METHOD/MODEL PRESENTATION
Pedagogy for Effective Learning of Clinical Skills: An
Integrated Laboratory Model
Michelle Reilly, PT, DPT, Kimberly Beran-Shepler, PT, DPT, and Karen A. Paschal, PT, DPT, FAPTA
Background and Purpose. e teaching,
learning, and assessment of clinical skills is
a critical component of entry-level physical
therapy education. e intention of this ar-
ticle was to describe a successful model for
teaching clinical skills in the context of the
patient and client management model across
the domains of physical therapist education
Downloaded from http://journals.lww.com/jopte by BhDMf5ePHKbH4TTImqenVBMHby7N9qoLVfmYj0p/hERVhyFdMhnTkitlfURaEPgVjldRchs5qds= on 09/17/2020
with emphasis on motor learning principles,
experiential learning, and clinical reasoning.
Method/Model Description and
Evaluation. e model describes a cohesive
laboratory learning environment that inte-
grates skills from the clinical science courses
that coincide each semester. A laboratory
director coordinates with faculty teaching
clinical sciences in a given semester to en-
sure the necessary psychomotor content is
included, creates experiential learning op-
portunities that integrate skills across con-
tent areas, and promotes clinical reasoning
in the context of the patient and client
management model. Success of this model
was measured through student outcomes on
skills competency tests (SCTs), Clinical
Competence Performance Examinations
(CCPEs), American Physical erapy
Association (APTA) Clinical Performance
Instrument (CPI) benchmarks, and the
National Physical erapy Examination
(NPTE).
Michelle Reilly is a board certified specialist in
Orthopedic Physical erapy, assistant professor
at Creighton University, 2500 California Plaza,
Omaha, NE 68178 (michellereilly@creighton.
edu). Please address all correspondence to
Michelle Reilly.
Kimberly Beran-Shepler is a board certified
specialist in Orthopedic Physical erapy, fellow
in the National Academies of Practice, and an
assistant professor at Creighton University.
Karen A. Paschal is a professor at Creighton
University.
e authors declare no conflicts of interest.
Received July 22, 2019, and accepted March 29,
2020.
Copyright © 2020 Academy of Physical erapy
Education, APTA
DOI: 10.1097/JTE.0000000000000145
234
Copyright © 2020 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
Outcomes. Each student passed SCTs ad-
ministered during semesters 1–6 given
a maximum of 3 trials. Every student
passed the CCPE administered at the end of
each semester in one of 3 trials except for
one student in semester 6. Each student met
expectations for performance as measured
on the CPI for 4 clinical education experi-
ences including entry-level performance for
the final 2terminal experiences. All students
were successful on the NPTE.
Discussion and Conclusion. Imple-
mentation of this model has prepared stu-
dents for authentic physical therapy
practice by promoting integration of cur-
riculum content and has fostered faculty
collaboration. While initial student and
curricular outcomes have been positive,
assessment of the model is ongoing.
Key Words: Clinical skills, Teaching,
Clinical reasoning.
BACKGROUND AND PURPOSE
Physical therapists, like many health care
professionals, are expected to perform specific
clinical skills as part of their everyday inter-
actions with patients and clients. ese are
foundational skills required for competent
clinical practice and range from simple, such as
palpation of anatomical landmarks, to com-
plex, such as performing a grade 5 spinal ma-
nipulation, assisted breathing techniques, or
gait facilitation. Often in a physical therapy
curriculum, clinical skills are taught in silos
without contextual factors that require the
student to demonstrate clinical reasoning in-
cluding appropriate application, in-
terpretation, and modification of these skills.
Clinical content is traditionally taught in
a laboratory setting and then practiced in the
context of clinical educational experiences that
occur in authentic settings.
ere is little research describing best
practices for teaching clinical and psychomo-
tor skills in physical therapy education to
enhance skill transfer to the clinical environ-
ment.1 Medical education literature suggests
that there are many ways to teach clinical skills
and these variations are influenced by
Journal of Physical Therapy Education
curriculum, availability of resources, and fac-
ulty involvement.1 When teaching clinical
skills, the objective is for students to demon-
strate the ability to perform the skill accurately,
efficiently, and consistently over time.2 is
objective of clinical skill teaching and learning
is achieved through guided practice, repetition,
and reinforcement. Educators are also com-
pelled to ensure that students achieve a true
change in behavior related to clinical skill
learning and retention, and avoidance of tem-
porary and simple skill recall and perfor-
mance,3 not only in the laboratory setting but
also within the context of patient care. Addi-
tionally, there is a need to facilitate the clinical
reasoning associated with the performance of
these skills.4,5 Inherent to teaching clinical
skills is a concern not only for the learner to
perform the skill but also interpret the resulting
outcome and discern implications for patient
care with consideration for the whole person
and creation of a patient-centered plan of care.6
When teaching clinical skills, faculty must seek
to maximize all these considerations.
Physical therapists readily apply motor
learning principles when teaching psychomo-
tor skills to patients and the same motor
learning principles should be used when
teaching clinical skills to physical therapy stu-
dents, but the evidence is lacking.7 Like
patients, students must progress through the
phases of motor learning: cognitive, associa-
tive, and autonomous,6 and practice schedules
can facilitate this progression.8 Distributed
practice is favored over massed practice for
skill retention and transferability to real-life
scenarios.7,9,10 Evidence also supports that skill
retention decreases after periods of nonuse.11
e rate and intensity of skill decay is influ-
enced by the amount of practice in early stages
of learning, the amount of time between initial
learning and recall, and the nature of the task.11
Other principles of motor learning (observa-
tional practice combined with physical prac-
tice, external focus of attention, positive
feedback, and self-controlled practice) have
been applied to teaching clinical skills with
positive influences on learning outcomes.12 For
these reasons, repetition and recall of skills over
the course of a curriculum are helpful in re-
tention of these skills.13
Vol 34, No 3, 2020
 In clinical practice, physical therapists select
interventions to match the context of
a patient’s needs. Similarly, in teaching clinical
skills, learning experiences should match the
context of the learner’s needs.7 Practice in the
laboratory must translate to clinical practice
and the need to address context of learning has
given rise to many forms of experiential
learning.14 Experiential learning includes sim-
ulations, role playing, and community en-
gagement that help to stimulate “higher
student motivation, more learning at higher
cognitive levels, greater appreciation of the
subject matter and its utility, and longer re-
tention of material” when compared with tra-
ditional lecture learning.15 Evidence in the
nursing literature suggests a “theory-practice-
gap” where there is an incongruence of skills
learned in the academic setting compared with
clinical practice and difficulty applying
knowledge and procedures learned in one
context to another.14,16 Laboratory settings are
meant to bridge the gap between theory and
practice, but their inauthenticity may limit the
transferability of skills.16 Learning in the con-
text of a patient case or encounter provides the
foundation needed for mastering clinical skills
early in the curriculum.10 Progressive, guided
practice with multiple opportunities to apply
skills to patients is needed to increase the au-
thenticity and real-world applicability of clin-
ical skills.10
Traditional skills laboratories teach clin-
ical skills as individual tasks, but this does
not reflect true clinical practice where the
findings of one measure may influence which
other tests and measures are chosen to ap-
propriately assess a patient’s physical ther-
apy needs. Skills taught as individual tasks
without considering context or outcome do
not promote translation of theory to clinical
practice.10 Incorporating the rationale be-
hind why a skill is chosen and the implica-
tions of the result of that skill on patient care
becomes integral to the skill itself,17 and thus,
the learning environment should provide the
clinical application and clinical reasoning
necessary to translate to patient-centered
practice.18 is learning in context could
“enhance the understanding and application
of course material, improve personal and
professional attributes and skills needed to
be an effective clinician and improve clinical
reasoning skills.”18 Still, literature is lacking
with regards to effective teaching strate-
gies to facilitate this type of clinical skill
attainment.7,14
e purpose of this article was to describe
a successful model for teaching clinical skills
across content areas in a physical therapy
curriculum with consideration for motor
learning principles, experiential learning, and
clinical reasoning.
Vol 34, No 3, 2020
Copyright © 2020 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
METHOD/MODEL DESCRIPTION
The Educational Model
Creighton University’s entry-level DPT cur-
riculum uses biopsychosocial sciences19 as the
foundation for progression to clinical sciences.
ose clinical science courses serve to prepare
students for clinical experiences that are both
integrated and progressive in the curricular
sequence. During a curriculum revision in
2015, a decision was made to move the teaching
of clinical skills out of system-specific labora-
tories and into a series of integrated laboratory
courses wherein all clinical skills are taught in
the context of a single course. is led to the
development of a 6-semester series of in-
tegrated laboratory courses. Each integrated
laboratory course facilitates the teaching and
learning of clinical skills across system
domains, addressing multiple components of
the movement system, and reinforcing con-
cepts from all clinical science courses in a se-
mester. Content from the clinical science
coursework that contributes to each integrated
laboratory course is listed in Figure 1.
All 6 integrated laboratory courses use the
patient and client management model20 as the
framework for skill development and practice.
Students are introduced to examination pro-
cedures, practice evaluation and interpretation
of clinical data to form an appropriate diagnosis
and prognosis, then learn and practice relevant
interventions.
e program embraces a developmental
learning approach across the curriculum in 3
areas: medical complexity of a patient, expected
clinical performance and clinical reasoning. In
the area of medical complexity, students are
initially introduced to medical management of
the “well adult,” which then progresses across 6
semesters to include more medically complex
scenarios with patients across the lifespan. In
expected clinical performance, students are
expected to progress from the beginner level of
the clinical reasoning grading rubric21 to the
competency benchmark by the completion
of semester 6. Regarding clinical reasoning,
students are expected to use a hypothetico-
deductive reasoning model early in the curric-
ulum and progress to more inductive methods
of reasoning. is developmental learning ap-
proach is depicted in Figure 1.
is model capitalizes on motor learning
principles and the use of laboratory time as
a means for distributed practice of skills across
the curriculum with progressive expectations of
complexity and flexibility of skills and required
decision making. Skills are reinforced across
content areas and start with an emphasis on
wellness and progress in medical complexity.
Experiential learning is threaded through the
model with early use of patient encounters
with simulated patients, standardized patients,
Journal of Physical Therapy Education
community volunteers, and authentic patients
to facilitate hands-on practice that translates to
clinical practice. Clinical skills are practiced
within the patient and client management
model to create a context for application of
skills and authenticity of real-world practice.
Inherent in our model is an integration of
hands-on skills with clinical reasoning and
a focus on critical self-reflection to overcome
the theory practice gap.
The Curriculum
Each didactic semester students are enrolled in
courses in both clinical and biopsychosocial
sciences that have a single clinical laboratory
course, Integrated Laboratory. is compre-
hensive laboratory experience encompasses the
content of concurrent clinical coursework and
promotes the developmental learning contin-
uum described above.
Within each integrated laboratory course,
a similar model is used to progress students
from early skill acquisition, to skill practice, to
skill application and eventual skill assessment.
For early skill acquisition, the integrated labo-
ratory functions similarly to system-specific
laboratories. Students are provided with read-
ing assignments, prelaboratory assignments,
and videos to review before attending labora-
tory. Once in the laboratory setting, skills are
demonstrated by content experts and students
are allowed ample time to practice skills on
their classmates with feedback from faculty and
expert clinicians. Special emphasis is placed on
distributed practice of psychomotor skills and
consideration of clinical skills in the context of
patient management while using motor learn-
ing principles.
Once skills are initially learned and prac-
ticed, appropriate skill performance is assessed
by intermittent skills competency tests (SCTs).
Skills competency tests are typically specific to
each clinical science course and allow faculty to
evaluate whether students have acquired the
psychomotor abilities required for clinical
practice. Basic skill instruction and perfor-
mance is introduced early in the curriculum,
then advanced to performing skills as they re-
late to a patient case, to finally in the later
semesters performing these skills on an au-
thentic patient. Students are allowed 3 attempts
to demonstrate acceptable performance on
a SCT. Skills competency tests allow for faculty
to provide feedback specific to each individual
student related to their psychomotor skill per-
formance, as well as provide a level of assurance
that the learner is prepared to progress to the
next step of the integrated laboratory model.
After students have successfully completed
their SCTs, the integrated laboratory model
calls for skill application in the context of
authentic experiential learning opportunities,
235
 Figure 1. Overview of Integrated Laboratory Model
which highlights the integrative nature of the
laboratory course sequence. Experiential
learning opportunities include patient care
simulations, practice with community vol-
unteers within the laboratory context, and
service-learning events with various commu-
nity partners. In earlier semesters, this
involves one-time patient encounters and
then progresses to regular patient treatment
sessions in semesters 4, 5, and 6. ese au-
thentic experiential learning opportunities
allow students to apply the skills they have
learned over the course of the semester in the
context of patient cases that are designed to
require skill sets from multiple physical
therapy domains and scaled to the appropri-
ate level of the learner. e application of
skills shortly after initial exposure helps to
solidify the content,22 and the use of experi-
ential learning in the didactic curriculum
allows for earlier identification of gaps in
knowledge and performance.23
After each experiential learning opportu-
nity, students engage in critical self-reflection
to enhance and highlight their clinical rea-
soning skills.24 Depending on the learning
opportunity, the reflection may be written or
in the context of large or small group
debriefing and discussion.
Once students have acquired skills, dem-
onstrated competence, and applied their newly
learned skills, summative assessment of skills in
the context of patient care can be completed. In
this curriculum, each integrated laboratory
course concludes with a Clinical Competence
Performance Examination (CCPE). is is
a case-based examination that is completed
236
Copyright © 2020 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
one-on-one with a core faculty member, an
associate faculty member, or a physical therapy
resident and serves as the final examination for
the integrated laboratory course. During this
examination, students are provided with a pa-
tient case that requires them to integrate skills
from all clinical science courses that have been
covered in the curriculum. Examples of in-
tegrated cases used in these examinations may
include a patient who has experienced a cere-
brovascular accident and is reporting shoulder
pain, a patient with Parkinson disease who is
experiencing low back pain or a postop ortho-
pedic patient with cardiopulmonary complica-
tions. ey are expected to treat the
examination as a patient care scenario and
progress through all stages of the patient client
management model. Students are assessed us-
ing the Clinical Reasoning Grading Rubric de-
veloped by Furze et al21 in 3 domains: content
knowledge, psychomotor skill, and conceptual
knowledge/reasoning. Expectations for perfor-
mance on the Clinical Reasoning Grading Ru-
bric are outlined in Table 1.
Successful completion of the CCPE serves as
a means of summative assessment to determine
readiness for clinical experiences. Expectations
for performance on the Clinical Reasoning
Grading Rubric are progressively increased in
all 3 domains over the course of the didactic
curriculum to respect introduction of new
content as well as advancement of student skill
and knowledge toward that of an entry-level
clinician.
e curriculum also uses both integrated
and terminal clinical experiences as a means to
apply didactic information in the context of
Journal of Physical Therapy Education
patient care. e Clinical Performance In-
strument (CPI) is used to assess student per-
formance on all clinical experiences, again
using the same progressive improvement ex-
pectation. Benchmarks related to CPI outcomes
are also described in Table 1.
Figure 2 demonstrates implementation of
this model using the second semester of the
curriculum as an example. In this semester,
Patient Management II, Cardiovascular and
Pulmonary Physical erapy I, and Move-
ment Science contribute content to Integrated
Laboratory II. Specific psychomotor skills
learned in this laboratory include transfers,
gait with assistive devices, cardiovascular and
pulmonary assessment, and manual muscle
testing and goniometry.
Motor learning principles are implemented
through distributed practice of these skills, in-
cluding recall and progression of skills learned
in the first semester (vital sign assessment) as
well as practice of skills in multiple laboratory
sessions. Students first observe a demonstration
of the skill before completing physical practice
and also have access to videos of all skills for
review at a later date. Positive and constructive
feedback is used by faculty during practice
times to further use motor learning principles.
Two to 3 weeks after initial learning, SCTs are
used to assess learning of specific psychomotor
skills, allowing for self-controlled practice, op-
portunities to seek clarification and enough
time to challenge recall of skill performance.
Once skill competency is established, au-
thentic experiential learning is used to apply the
learned skills in the context of a patient case.-
For this example, students complete
Vol 34, No 3, 2020
 Table 1. Benchmarks for Student Outcomes on the Clinical Reasoning Grading Rubric and CPI

CCPE

Courses Integrated Content Knowledge Procedural Knowledge Conceptual Knowledge

1 Exercise Physiology Beginner Beginner Beginner
Patient Management I
2 Movement Science Beginner Beginner Beginner
Patient Management II
Cardiovascular and Pulmonary I
3 Musculoskeletal I Intermediate Beginner Beginner
Integumentary
First integrated clinical experience with CPI expectation at Advanced Beginner
4 Musculoskeletal II Intermediate Intermediate Intermediate
Neuromuscular I
Motor Control
5 Musculoskeletal III Competent Intermediate Intermediate
Neuromuscular II
Second integrated clinical experience with CPI expectation at Intermediate
6 Differential Diagnosis Competent Competent Competent
Integrated Patient Care
Cardiovascular and Pulmonary II
First terminal clinical experience with CPI expectation at entry level
Second terminal clinical experience with CPI expectation at entry level

Abbreviations: CCPE = Clinical Competence Performance Examination; CPI = Clinical Performance Instrument.

a simulated acute care experience with stan-
dardized patients as well as community-based
cardiovascular and pulmonary screens with
volunteers. Both experiences require students
to implement multiple skills from the semester
(transfers, gait, cardiopulmonary status,
strength, and range of motion) to assess patient
function.
After each of these experiential learning
opportunities, clinical reasoning is promoted
through large group discussion and debriefing
and the use of guided critical self-reflection in
written assignments. Finally, formative assess-
ment of skills learned is completed with the
CCPE in the context of a patient case. Cases
used for this examination necessitated the
demonstration of skills from all content areas
(Patient Management II, Cardiovascular and
Pulmonary Physical erapy I, and Movement
Science) to be successful.
Methods
is study used retrospective outcome data
collected throughout the 6 semesters of in-
tegrated laboratories for the first cohort of
students taught using this model. ese data
included SCTs in each semester, the 6 CCPEs,
CPI outcomes for 2 integrated clinical educa-
tion experiences and 2 terminal clinical edu-
cation experiences, clinical education
summaries, and National Physical erapy
Examination (NPTE) results. Narrative
responses from the CPI were compiled by
clinical education faculty into clinical education
summaries, which were reviewed by the
authors. Figure 3 represents the data points that
were collected in review of this model. is
study received approval from the Creighton
University Institutional Review Board.
OUTCOMES
Evaluation of success of the integrated labo-
ratory model utilized assessment methods
used within the 6 integrated laboratory
courses, clinical education benchmarks, and
NPTE results.
e integrated laboratory model was
implemented with an initial cohort of 62 stu-
dents. Fifty-nine students successfully com-
pleted the didactic and clinical education
curriculum and passed the NPTE. Two students
were unsuccessful in non–laboratory-based
coursework and rejoined the program with
the following cohort; one student was
unsuccessful in the laboratory-based course in
semester 6 and also rejoined the program with
the following cohort.
e 59 students who graduated met pro-
grammatic benchmarks throughout the in-
tegrated laboratory course sequence. Each
student passed the SCTs administered during
semesters 1–6, given a maximum of 3 trials.
Except for the one student in semester 6, each
student passed the CCPE administered at the
end of each semester in one of 3 trials (Table 2).
Having been deemed safe and competent
to progress into clinical education experi-
ences, each student met expectations for
performance as measured on the CPI, in-
cluding entry-level performance after each of
the 2 terminal experiences. Eight CPI ele-
ments that most closely reflected the objec-
tives of integrated laboratory were chosen for
assessment of this model. ese elements
were most closely aligned with the outcome
objectives for the integrated laboratory
courses and focused on clinical skills and
clinical reasoning. ey included clinical
reasoning, screening, examination, evalua-
tion, diagnosis and prognosis, plan of care,
procedural interventions, and educational

Vol 34, No 3, 2020 Journal of Physical Therapy Education 237

Copyright © 2020 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
 Figure 2. Model Example: Integrated Laboratory II, Semester 2. CCPE = Clinical
Competence Performance Examination; CVP = cardiovascular and pulmonary;
MMT = manual muscle testing
interventions. Students were expected to
meet Advanced Beginner at the end of their
first integrated clinical experience, In-
termediate at the end of their second in-
tegrated clinical experience, and Entry Level
at the end of their last 2 terminal clinical
experiences. Subjective comments from
clinical instructors were required to support
and confirm CPI markings. All students met
these expectations for each of their clinical
Figure 3. Outcome Data Collection Timeline. CCPE = Clinical Competence
Performance Examination; ICE = clinical education experiences; NPTE = National
Physical Therapy Examination; SCT = skills competency test
238
Copyright © 2020 Academy of Physical Therapy Education, APTA Unauthorized reproduction of this article is prohibited.
education and practice. Furthermore, stu-
dents cited the integrated laboratory expe-
rience as a curricular strength after each
clinical experience on the Student Assess-
ment of Clinical Experience form, noting
that early and frequent interaction with
patients was valuable to their professional
development.
Students identified the integrated labora-
tories as strong preparation for clinical
experiences:
I believe that the added integrated labs to
the curriculum was the most beneficial in
preparing me for this clinical experi-
ence…e skills that were developed from
the combined courses brought into in-
tegrated laboratory and documentation
and patient management skills were
strengths that were apparent in my third
clinical experience.
e blending of the different classes was
also very helpful. It allowed me to make
almost a seamless transition between
cardiopulm interventions, to orthopedic
intervention to neuro interventions.
Strengths of curricular preparation in-
clude: case examples of common out-
patient physical therapy diagnoses and
practicing examination and evaluation
skills on mock and real patients.
e CCPE greatly prepared me for this
experiences and many students exceeded clinical having previous experience of
these expectations. Figure 4 displays the practicing in the acute care setting with
percentage of students who exceeded per- a professor before participating in this
formance expectations for each clinical ed- clinical experience. It was also beneficial
ucation experience. having observation experiences in the
Narrative responses from students and acute care setting throughout our
clinical instructors on the CPI suggest that curriculum.
the integrated laboratory model for teaching I also think doing the CCPE’s was helpful
clinical skills and clinical decision making to realize we are treating the whole person
leads to successful preparation for clinical and to put everything together. I feel like
going into this clinical I was extremely
well prepared. I really appreciate going
over standardized tests and knowing the
different ones for balance and gait etc. I
felt comfortable with evaluations and
examinations. I think the curriculum re-
ally prepared me well for this setting.
I believe the pediatric related course-
work was very sufficient in preparing me
for this clinical experience. I felt like I
had the foundational information for
various diagnoses and had the resources
to look information up when I had
questions. I also feel like I had basic
manual and handling skills when
working with infants. I especially
enjoyed the pediatric patients that came
into laboratory because that was a real-
life situation/scenario.
All 59 students passed the NPTE after
graduation; 98.3% passed on the first attempt.
Journal of Physical Therapy Education Vol 34, No 3, 2020
 Table 2. Comprehensive Clinical Performance Examination Outcomes

First-Time Total Pass After First Total Pass After Third Exemplary Overall Pass,
Semester Pass, No. (%) Attempt, No. (%) Attempt, No. (%) Performance, No. (%) No. (%)
1 61 (98.39) 62 (100) 6 (9.68) 62 (100)
2 54 (88.52) 61 (100) 10 (16.39) 61 (100)
3 58 (95.08) 61 (100) 11 (18.03) 61 (100)
4 58 (96.67) 59 (98.33) 60 (100) 3 (5.00) 60 (100)
5 58 (96.67) 60 (100) 1 (1.67) 60 (100)
6 59 (98.33) 59 (98.33) 59 (98.33) 1 (1.67) 59 (98.33)

DISCUSSION AND CONCLUSION
is model was designed and implemented to
reinforce motor learning strategies in clinical
skill development, increase experiential learn-
ing opportunities, and promote clinical rea-
soning across the curriculum. Outcomes
demonstrate that this model of teaching clini-
cal skills and clinical reasoning across content
areas in the context of the patient and client
management model was successful in meeting
expected student outcomes. Because the in-
tegrated laboratory model was implemented in
the context of a larger curriculum revision,
there were associated confounding variables
that limit opportunities to isolate the impact of
the model on student outcomes. Although
comparison between models is beyond the
scope of this article, variance of student
learning outcomes between the nonintegrated
and integrated models is inadequate for sta-
tistical analysis, with both models resulting in
similar student outcomes related to success on
clinical experiences, postgraduation employ-
ment, and NPTE pass rates. In the absence of
Figure 4. Student Outcomes Related to CPI Performance Above the Course
Requirement. CPI = Clinical Performance Instrument
significant differences in student outcomes
between models, future studies could examine
outcome differences related to faculty work-
loads and engagement of the clinical commu-
nity in the academic program partnerships.
Essential to this model is the consistency of
a single instructor of record over consecutive
integrated laboratory courses (one laboratory
director for semesters 1–3 and a second labo-
ratory director for semesters 4–6). Because
these faculty members are involved in multiple
clinical science content areas and are familiar
with the content taught, the laboratory direc-
tors become experts on the curriculum and
have firsthand knowledge of students’ previous
clinical skill development. is unique knowl-
edge and perspective facilitate the creation of
experiences that allow for distributed practice
of previously learned skills and well as pro-
gression of performance expectations related to
those skills. e laboratory director has specific
knowledge of how each skill was taught and
can reinforce important concepts with confi-
dence. Additionally, the laboratory director
becomes the point of contact for students and
other faculty members for all things related to
laboratory learning because of their in-depth
knowledge of content across the curriculum.
For example, students learn how to assess
vital signs in the first semester. e laboratory
director knows the specific expectations of how
these skills should be performed, is familiar
with how students were exposed to the skills,
can reinforce practice in subsequent classes
with the same expectations and can progress
expectations with regards to accuracy and effi-
ciency of skill performance. e laboratory di-
rector can thread this skill through assessment
of the well adult, individuals with pathology,
across the lifespan and in unique situations.
is allows for application of motor learning
principles through distributed practice of clin-
ical skills7,9,10 with progressive expectations re-
lated to complexity, efficiency, and flexibility,
and requires the learner to consider the skill
within the context of the situation, thus further
challenging clinical reasoning abilities.10
In addition to student outcomes, there are
several curricular outcomes that have been en-
hanced with implementation of the integrated
laboratory model. is model allows for im-
proved integration of clinical sciences and
a laboratory environment that more closely
reflects clinical practice. Because patients seek-
ing physical therapy treatment frequently have
impairments in multiple domains,25-28 and
multiple domains contribute to the movement
system,29 teaching and practicing skills across
domains promotes physical therapy manage-
ment of the patient as a whole. is model
allows for consistent exposure to a comprehen-
sive and holistic approach to patient care. e
integrated laboratory model has also contrib-
uted to increased faculty communication and
collaboration in development of experiential
learning opportunities that cross content areas.
Although increased collaboration among faculty
is required, individual faculty are asked to forgo
some of the dedicated, content-specific labora-
tory time to promote integrated experiences.
e use of experiential learning in de-
velopment of clinical skills and clinical rea-
soning is supported by the literature.18,30 is

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 model allows for early and frequent exposure
to real clinical situations and the use of re-
flection after these experiences helps students
to integrate the impact of simulations and pa-
tient encounters on their future practice
and to gain confidence in providing quality
care.24,31-33 e pairing of experiential learning
and reflection is intentional to promote the
development of clinical reasoning skills. ese
authentic experiences with patients, distrib-
uted across the curriculum, encourage the
translation of skills from the laboratory setting
to clinical practice.
Student feedback about the integrated lab-
oratory learning model has been positive. ey
feel confident in their abilities to integrate the
various clinical sciences together to treat the
whole person. ere are benefits for the faculty,
as well. is type of laboratory course design
promotes faculty engagement and interaction.
No longer are faculty teaching their individual
courses in isolation but rather faculty are
coming together to plan laboratories that sup-
port multiple clinical science courses. For ex-
ample, in semester 5, the neuromuscular and
musculoskeletal courses faculty coordinate an
entire lecture and laboratory experience around
concussion management and how one would
preferably manage a patient with a concussion,
highlighting content from the musculoskeletal
and neuromuscular physical therapy courses.
Implementation of this model has shown
several benefits, but there have been several
challenges. With more faculty involved in the
laboratory to maintain content expertise as
well as appropriate faculty to student ratios,
more consideration has been paid to sched-
uling, coordinating, and preparing for labo-
ratory sessions. Although time intensive
initially, this has become less burdensome in
subsequent years based on experience. Addi-
tional challenges are posed when clinical skills
do not integrate seamlessly across the clinical
science course content being taught.
e challenge in the role of laboratory di-
rector is the need to have knowledge and skill
across content areas and strong organiza-
tional skills to ensure that all laboratory
objectives from multiple domains are
addressed. In recognition of the fact that the
laboratory director does not possess expertise
in all fields of physical therapy, this model
requires that several content experts be pres-
ent in each laboratory class to ensure con-
temporary expertise. Associated faculty from
the community that have content expertise
are frequently used as laboratory assistants to
ensure that students are getting contemporary
expertise. Although this poses challenges in
recruitment and scheduling, there is immea-
surable benefit in the collaboration and in-
volvement of community clinicians within the
department.
240
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Assessment of the model is ongoing. Areas
of interest moving forward will be assessment
of skill development and retention, assess-
ment of individual laboratory activities in
meeting learning outcomes, expansion of ex-
periential learning opportunities, and assess-
ment of clinical reasoning skills resulting
from model implementation.
CONCLUSION
A model for teaching clinical skills across con-
tent areas was implemented in an entry-level
DPT program and was successful in meeting
expected student and program outcomes. Ini-
tial assessment of the model is positive related
to both didactic and clinical outcomes. e
integrated laboratory framework can be used by
programs using different curriculum models by
adjusting the content to correlate with con-
current classroom learning. Assessment of the
model and related outcomes is ongoing, and
refinement of the model will continue through
evaluation of assessment data.
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ERRATUM

Letter to the Editors: Erratum

In the Letter to the Editor that appeared on page 94 of the June 2020 issue, the author information incorrectly listed the location of
Saint Mary’s University. e correct city is Los Angeles, California.
Lee, Alan Chong W. Letter to the editors. J Phys er Edu. 2020;34 (2):94–95.

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