of new integrated technologies, have driven the profession over the past 50 years to modernize, evolve training
and service delivery models in line with new attitudes toward clients, and search for new ways to improve users’ quality
of life. In this narrative review, the authors examined the evolution of prosthetic and orthotic education, the impact
of changing educational techniques and technologies, and the impact of the International Society for Prosthetics and
Orthotics in that process. Through conversations with experts and review of peer-reviewed literature, accreditation
documents, and the International Society for Prosthetics and Orthotics records and databases, the authors identified
three areas of change in prosthetics and orthotics education over the past 50 years: (1) prosthetic/orthotic curriculum
content, (2) pedagogy and course delivery, and (3) internships/residencies. This narrative review is a snapshot of a
growing profession and we can only speculate where the next 50 years will lead us as we strive to serve patients, ever
placing their needs and aspirations at the center of this professional service.

Keywords
Prosthetic, orthotic, education, training

Date received: 5 August 2020; accepted: 18 September 2020

History of prosthetic and orthotic
education
Since the initial interregional seminar on standards for the train-
ing of prosthetists in 1968, efforts continue to improve the
implementation and outcomes of prosthetic and orthotic (P&O)
education to serve patient-specific needs. P&O leadership has
engaged stakeholders in workshops throughout the world to
continually reassess the status of P&O education and further
develop the profession (Table 1). This article describes changes
in P&O education worldwide, focusing primarily on efforts by
the International Society for Prosthetics and Orthotics (ISPO)
over the past 50 years and considerations as we progress for-
ward in the next 50 years. Specifically, this article explores
changes within these three major areas: (1) program and aca-
demic requirements from ISPO, (2) pedagogy and course
delivery, and (3) requirements of internships/residencies.
During the 1968 seminar in Holte Denmark, international
researchers, clinicians and educators developed an outline to
formalize P&O professional education.1 The authors of the
Holte report recognized that the professional contributions of
prosthetists–orthotists were not generally understood, thus
they made a concerted effort to define the roles of P&O pro-
fessionals and to demarcate the distinct professional responsi-
bilities between the prosthetist–orthotist and the P&O
technician. They also emphasized the importance of research,
1
 epartment of Rehabilitation Medicine, University of Washington,
D
Seattle, WA, USA
2
Department of Prosthetics and Orthotics, National Institutes of Social
Affairs, Exceed Worldwide, Lisburn, UK
3
Exceed Support Office, Hillsborough, UK
Corresponding author:
Susan Ewers Spaulding, Department of Rehabilitation Medicine,
University of Washington, Box 356490, Seattle, WA 98195, USA.
Email: ewers2@uw.edu
Associate Editor: Sarah Anderson
Spaulding et al. 417

Table 1.  Timeline of P&O education workshops.

Date Location Seminar/workshop

1968 Holte, Denmark Interregional seminar on standards for the training of prosthetists
1970 Ponte Vedra Beach, FL, Workshop aimed at developing an overall, coordinated, prosthetic and orthotic educational
USA program in the United States
1974 Les Diableret, Switzerland Needs in Prosthetics and Orthotics Worldwide
1976 Ponte Vedra Beach, FL, A conference on Educational, Certification, and Manpower Requirements in the Orthotics-
USA Prosthetics Profession in the U.S.
1984 Moshi, Tanzania Prosthetics and Orthotics in the Developing World with respect to Training and Education
and Clinical Services
1985 Jonkoping, Sweden Training and Education in Prosthetics and Orthotics for Developing Countries
1987 Glasgow, Scotland Upgrading in Prosthetics and Orthotics (for Technicians from Developing Countries Trained
on Short Courses)
1988 Moshi, Tanzania Regional workshop on prosthetics and orthotics for African countries
1988 Conakry, Guinea Rapport due Seminaire sur les Aides Techniques pour Personnes Handicapees
1990 Alexandria, Egypt Consultation on Training or Personnel in Developing Countries for Prosthetics and Orthotics
1990 Phoenix, AZ, USA Conference on Prosthetics and Orthotics Education
1992 Lome, Togo Rapport due Seminaire de Perfectionnement sur les Aides Techniques pour les Personnes
Handicapees
1993 Amman, Jordan Report of the workshop for key medical and technical personnel in prosthetics and orthotics
for Western Asia and Easy Mediterranean Region
1995 Phnom Penh, Cambodia ISPO consensus conference on appropriate orthopaedic technology for developing countries
2000 Moshi, Tanzania ISPO consensus conference on appropriate orthopaedic technology for developing countries
2004 Seattle, WA, USA Advanced Education & Research Training Initiative [AERTI]: Prosthetic-Orthotic Strategic Plan
for a Ten-Fold Increase in the Academic and Research Capacity of the Profession
2004 Glasgow, Scotland Revision of Prosthetics and Orthotics Training Package
2005 New Orleans, LA, USA O&P Education Summit Meeting
2007 Valence, France Strategies for Prosthetic Orthotic Education and Training in Europe
2009 Chicago, IL, USA Advanced Education & Research Training Initiative AERTI
2015 Bangkok, Thailand WHO Prosthetics and Orthotics Service Standards Development Group
2018 Göttingen, Germany Revision of Standards of Education of Prosthetic and Orthotic Occupations

P&O: prosthetic and orthotic; ISPO: International Society for Prosthetics and Orthotics; AERTI: Advanced Education & Research Training Initiative;
WHO: World Health Organization.
This table lists workshops that have been published in the literature. Workshops with unpublished proceedings may be missing from this table.

and interprofessional collaborations with other healthcare pro-
fessionals and engineers:
For the prosthetist, it is no longer sufficient just to know his
trade since by virtue of his greater knowledge of medical
aspects, he must cooperate with doctors and therapists. He must
also be able to understand the engineer first of all to utilize the
special knowledge of the engineer, secondly to be able to
contribute to prosthetic/orthotic research. (Lynquist E.)1
The prosthetist/orthotist who is educated in a college will not
have the tasks of carrying out professional skills in a
workshop, which will be done by a technician. But he will
concentrate on the more complex duties of fitting and
alignment on patients. (George S.)1
In 1990, in Alexandria, Egypt, a World Health Organization
(WHO) Consultation group advanced the Guidelines for train-
ing personnel in developing countries to provide P&O ser-
vices. The Alexandria report defines the scope of practice and
the education Guidelines for four levels of P&O professionals:
the engineer (i.e. researcher), the prosthetist–orthotist, the
assistant, and the technician. Role overlap was introduced
between the prosthetist-orthotist and the PO assistant in order
to address clinical needs in absence of trained prosthetists–
orthotists in low and middle income countries (LMIC).2,3
Founded in 1970 as a multidisciplinary society, ISPO
developed the most recent 2018 Education Standards4 in par-
allel with the World Health Organization (WHO) Standards
for P&O service delivery. The standards, which parallel the
format of standards for other health professionals, define the
core competencies for P&O professionals across the globe:
prosthetist–orthotist (formerly Category I), associate P&O
(formerly Category II) and P&O technician (formerly
Category III). ISPO recognizes P&O programs internation-
ally, some of which are in countries where national accredita-
tion agencies do not exist. With the publication of the 2018
Standards,4 ISPO acts as a program auditor and offers
“accreditation” both in high income countries (HICs) and
LMICs. Prior to 2018, education programs were only
“recognized.”
The scope of practice defined by the three levels of
P&O professionals has remained consistent over time
Table 2.  Changes in descriptions of P&O professionals over time.
1968 Holte report
Prosthetist– As a full member of the clinic team, advises the
orthotist team on the design of the prosthetic/orthotic
device, including the socket, the method of
suspension, and the selection of the proper
components; advises the team and participates
directly in the evaluation of the final design;
include fit, function, and cosmesis; records and
reports any pertinent information regarding
patients and patients’ families; assists and
advises in the pre-surgical planning and in the
post-surgical management requiring prosthetic/
orthotic services.
Associate
prosthetist/
orthotist
Prothetic/orthotic In direct assistance to the prosthetist/orthotist:
technician fabricates and assembles prosthetic/orthotic
devices, including component parts, sockets, and
suspension systems as designed by the prosthetist/
orthotist; performs bench alignment of the device
to the specifications of the prosthetist/orthotist;
as directed, assists the prosthetist/orthotist in
the fitting and alignment activities with patients;
performs finishing operations on prostheses and
orthoses, including the use of alignment transfer
tools and equipment; reports any pertinent
information regarding the device or the patient
to the prosthetist/orthotist; repairs prostheses
or orthoses as assigned and directed by the
prosthetist/orthotist; and is responsible for the
care and economy of use of laboratory materials,
equipment, and tools.
P&O: prosthetic and orthotic; P/O: prosthetist/orthotist; WHO: World Health Organization; ISPO: International Society for Prosthetics and Orthotics.
1990 WHO (Alexandria) guidelines
The prosthetist/orthotist is responsible for direct patient services
and management of the orthopaedic workshop. As indicated in the
distribution of tasks, the major role of the prosthetist/orthotist is
in patient care. The P/O has the ability to advise on the selection of
an appropriate appliance to meet the needs of an individual patient,
to prepare the appliance with the assistance of skilled workmen,
and to do a biomechanical analysis of the appliance on the patient.
The management tasks of the prosthetist/orthotist focus on the
management of his workshop. This includes the supervision of
the technicians who assist him in the production of appliances. In
addition, he may participate in the planning and implementation of
the national system for the distribution of orthopaedic appliances.
He may also have responsibility in the practical training of
technicians and student prosthetists/orthotists. As such, the P/O
must interact with other rehabilitation professionals and workers,
including those who deliver services at the community level.
Some countries have special situations which require the production
of an unusual number of orthotic or prosthetic appliances. In such
cases, personnel may be trained for work with only one type of
appliance, such as lower limb orthotics or lower limb prosthetics.
Because this person’s training and work is limited to a special need
within the total prosthetic and orthotic services of a country, he
may be referred to as a prosthetic or orthotic assistant.
The responsibilities of this category of personnel are the same as
the fully trained prosthetist/orthotist, but with reference to the
production and management of one type of orthopaedic appliance.
The technician has an important role in the production of
the appliances, but does not have direct patient contact. He
fabricates and assembles the appliance. He does not do the
measurements for fitting of an appliance, nor can he analyze the
function of an appliance in order to adjust it to the individual
patient.
2004 ISPO WHO guidelines
The prosthetist/orthotist (ISPO Category I)
is responsible for direct user/patient services
and management of the orthopaedic workshop
usually at Reference Centres or Training
Institutions. In respect of providing user service,
the prosthetist/orthotist is a full member of
the rehabilitation team, can advise on the
design of an appropriate prosthetic/orthotic
device to meet the needs of any user requiring
prosthetics/orthotics service and with the
assistance of the orthopaedic technologist and
technician/bench worker prepare the prosthesis
or orthosis to fit the individual, and ensure its
optimum use and user’s satisfaction. He/she will
have the skills necessary to assess the fit and
function of the device and make adjustments as
necessary.
The orthopaedic technologist (ISPO Category
II) will be responsible for direct patient care or
providing direct service to persons with disabilities
and management of the orthopaedic workshop
if a Category I professional is not available and at
provincial- and district-level institutions. The tasks
are similar to those of the prosthetist/orthotist
but with some differences in emphasis. The
orthopaedic technologist is capable of providing
quality service for persons requiring the more
common levels of prosthetic/orthotic devices.
For more difficult conditions he/she will normally
have access to a prosthetist/orthotist either for
advice on treatment or for onward referral. The
orthopaedic technologist will not normally be
involved in research and development activities.
The technician/bench worker (ISPO Category
III), in direct assistance to the prosthetist/
orthotist or orthopaedic technologist, fabricates
and assembles prosthetic/orthotic devices and
takes part in their maintenance, repair, and
replacement. He/she will be responsible for
the economic use of tools and materials and
may have management supervision and training
duties assigned to him/her. The technician/
bench worker is not involved in direct
prosthetic/orthotic services to the user.
2018 ISPO education standards
A health care professional who uses
418
evidence-based practice to provide
clinical assessment, prescription,
technical design, and fabrication of
prosthetic and/or orthotic devices.
Prosthetists/orthotists work
independently or as part of the
health professional team. They set
goals and establish rehabilitation
plans that include prosthetic/
orthotic services and clinical
outcome measures. The profession
aims to enable service recipients so
they have equal opportunities to
fully participate in society.
A health care professional who uses
evidence-based practice to provide
clinical assessment, technical
design, fabrication of prosthetic/
orthotic devices, and implement the
clinical treatment plan. Associate
prosthetist/orthotists work as
part of the health care team under
the supervision of the prosthetist/
orthotist. They set goals for the
use of prosthetic/orthotic devices
and deliver services to achieve the
desired outcomes. This occupation
aims to enable service recipients,
so they have equal opportunities to
fully participate in society.
Nonclinical service providers
that support technical design of
prosthetic/orthotic devices and
are competent in the fabrication
of prosthetic/orthotic devices.
Prosthetic/orthotic technicians
work as part of the health care
team.
Prosthetics and Orthotics International 44(6)
Spaulding et al. 419
(Table 2), but P&O education has changed over the years.
Through conversations with experts and review of the
peer-reviewed literature, accreditation documents, and
ISPO records and databases, the authors identified three
major areas of change in P&O education worldwide over
the past 50 years: (1) prosthetic and orthotic curriculum
content, (2) pedagogy and course delivery, and (3) intern-
ships/residencies.
Prosthetic and orthotic curriculum content
Accreditation of P&O education has followed a path simi-
lar to that of other health professions, moving from a focus
on structure and content to process and outcomes. With
this movement toward competency-based professional
standards, academic programs design curriculum to
achieve required competencies rather than specific courses.
Competencies are defined as
the cluster of related knowledge, skills, and abilities that
affects a major part of one’s job (a role or responsibility), that
correlates with performance on the job, that can be measured
against well-accepted standards, and that can be improved via
training and development.5
Early P&O education Guidelines listed the specific
courses, and laboratory and clinical practice experiences
necessary to prepare P&O graduates to perform job-related
responsibilities. The description of specific courses
expanded with each revision until the establishment of the
2018 ISPO Education Standards6 and the WHO Standards4
in P&O Services. This change did not signify a reduction
in educational content. Rather, compared with the earlier
Guidelines, the 2018 Standards more closely align with
other health professionals in format, and with the P&O
professionals’ scopes of practice, leaving the specific path-
way of how to prepare students for clinical practice to each
program’s discretion. The Standards include professional
competencies that align with societal health goals, includ-
ing equity, quality, and efficiency. Furthermore, they
define global standards as listed in the International
Qualifications Framework7 to facilitate the assessment of
the national and international comparability of qualifica-
tions. The movement toward international standards aligns
with the suggestion from the Lancet Commission Report:
the importance of global principles with context specificity is
ever more relevant for professional education in our mobile
and interdependent world. Global principles would bring
consistency, transparency, and open accountability to the
accreditation process, while easing the emergence of
communities of knowledge and practice. Achievement of
some global–local balance is a priority, indeed a necessity, as
institutional interdependence grows.8
Competency-based accreditation standards also enable
programs to adapt to regional variations.5,8 While P&O pro-
grams from a range of regions have substantial consensus
regarding the importance of program objectives dealing
with student abilities, professional skills, and contemporary
understanding, several regions highlight distinctive objec-
tives, such as management and supervision in the Middle
East and Southern Asia, internationalization in Europe and
Southern Asia, and information and communication tech-
nology in Oceania P&O programs.9 The ISPO Standards
are adaptable to local educational needs.
Pedagogy and course delivery
Curriculum provided through multiple strategies and tech-
nologies foster students who are engaged, and can subse-
quently retain and demonstrate knowledge. Health education
is often viewed as being static and providing fragmented, sub-
optimal education to students.10 However, P&O programs
across the globe use varying teaching strategies. HICs tend to
put the responsibility of learning on the student, whereas the
faculty in LMICs guide students more carefully under super-
vision.11 The internet also offers a plethora of resources for
educators and students. As faculty embrace these resources
and use them, in addition to more traditional textbooks and
laboratory manuals, students learn to be resourceful and crea-
tive in their approach to learning and to patient care.10 The
most notable change in recent times is the ability to reach dif-
ferent audiences through communication technology, specifi-
cally video conferencing software such as Zoom (Zoom
Video Communications, San Jose, CA, USA) or GoToMeeting
(LogMeIn, Inc., Boston, MA, USA) and e-learning platforms
such as Canvas (Instructure, Salt Lake City, UT, USA) or
Blackboard (Blackboard, Inc., Washington, DC, USA). To
provide meaningful learning, faculty who design curriculum
are encouraged to select strategies that match the learning
objectives as well as the students’ learning styles, experi-
ences, and interests.10,12
Many teaching strategies exist, some long-standing and
some more current and innovative, each with levels of suc-
cess commensurate with the amount of preparation by fac-
ulty and the amount of enthusiasm with which they are
delivered. One example, problem-based learning (PBL)
puts the obligation of learning on the student, while the fac-
ulty role becomes that of a facilitator. Principles of PBL are
collaboration, self-directed learning, and student-centered
learning; it uses small group discussion and debate, gener-
ally to problem solve and answer a clinical question.12,13 It
is most ideal when case based, guiding students through the
clinical decision-making process, and when they show
mastery of the material. This clinical focus has been shown
to result in improved retention and clinical skills, as case
scenarios simulate what the students will encounter once
they begin practicing.13
Clinical and technical training prior to internship or resi-
dency is a component of all P&O programs and varies in
length, location, and intensity.12 This training may occur by
using volunteer patient models and/or in clinics under the
mentorship of practicing clinicians providing for an even
more valuable learning experience.14,15 Hands-on laboratory
work occurs in both locales to complement didactic and clin-
ical work.
420 Prosthetics and Orthotics International 44(6)
Internship (or residency)
Internships are the real-world learning experiences required
prior to graduation and/or prior to becoming certified/
licensed as a prosthetist–orthotist, associate P&O, and
P&O technician, depending on the education pathway and
national requirements. Although clinical internships have
always been an important component of P&O educa-
tion,1–4,6 a noticeable shift is the recognized need for struc-
ture and a common set of requirements.6,16 Internships
provide opportunities for students to respond to frontline
service, work in various clinical/laboratory settings, and
understand business operations and different models of
P&O service provision and funding.17 In the past, time in
the clinic without clear expectations was the norm and led
to varied experiences for students. P&O internships are in
the process of changing to include clear expectations and
oversight. Following a competency-based education model,
clinical and technician students demonstrate their ability to
perform common learning outcomes and professional com-
petencies, as set forth by the program and/or accreditation
agency. Students receive formative feedback about their
level of competence and independence.
Clinical internships have been shown to be essential when
the academic program is delivered online.18 As a single disci-
pline (i.e., prosthetics or orthotics) or dual discipline (i.e., pros-
thetics and orthotics) internship, they provide opportunities
for collaboration between the interns and programs with host
institutions to facilitate development of both soft and hard
skills.19 Aligning the prosthetist–orthotist and associated
P&O clinical skills within the health professions is important
as rehabilitation interventions shift with the growing global
need of assistive and rehabilitation technology.6,20
Development of professional integrity and ethical practice
with equity, diversity, and inclusion principles have all been
identified as highly valuable qualities in P&O practice4
Current state of prosthetic and
orthotic education
Approximately 140 clinician (prosthetist–orthotist and
associate P&O) programs and 17 P&O technician pro-
grams currently exist worldwide. Of these, 35 P&O pro-
grams, 16 associate P&O programs, and 1 P&O technician
program have been accredited/recognized by ISPO. The
current ratio of accredited or unaccredited clinician (pros-
thetist–orthotist and associate P&O) programs to techni-
cian programs is 8:1. If we assume the number of students
graduating from these programs is somewhat equivalent,
this ratio is opposite to that suggested by the 1990 report,2
20043 guidelines and the 2018 standards,4 which range
between 1:1 and 1:5. Although the number of P&O techni-
cians is underrepresented as many are trained “on the job,”
there remains a need for trained technicians to reduce the
inefficiency of prosthetists–orthotists and associate P&Os
tasked with technical work.4,17,21 Further inefficiencies to
P&O clinical care occur when associate P&O in LMIC
take responsibility for roles in physical rehabilitation inter-
ventions, out of necessity, when other rehabilitation mem-
bers such as, P&O technician, occupational therapist,
physical therapist, rehabilitation doctor, shoemaker, or
podiatrist, are unavailable.
The ratio of ISPO accredited prosthetist–orthotist pro-
grams to associate P&O programs is 2:1, with a ratio of
27:1 in HICs and 8:15 in LMICs. Only China and Germany
have both levels of ISPO-accredited clinician programs
within their countries. More P&O users could be treated per
team with associate P&Os working under the direction and
supervision of the prosthetist–orthotist.4,21 In addition, the
capacity of some graduates is underutilized due to lack of
resources or poor organizational capacity.21 Although this
is a service delivery issue, it is recommended that P&O
education systems respond to the lack of resources by pro-
viding more associate P&O graduates to support prosthe-
tists–orthotists.16,17 In addition, training of
prosthetists–orthotists might include leadership skills to
communicate effectively and manage P&O associates and
technicians.
Graduate and employer surveys provide useful infor-
mation to assess professional preparedness.21–23 Recent
P&O graduates report difficulties in biomechanics24,25 and
clinical management of specific pathological conditions.26
Some report feeling unprepared for rural working condi-
tions25 and many request continuing professional devel-
opment.22,24,26 Graduates suggest that the teaching faculty
need teaching qualifications and greater instruction on the
use of technology,27,28 not unlike early recommendations
for P&O instructors.1 Graduates in HIC feel strongly that
their technical skills are essential to their role;22 while
graduates in LMIC report difficulties when working in
clinics with lack of infrastructure17,29 and when there is
low awareness and prioritization of P&O services.26,29
Consideration for the coming 50
years
P&O professionals have a unique combination of knowledge
and skills that require substantial clinical and technical judg-
ment. Early and ongoing challenges of P&O education
include the need for additional clinical and education
research;1,2,30–32 a stronger foundation of scientific knowl-
edge;31 a more evidence-based approach to applying new
technology and materials: more explicit competencies and
self-assessment of education standards;33 increased level of
education;34 enhanced sustainability and cost-effectiveness of
P&O education programs;1,33 improved coordination and
communication between P&O providers and education insti-
tutions;34,35 improved legislation affecting persons needing
P&O services;34 and more P&O professionals.33,36
The ISPO accreditation 2018 Education Standards6
established a new level of professionalism that encourages
Spaulding et al. 421
Box 1.  Areas of consideration for the coming 50 years.
1. Demonstrate evidence of professional preparedness
through student assessment and program quality assurance
metrics;
2. Maintain frequent communication with all stakeholders;
3. Nurture a culture of critical inquiry and promote evidence-
based clinical reasoning;
4. Balance theoretical learning and skills training;
5. Maximize the use of information technology for learning;
6. Use active learning strategies for teaching and learning;
7. Strengthen educational resources and ensure sustainability
of P&O education programs;
8. Use systematic methods to develop student-centered
internships and promote a broad range of experiences;
9. Participate in the development, implementation, and
assessment of continuing education;
10. Ensure focus on patient/client-centered care;
11. Promote leadership, change management, and strategic
planning skills;
12. Participate in the development of research questions,
implementation, analysis, and dissemination of findings.
P&O: prosthetic and orthotic.
common attitudes, values, and behaviors as the foundation
in clinical service. They also promote common P&O
knowledge, skills, and evidence-based practices. The fol-
lowing statements are considerations for the coming
50 years to prepare students for the realities of clinical ser-
vice, teamwork, leadership, and lifelong learning (Box 1).8
Demonstrate evidence of professional
preparedness through student assessment and
program quality assurance metrics
P&O education accreditors are beginning to require evi-
dence of professional preparedness and program outcomes
with reliable evaluation methodologies.6 P&O education
needs effective educational assessment tools to evaluate
and demonstrate program outcomes, as well as student
learning outcomes in each competency area.37 Once the
program selects appropriate tools, it can systematically
gather and monitor outcomes at five levels of quality
assurance: student learning within courses, student learn-
ing across courses, individual courses, programs, and the
institution.38 The WHO suggests that institutional-level
quality assurance metrics address the teaching staff needs;
equipment and teaching methodologies; learning environ-
ments; curricula to match the realities of local environ-
ments; and the promotion of a culture of social
accountability.39 Program, course, and student-level out-
comes may improve as more P&O instructors become
involved in accreditation procedures, critical assessment
of program outcomes, and self-assessment of teaching
methods. Additional resources on assessment methods are
available.7,38,40–42
Maintain frequent communication with all
stakeholders
Frequent and transparent communication among stakehold-
ers such as health employers, credentialing agencies, inter-
professional colleagues, and educators will continue to be
essential. Communication between educational institutions
and health employers is necessary to align program goals
with population healthcare needs.8,39 Systematic implemen-
tation and analysis of graduate and employer surveys pro-
vide valuable feedback about professional preparedness,21–23
and can be used to adapt program competencies for local
needs.43 Educator–employer communication may be further
enhanced through advisory meetings with stakeholders, con-
tinuing education efforts, collaborative research projects, and
development of clinical cases for student learning. In addi-
tion, communication with credentialing agencies may inform
educators about challenging content for graduates.
A notable benefit of the small scale of the P&O com-
munity is the potential to connect with educational institu-
tions worldwide. ISPO Global Educators Meetings44
provide opportunities for educators to share academic
materials, strategies and challenges, (e.g., curriculum
resources, didactic materials, student and program assess-
ment tools, technology transfers, models of care concepts,
standards of operation, and quality assurance approaches).
They also serve as a means to connect students and faculty
internationally through placement holding, exchange pro-
grams, or online instruction.
Health care is increasingly multidisciplinary and col-
laborative. P&O health care professionals recognize the
need to further strengthen relationships with other health
disciplines to improve communication for clinical ser-
vices, and to reduce delays and service gaps.1,6,17 While in
school, interdisciplinary education could focus on learning
general competencies, such as communication, leadership,
and evidence-based practice skills8 together, so as to better
reflect the situations students are likely to encounter after
graduation.
Nurture a culture of critical inquiry and
promote evidence-based clinical reasoning
“Critical inquiry is crucial to mobilise scientific knowl-
edge, ethical deliberation, and public reasoning and
debate.”8 Educators should promote critical inquiry through
activities that involve synthesis of information from multi-
ple sources that then lead to new ideas and deeper questions
(inquiries) about a topic. This educational approach requires
that students know how to use information technology to
422 Prosthetics and Orthotics International 44(6)
search, identify, and critically appraise literature; activities
that enable a culture of lifelong learning. Consequently, this
approach may enable development of students’ evidence-
based practice skills and address graduates’ desire to criti-
cally analyze and be more discerning with prescription
choices.25,45,46 In addition, this approach could mobilize
P&O scientific knowledge as there remains a need for more
scientific,31 clinical,30,47,48 and educational32 evidence in
P&O.
In the future, P&O clinicians will need to make judg-
ments based on expanding amounts of information and
data. P&O students’ critical thinking skills have been
shown to improve with P&O education.49 To develop stu-
dents’ clinical reasoning skills in a systematic way, stu-
dents could use frameworks to map and compare variables
that affect desired technical and functional outcomes.50,51
Once students identify a pathway to make clinical deci-
sions about a case, they can explore how various contexts
might alter the outcomes and, thus, the clinical decision.
Finally, to further develop critical inquiry, educators could
use prosthetic threshold concepts (i.e. content that is diffi-
cult to learn and changes the way one thinks about a con-
cept) such as “how we walk,” “learning to talk,” and
“considering the person” to enhance student understanding
of difficult concepts.52
Balance theoretical learning and skills training
In addition to the minimum competencies required by
students in any health profession, P&O students must
practice to be skilled in evaluation, fitting, alignment,
aesthetics, and outcome assessment; and P&O techni-
cians must be skilled with materials and fabrication.4
With the addition of new technologies and techniques,
there is never enough time in the academic schedule to
cover everything. P&O clinician graduates report the
importance of technical skills22 and some employers
complain that P&O clinician graduates have poor practi-
cal hand skills. Fabrication knowledge and skills (i.e.
mechanical reasoning, material science, and psychomo-
tor skills) will continue to be important foundations in
P&O. Educators may explore educational theory from
other professions to improve the efficiency of student
learning and consider different academic pathways to
create the right balance of theoretical and skills training.
Maximize the use of information technology for
learning
Accreditation agencies do not dictate how curriculum is
delivered, but instead focus on learning outcomes.15 With
the abundance of electronic information, schools now play
a larger role than ever before in helping students access
and use data to improve their own learning. Programs of
the future will require information technology departments
to manage connectivity and instructional technology
experts to design virtual experiences, quality distance
learning programs, and implement instructional strategies
that align with future technologies.8 The authors envision
software applications, available to all P&O schools, that
will allow for clinical simulations such as dynamic align-
ment including changing socket pressures and force cou-
ples throughout gait, orthotic corrective forces, prescription
formulation, interprofessional communication, critical
inquiry, and interpretation of outcome data.
E-learning, which takes multiple formats, not only
enhances the learning experience but also affords learning
opportunities to many across the globe. Open or distance
learning was introduced in 1969 by the Open University in
the United Kingdom. With advancements in technology, dis-
tance learning has morphed from hardcopy learning packets
to synchronous and asynchronous delivery methods.
E-learning can be used to support on-campus seated students
through a learning management system for content manage-
ment, or it can be used to communicate with and deliver cur-
riculum to students at a distance. One P&O program recorded
synchronous lectures to seated students for transmission to
the distance learning cohort.15 The 24/7 availability gives
students the freedom to work from anywhere, anytime allow-
ing for employment and cost-savings by not having to relo-
cate.14,53 A blended model of electronic and face-to-face
delivery can promote quality learning.18 Even with face-to-
face interaction, which can be live or via a conferencing sys-
tem, e-learning benefits students by allowing access to
demonstrations and lectures multiple times in preparation for
exams without additional faculty resources.53
Use active learning strategies for teaching and
learning
Educators have limited time to provide increasing amounts of
content and learning experiences to students. Thus, focusing
on the selection of teaching strategies that match learning
goals could maximize the learning outcomes. One engaging
learning strategy that has a growing body of evidence is the
use of simulations prior to actual patient contact.54,10 For
example, by allowing students time to practice their psycho-
motor skills on models of hands or residual limbs, they are
able to take their time and think through the task in a less
stressful environment and are better able to transfer those
skills to a live patient care session.54 Game-based education
simulation can complement other strategies while keeping stu-
dents engaged.10 Finally, providing immediate and authentic
feedback is a teaching strategy to employ as often as possible.
Portfolios help students organize their thoughts, remain
accountable, and structure their own learning environ-
ment. Students use portfolios to reflect and understand
what and how they learned.55 The problem-based learning
approach has shown promise at improving students’ criti-
cal thinking about their own clinical and technical
Spaulding et al. 423
decisions after completing a research-informed clinical
practice module.56 Small group learning, where students
are given the opportunity to share and contribute, can be
more effective than traditional lectures.12 Active learning
includes discussion, role-playing, case studies, group pro-
jects, clinic and lab experiences, peer teaching, and debates
to name a few. These strategies help students to build
knowledge as faculty support their learning by adding on
more difficult concepts. This helps students to become
more competent and confident. When initially introducing
theoretical material, better outcomes may be achieved by
balancing a teacher-centered with a student-centered
approach.12
Strengthen educational resources and ensure
sustainability of P&O education programs
Academic program resources will continue to be necessary
instruments to achieve professional competencies.8 For
example, prosthetist–orthotist and associate P&O students
must demonstrate basic skills in conducting research.
However, graduates report challenges participating in
research due to limited infrastructure.28 Resources include
personnel and human resources, physical facilities,
budget allocation, student-support services, didactic and
laboratory teaching tools and materials, communication
technologies, and open access to journals. Furthermore,
P&O graduate feedback has suggested that faculty need
teaching qualifications.27,28 Programs could consider using
a systematic process to track resources, for example, to
ensure that faculty responsible for P&O-specific courses
possess relevant teaching and clinical experience and have
opportunities for professional development,6 including the
support of advanced degrees (i.e. MEd and PhD).
Universities in the future will likely require teaching fac-
ulty with Master’s and PhD-level degrees.
Funding of P&O academic programs continues to be a
challenge. The development of rich teaching resources,
international partnerships, development of digital foot-
prints of the program, preparedness for the market demand,
and multiple sources of funding contribute to the sustain-
ability of programs. The majority of P&O programs around
the world have found accreditation useful. Other branding
and positive images of programs may include international
exchanges (educators and students, either South–South or
North–South) with a focus on inclusion, diversity, and
equitable opportunity, where programs could impact social
changes and elevate the professional credential both
locally and globally. The inclusion of different aspects of
physical rehabilitation interventions and technologies
equip students to respond to the needs of case management
in real-world practice.4 Furthermore, programs might con-
sider participating in policy development, policy changes,
and professional standards to set a professional footprint
for national, regional, and global awareness.
Use systematic methods to develop student-
centered internships and promote a broad
range of experiences
Practical experiences in clinics or technical laboratories
will continue to be an important aspect of P&O student
learning. Universally, the learning outcomes of an intern-
ship (or residency) program are developed within the core
competencies rubric evaluation.6 Because each student
enters their internship with differing strengths and areas
for improvement, the balance of exposure to technologies,
clinical experiences, and technical skills, as well as prepar-
edness for employment, needs to be organized once a
placement is set. To mitigate potential risks for an unsuc-
cessful internship, the program can review its internship
protocols with stakeholders (i.e. graduates, employers,
supervisors, mentors, placement hosts, and users of P&O
services) to assure common expectations. Repository
resources to support the students could be helpful for
interns, supervisors, and hosts to monitor and evaluate stu-
dents’ progress.
The affective domain will continue to be important for
healthcare professionals. When determining the level of
oversight, clinical internship mentors (supervisors) report
the value of interpersonal skills (e.g. recognition of per-
sonal limitations, self-evaluation, and reflection skills)
and patient evaluation skills more than technical skills.19
Reflective writing57 and effective communication have
been endorsed to enhance emotional intelligence, partic-
ularly over the placement period, where caseload man-
agement in real life could be made with qualitative
analysis, on-time feedback, and debriefing techniques.
Internship portfolios can be useful tools for in-depth
analyses of learning with the use of reflective writing to
enhance clinical decision-making skills and academic
performance.58
P&O internships of the future will include case confer-
ences, case reflections, skill advancement appraisal, inter-
professional communication, and systematic assessment of
practice skills with regular constructive feedback from clini-
cal supervisors and clinical mentors. This could contribute
to 360-degree performance reviews and lifelong learning
skills. In addition, advancements in technologies, e-learn-
ing, and e-health are seen to have a potential impact on how
students conduct their internships. Thus, the inclusion and
early introduction of these educational strategies in the aca-
demic programs would be helpful for students. Finally, sys-
tematic, documented internship outcomes and actual
placement outcomes have been shown to be essential for the
program to review its trend of internships, impacts, and
effectiveness of clinical placement guidelines. As with aca-
demic program outcomes, internship outcomes needs to
demonstrate how much students learn, and not how much
instructors or mentors have taught (Outcome Based
Education and Professional Competencies Performance).6
424 Prosthetics and Orthotics International 44(6)
Participate in the development,
implementation, and assessment of continuing
education
P&O professionals will need to continue to stay up-to-
date with new technologies and techniques in order to
maintain their skills and understanding of P&O after grad-
uation.21 In graduate surveys, P&O graduates often
request continuing professional development (CPD).22,24,26
In low resource settings or where the national regulations
on CPD are absent, educational programs and profes-
sional associations often take the lead and contribute to
the development, implementation, and delivery of CPD.
However, in many countries, the assessment and accredi-
tation of CPD does not exist. Participation in the develop-
ment, implementation, and assessment of CPD experiences
could create potential national and international collabo-
rations, and develop partnerships between education pro-
grams and employers. The projected increase in the
number of people with disabilities59 encourages both
innovative models for training more students and advanc-
ing skills of current practitioners. E-learning, blended
education, and distance programs have potential for the
future upscaling of the number of practitioners and CPD
activities in flexible learning environments at a reduced
cost (capital and administrative). However, accreditation,
quality assurance, and structured monitoring systems will
continue to be essential for programs to safeguard the
quality of education and to ensure patient safety.
Ensure focus on patient/client-centered care
The patient-specific context will continue to be paramount
to the success of P&O interventions. So it is surprising that
schools in only one region (N. Europe) reported it in their
program objectives.9 Patient/client-centered care is an
overarching principle of clinical care60 that needs to be
integrated through all aspects of the P&O treatment plan.
The patient-specific focus is an important focus of clinical
care now and in the future; P&O educators should make
this consistently explicit throughout the P&O curriculum.
Promote leadership, change management, and
strategic planning skills
Leadership skills are vital for P&O professionals at all levels.
Leadership skills promote integrity, stewardship, and account-
ability.60 They are the foundation of interdisciplinary team-
work5 and are necessary to advocate for the profession.21
Thus, P&O programs can promote student leadership skills
by threading teaching strategies that promote leadership
behaviors throughout the curriculum. Furthermore, CPD
training can provide graduates who are service managers with
leadership, change management, and strategic planning
skills.21 These skill sets could provide opportunities for grad-
uates to assume leadership positions, advance service deliv-
ery models, and participate in research.4
Participate in the development of research
questions, implementation, analysis, and
dissemination of findings
The need for evidence in P&O has been repeatedly noted
since the 1968 Holte report. A recent systematic review of
education research found that 21 of the 25 identified arti-
cles were published in the past decade when searching
back to 1966. The identified topics of research included (1)
teaching/learning methods such as web-based and e-learn-
ing approaches, study abroad experiences, critical thinking
development, and education strategies; (2) aspects of cur-
riculum like interprofessional education and general cur-
riculum development; (3) program-level topics such as
competency standards, theoretical concepts, and graduate
competency; and (4) country/region-level topics such as a
description of current clinical practice and education and
country-level outcomes.32 The authors of that review
reported a need for high-quality evidence to improve P&O
education and to promote global advancement of the P&O
profession. P&O educators at academic institutions and
clinical/technical sites of the future will have more oppor-
tunities to take part in research at any stage. The advance-
ment of P&O education and the profession requires
professionals who are qualified and competent to conduct
and lead research efforts.
Conclusion
Continued advancements in P&O education need to antici-
pate and reflect shifts in healthcare,10 pedagogical think-
ing, technology, and student expectations. Accrediting
agencies encourage innovation in education with a focus
on competency-based standards and student learning out-
comes. P&O programs of the future will implement sys-
tematic quality assurance metrics that demonstrate student
learning of evidence-based practice skills, emotional intel-
ligence, and discipline-specific cognitive (knowledge);
psychomotor (skills); and affective (behavior) learning
domains that contribute to quality patient care, clear com-
munication with interdisciplinary colleagues, and advance-
ment of practice standards. P&O education and the
profession will advance through professionals who are
qualified and competent to conduct and lead research
efforts. Finally, consistent communication with all stake-
holders will continue to be essential. Communication is
important between educators, recent graduates, and clini-
cal sites to ensure that learning outcomes remain relevant
to changing technology and outcome-oriented healthcare
environments; and communication with fellow educators
is important to further develop innovative programs,
research collaborations, and international partnerships for
Spaulding et al. 425
more equitable and inclusive efforts. Continued efforts
toward cooperation and collaboration remain a challenge
and a goal.35
Acknowledgements
The authors thank Helen Cochrane, CPO(c), Dan Blocka, CO(c),
FCBC, Nerrolyn Ramstrand, PhD, BP&O(Hons), and Sarah
Anderson, PhD, MPH, BPO, for their helpful information for this
manuscript.
Author Contributions
Conceptualization: SES, SK, SK, CH.
Acquisition of articles: SES.
Writing-original draft: SES, SK, SK.
Writing-review and editing: SES, SK, SK, CH.
Final approval of the version to be published: SES, SK, SK, CH
Declaration of Conflicting Interests
The author(s) disclosed no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed that they received no financial support
for the research, authorship, and/or publication of this article.
ORCID iD
Susan Ewers Spaulding https://orcid.org/0000-0001-7841-6506
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