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Mandatory Continuing Education in Physical Therapy: Survey of Physical Therapists in States With and States Without a Mandate

MR Landers, PT, DPT, OCS, is Assistant Professor, Department of Physical Therapy, School of Health and Human Sciences, University of Nevada, Las Vegas, 4505 Maryland Pkwy, Box 453029, Las Vegas, NV 89154-3029 (USA) (merrill.landers{at}ccmail.nevada.edu).
JW McWhorter, PT, PhD, is Associate Professor, Department of Physical Therapy, School of Health and Human Sciences, University of Nevada, Las Vegas
LL Krum, PT, PhD, is Assistant Professor, Department of Physical Therapy, Rueckert-Hartman School for Health Professions, Regis University, Denver, Colo
D Glovinsky, PT, MSPT, is Staff Physical Therapist, St Joseph's Hospital and Medical Center, Phoenix, Ariz
Dr Landers, Dr McWhorter, and Dr Krum provided concept/idea/research design. All authors provided writing and data collection. Dr Landers provided data analysis and project management. Dr Landers and Dr McWhorter provided fund procurement, subjects, and facilities/equipment

Address all correspondence to Dr. Landers

Submitted August 25, 2004; Accepted March 11, 2005

	Abstract

 
Background and Purpose. Although formal continuing education (CE) in physical therapy is one part of professional development, its value for renewing licensure is not shared by all states. The purpose of this study was to explore the differences in how physical therapists pursue formal continuing education on the basis of state mandate, sex, years of experience, practice specialty, American Physical Therapy Association membership, motivation, and perception of the benefits of CE. Subjects and Methods. A survey questionnaire was sent to 3,000 physical therapists in 7 states—1,500 to physical therapists in states with mandatory CE and 1,500 to physical therapists in states without a requirement. A total of 1,145 usable survey questionnaires were returned, for a response rate of 38.2%. Results. Physical therapists in states with mandatory CE averaged 33.8 hours of CE per year, whereas physical therapists in states without a mandate averaged 28.3 hours per year; 5.9% of therapists in states without a mandate reported taking no CE at all, and 10.8% reported taking 2 or fewer hours of CE within the preceding 5 years. No statistically significant relationships were observed between the amount of CE taken and years of experience, sex, or practice specialty. Therapists who reported membership in the American Physical Therapy Association participated in 7.2 more hours of CE per year than therapists who did not report membership. Significant motivational variables that respondents noted for taking CE were state mandate, increased clinical competence, and certification. Therapists overwhelmingly (96.2%) believed that CE had a beneficial effect on their clinical practice. Discussion and Conclusion. Results from this study suggest that mandatory CE does have a significant association with the number of formal CE hours taken by physical therapists.

Key Words: American Physical Therapy Association: policies, positions, and standards • Education: continuing • Education: professional • Professional issues

	Introduction

Top Abstract Introduction Method Results Discussion Conclusion References

 
Continuing education (CE) is a common professional pursuit for health care practitioners. Health care practitioners (ie, physicians and nurses) have been reported to spend between 1 and 3 weeks per year on professional CE meetings.^1–5 There are many reasons why health care practitioners participate in CE, but one logical reason is to enhance clinical practice to improve the quality of patient care. Health care practitioners also participate in formal CE because it is a crucial component of professional development^6,7 and is a practical way to stay abreast of ongoing changes in the health care environment.⁸ By participating in CE, practitioners also are afforded the opportunity to learn emerging science, apply innovations in clinical settings, and expand understanding of caring for patients.⁹

Participation in CE is a way to prevent professional obsolescence⁸ by staying current with new developments in theory and practice and to prevent skill and knowledge deterioration. The concept of obsolescence assumes that physical therapy practitioners who fail to keep up with new knowledge, skills, and scientific information become obsolete in their professional knowledge and skill set at the same rate at which scientific knowledge increases.¹⁰ Additionally, Campbell¹¹ proposed that participation in CE, in light of rapidly expanding knowledge, should be a constant in a person's professional life. This well-ordered, sustained progress of professional learning, which has been termed "intellectual fitness," is unlikely to be achieved and maintained simply through infrequent remedial sessions and sporadic bursts of participation.¹¹

Although formal CE is not the only way to stay abreast of new knowledge, skills, and scientific information, it has been shown to be an effective conduit for positive change in professional practice^12–14 and patient health outcomes.^13,15–17 Thomson O'Brien et al¹⁸ included 32 randomized or quasi-experimental studies in their systematic review of the literature investigating the effect of CE meetings on the clinical practice of health care professionals or health care outcomes. Although there were substantial variations in the complexity of targeted behaviors, baseline compliance, characteristics of interventions, and study results, they concluded that workshops and workshops combined with didactic presentations led to moderate to moderately large changes in professional practice. Umble and Cervero¹⁶ drew 2 important conclusions from their critique of the literature, which was essentially a systematic review of systematic reviews investigating the effectiveness of CE by meta-analyses, vote count, and narrative review: (1) CE can improve knowledge, attitudes, competence, performance, and patient health status across the health care professions, and (2) measurable changes are most likely in knowledge and competence and then in performance and patient health outcomes.

More recent research by Robertson et al¹⁷ identified 15 research syntheses (systematic reviews), published after 1993, in which primary CE studies were evaluated and the performance of health care professionals or patient health outcomes were examined. Their findings confirmed previous research¹⁶ indicating that CE can improve knowledge, skills, attitudes, behavior, and patient health outcomes. In addition, they suggested that, "On the research front, primary studies and syntheses no longer need to ask if CE, in general, improves practice or other outcomes because there is so much evidence that many kinds and combinations of CE can do so."^17(p154)

On the basis of a recommendation made by the National Advisory Committee on Health Manpower in 1967,¹⁹ health care professions began mandating CE as a way to ensure that health care professionals were constantly maintaining and improving the original quality of their professional education. Their recommendation stipulated that all professional associations and governmental regulatory agencies should take steps to ensure the maintenance of competence in their individual professions. However, despite this far-reaching recommendation, few health care professions (eg, medicine, nursing, occupational therapy) have established a nationwide consensus on mandatory CE (Tab. 1).^20–24 This situation has led to a lack of unanimity from state to state on what kind of CE is needed, how much CE is needed, and when health care providers should participate in CE. This situation includes the physical therapy profession. At present, only 29 states and the District of Columbia mandate some level of CE to renew licensure (Tab. 2). The required amounts of CE vary considerably in these locations (10–20 hours per year). Moreover, there are considerable variations in the lengths of the renewal period for fulfilling this mandate in these locations (1–3 years). Recently, more external pressure has come from 2 entities, the Taskforce on Health Care Workforce Regulation of the Pew Health Professions Commission²⁵ and the Citizen Advocacy Center,²⁶ which have issued reports to recommend that states and licensing systems take steps to ensure the continuing competence of health care professionals.

It also should be considered that attending CE does not necessarily equate to increased competence. Rockhill³² suggested that it is fallacious to equate education with competence and accountability. Furthermore, Rothstein³³ and others^12,34 have questioned the quality and currentness of the content taught in many CE courses. However, perhaps the most compelling argument against mandatory CE is that an individual cannot be forced to learn.^32,35,36 Although these arguments against mandatory CE appear valid, studies presenting physical therapists' and other allied health professionals' opinions on alternatives to mandatory CE indicate that periodic retesting,^37,38 peer review, or on-the-job performance evaluations are even less appealing.³⁹

At present, some states without a mandate are considering the impact of implementing mandatory CE for renewing licensure.⁴⁰ However, there is little information in the literature to evaluate the consequences of such action. A search of the literature relating to physical therapy and other health care professions resulted in few recent articles devoted to mandatory CE. This finding may indicate that the debate may not have the support it had in the 1970s and 1980s, when most of the research on mandatory CE was being conducted.⁴¹

Despite the fact that a mandate for CE has been a part of many states' practice acts for more than 20 years, no studies have examined the impact of this legislation on the amount of formal CE pursued by licensees. The purpose of the present study was to compare the numbers of formal CE hours taken by physical therapists who are and physical therapists who are not compelled by a state CE mandate for renewing licensure. This information may provide a basis for judgment for states considering the impact of implementing mandatory CE. Our study was guided by 4 questions.

1. What is the difference in the amounts of formal CE pursued by physical therapists in states with mandatory CE requirements and those in states that do not require CE?
   
2. Are variables such as a person's sex, years of experience, APTA membership, and practice specialty associated with the amount of formal CE that a physical therapist pursues?
   
3. What factors motivate physical therapists to pursue formal CE?
   
4. Do physical therapists perceive that formal CE has improved their clinical practice?
   

	Method

Top Abstract Introduction Method Results Discussion Conclusion References

 
Design and Subjects

A cross-sectional survey was used to gather data for this study. A questionnaire was mailed to 3,000 physical therapists in 7 western states (Tab. 3). These states were chosen because they were similarly sized, had relatively similar urban and rural physical therapist populations, and had no recent changes (ie, within the last 5 years) in their licensure laws pertaining to mandatory CE. Mailing labels were obtained from each state licensure board. Systematic random sampling techniques (ie, every fifth mailing label) were used to select all participants. Of the 3,000 total questionnaires, 1,500 were sent to randomly selected physical therapists in 3 states without mandatory CE (Colorado, Idaho, and Utah). This number represented 21.28% of the licensed physical therapists in those states. Likewise, the remaining 1,500 questionnaires were sent to randomly selected physical therapists in 4 states with mandatory CE (Washington, Nevada, Montana, and New Mexico). This number represented 24.52% of the licensed physical therapists in those states.

Procedure

The questionnaire was mailed to the sample population in May 2002. A follow-up postcard was mailed to each of the 3,000 physical therapists surveyed approximately 4 weeks later as a reminder to increase the response rate. The postcard served as a reminder to return the survey questionnaire and instructed those who had lost or misplaced the questionnaire to visit a Web site and submit their questionnaire responses electronically.

Data Analysis

All data were analyzed with SPSS, version 11.0.^* Descriptive statistics were used to summarize responses as means, percentages, and frequencies. To test the relationship between categorical variables of 2 or more sets of responses, data were arranged in a contingency table (cross-table). The CE hours were arranged in 4 intervals (<20 hours, 20–29.9 hours, 30–39.9 hours, and 40 hours) to limit the influence of outliers. These data were cross-tabulated with other categorical variables and analyzed with chi-square tests. Independent sample t tests also were used to examine the differences between mean CE hours. Ordinary least squares regression analysis was used to analyze Likert scale responses regarding motivation for attending CE.

	Results

Top Abstract Introduction Method Results Discussion Conclusion References

 
Respondents

Survey questionnaires were received from 1,205 physical therapists (40.1% response rate). However, 60 responses were not included in the data analysis for various reasons (eg, the therapist was no longer working or living in 1 of the 7 study states; therapists held licenses in multiple states, with and without mandatory CE; questionnaires were filled out improperly; and forms were incomplete). Therefore, 1,145 responses were analyzed (38.2% usable response rate) (Tab. 3). Of this total, 708 responses (61.8%) were from states with mandatory CE requirements and 437 responses (38.2%) were from states without mandatory CE requirements. Of the total survey respondents, 70.3% (797) were women (336 were men) and 46.6% reported membership in APTA (532 members and 609 nonmembers). Figure 1 shows a breakdown of respondents by reported specialty practice area.

View larger version (51K): [in this window] [in a new window]   Figure 1. Frequency of respondents by reported physical therapist practice area.

View larger version (77K): [in this window] [in a new window]   Figure 2. Mean continuing education hours per year on the basis of state mandate, American Physical Therapy Association (APTA) membership, and sex.

View larger version (24K): [in this window] [in a new window]   Figure 3. Percentage of responses for hours of continuing education (CE) taken per year for physical therapists in states with and states without a mandate.

Sex, Experience, and Specialty

There were no statistically significant differences between male and female respondents and the number of CE hours taken during a given year (t=0.136; df=1,075; P=.892) (Fig. 2). Likewise, there were no statistically significant differences in respondent years of experience (²=150.885, df=132, P=.125). Although chi-square tests with the cross-tabulated CE data showed statistically significant differences between type of practice specialty and the number of annual CE hours taken, the tests were not reliable because some of the subgroups were not large enough to have normal distributions (Figs. 1 and 4).

View larger version (34K): [in this window] [in a new window]   Figure 4. Continuing education (CE) hours per year for therapists on the basis of physical therapist practice area.

The results of the regression analyses of motivational variables for physical therapists in states with mandatory CE were similar to those for the overall sample; however, only 2 variables were associated significantly with the number of CE hours taken. The more motivated a therapist was by the state requirement, the fewer the CE hours taken (b=–4.17, ß=–.313, t=–7.702, P<.001). The other statistically significant factor was clinical competence. Because of the large influence of mandatory CE on the model, the state mandate variable was excluded and another regression analysis was performed; the result was a reduction in the adjusted r² value. Although the full model explained approximately 11% of the variance (adjusted r²=.11), regression analysis without the state mandate variable explained only 2% of the variance (adjusted r²=.02). That is, the mandatory CE requirement appeared to have the most influence on the variance in the number of CE hours taken. When the state mandate variable was excluded from the analysis, the model explained very little variance, and only the clinical competence variable was significant. In states without a mandate, regression analysis showed that 3 variables (clinical competence, certification, and expansion of clinical practice) explained 10% of the variance (adjusted r²=.10).

Other Issues

The overwhelming majority of all respondents, 96.2% (95.6% of therapists from states with a mandate and 97.2% of therapists from states without a mandate), believed that they improved as physical therapists from their participation in CE.

	Discussion

Top Abstract Introduction Method Results Discussion Conclusion References

 
The purpose of our study was to explore differences in how physical therapists pursue CE on the basis of state mandate, sex, years of experience, practice specialty, APTA membership, motivation, and perception of how formal CE has improved their clinical skills. The results of this study indicate that physical therapists in states with mandatory CE participated in 5.5 hours more CE annually than those in states without mandatory CE. Although this difference may be intuitive, it does indicate that therapists who are not compelled by a state mandate participate, on average, in less CE. There were no statistical differences in CE hours reported on the basis of sex, years of experience, and practice specialty. Physical therapists who reported membership in APTA participated in 7.2 more CE hours annually than those who did not report membership in APTA. Although the effect sizes for the differences in the groups compared (5.5 hours for mandatory CE versus nonmandatory CE and 7.2 hours for APTA membership versus no membership) were statistically small, it could be argued that the practical differences are important considering the amount of learning that could occur over those time periods.

The overall CE hour means for therapists in states with mandatory CE (33.8 hours per year) and without mandatory CE (28.3 hours per year) demonstrate that, as a group, physical therapists attend significantly more CE than the amount required for renewing licensure in their respective states. Thus, most physical therapists are intrinsically motivated to pursue learning experiences. This behavior is consistent with that of other allied health care professionals, who are generally motivated by the pursuit of knowledge rather than by compliance with a mandate.⁴³ However, licensure requirements such as the CE mandate are not necessarily imposed for the general body of physical therapists, whose intrinsic motivation drives them to pursue more than their respective requirements; rather, they are often put in place for those few therapists who would not uphold a certain professional standard unless compelled to do so.^28,44 That is, CE mandates are for therapists who are not self-motivated to attend CE and would not attend unless compelled to do so by law. Houle⁴⁴ referred to these people as "laggards," who on their own tend not to devote many hours to CE; Houle further suggested that mandatory CE requirements are intended to target this group.

In our study, 5.9% and 10.8% of physical therapists in states without a mandate reported that they had not attended any CE and that they had attended fewer than 2 hours of CE in the preceding 5 years, respectively. However, this finding does not indicate that these respondents did not participate in any learning experiences (eg, self-study, mentorship), only that they did not attend formal, documentable CE. Interestingly, it has been reported in the nursing literature that the least educationally prepared nurses were the ones who most often refused to participate in CE.⁴⁵ Puetz⁴⁵ argued that this finding was a good rationale for making CE mandatory. Along the same lines, other authors have reported that more highly educated nurses not only were more in favor of mandatory CE⁴⁶ but also accumulated more hours of CE.⁴⁷ The support for mandatory CE in nursing is further highlighted by the finding that nurses most in need of mandatory CE were those who were least likely to take advantage of it.⁴¹ The justification for a mandate becomes even more salient when one considers the typical nonattender (ie, least educationally prepared and most in need of CE), who is minimally prepared for practice (ie, basic education) and is currently treating patients. We believe that future research should investigate the relationships among CE attendance, education level, and clinical competence.

In our study, therapists who were not compelled by a mandate still participated, on average, in 28.3 hours of CE per year. These results parallel data from the nursing literature, which suggest that nurses attended CE for reasons other than meeting employer or state requirements.^47,48 In a study of 87 nurses, the nurses reported attending an average of 13 programs per year—more than double their requirements.¹⁹ In addition, physical therapists from states with mandatory CE (Montana, Nevada, New Mexico, and Washington) reported taking more hours than their required annual CE mandates (28.5%, 64.7%, 52%, and 97% more hours, respectively) (Tab. 4). Taken together, these results indicate that respondents, in general, were motivated beyond their respective licensure mandates.

Physical therapists who reported professional membership in APTA participated in more CE than those who did not. This result was not surprising, because both CE attendance and APTA membership are professional responsibilities. That is, members of APTA may be more likely to participate in CE because they have a strong sense of professional identity. The results of the present study parallel the results of a survey study of registered nurses, which showed that those who belonged to a professional organization accumulated, an average, 10 more hours of CE per year than those who did not belong.⁴⁷ In addition, survey research conducted by Brinski and colleagues⁴⁹ suggested that physical therapists who are members of APTA overwhelmingly (81.8%) believe that CE should be mandatory.

In the present study, state mandate, increased clinical competence, and certification were significant motivational variables for taking CE for all respondents. Increased clinical competence appears to be the strongest motivating factor for attending CE. This finding is consistent with the findings of other studies,^31,41 which showed that the most important reason to participate in CE was to increase job competence. However, for physical therapists practicing in states with mandatory CE, the strongest motivating factor was the state mandate. Interestingly, the more a therapist was motivated by the state mandate, the fewer the CE hours taken. For each step increase in motivation on the 5-point state mandate Likert scale, the respondent took 4.17 fewer CE hours per year. This result probably indicates that those therapists took only the required amount of CE and simply were not motivated beyond the requirement. These findings could mean that the mandate is an excellent motivator or simply a compulsory nuisance for a large number of therapists in states with a mandate. However, this model explained only 4% of the variance (r²=.044); this result indicates that other variables that could not be explained by this model influence CE.

Physical therapists in states without mandatory CE were motivated by clinical competence, expansion of clinical practice, and certification. However, the models used in the present study explain only a small portion of the variance, suggesting that other factors also may play a motivational role; these include technologic innovations, research, and the development of new procedures.⁵⁰ Likewise, other incentives include fostering of community participation, social interactions, relief from routine or boredom,⁴³ rewards by employers,⁴¹ salary advancement,²³ increased demands by the public for professional accountability,¹² feelings of inadequacy,⁷ and increased opportunity for networking.

In the present study, 96.2% of all respondents reported that they had improved as physical therapists from their participation in CE. We made no attempt in this study to investigate what the particular improvements were. We asked this question only to discover whether therapists universally reported a perceived benefit. That is, even therapists who attended CE only to satisfy a requirement reported a beneficial effect as a result. The results of this study parallel the results of a study by Mays,⁵¹ who also described physical therapists' self-reported improvement as a result of CE. Other researchers examining the effectiveness of mandatory CE have reported similar findings. McCormick and Marshall²⁷ reported that 80% of physical therapists in New South Wales, Australia, considered that mandatory CE enhanced their clinical practice. Research from a wide collection of health care professions that have adopted mandatory CE has indicated that approximately 72% of respondents believe that mandatory CE makes them better practitioners.¹⁴ Similarly, research has indicated that nurses who attend CE believe that they are more competent in practice than nurses who do not attend CE.⁵²

In contrast to the many beneficial reports about CE in the literature,^12–17 there have been some concerns about mandating CE.⁵³ These concerns may stem from dated research. In a survey of physicians in 1988, 79% reported that implementation of mandatory CE had "no effect" on their ability to care for their patients.⁵⁴ In another survey of physicians in 1987, the authors concluded that there is "no scientific evidence to endorse a relationship between mandatory CE participation and improved patient care."^55(p25) In a study in 1970, CE was reported as having little effect on how respondents actually practiced their professions.⁵⁶ In addition, other authors have suggested that the costs of implementing mandatory CE would have a negative impact on patients by ultimately increasing costs because of state expenses (staffing and managing the mandate),^39,57 practitioner expenses (tuition, travel, time off, and increases in state licensure fees to offset the state's expenses), employer expenses (tuition, travel, and time off), and patient expenses (increased fees to offset costs).²⁹

The primary limitation of this study was the low response rate (40.1% total; 38.2% usable), which raises the possibility of responses that do not reliably reflect the entire population of physical therapists. It is conceivable that nonrespondents may have had CE attendance patterns and views on CE different from those of our respondents. In addition, the fact that the response rates were different for states with and for states without a mandate indicates that some type of bias (eg, stakeholder response bias) likely played a role. Therefore, in light of this potential bias, the results of this study should be interpreted with some caution. Another limitation is that the motivation questions were attitudinal in nature and represent only a point in time; therefore, they are subject to change. Another limitation is that only formal CE, which is only 1 component of professional development, was investigated. We believe that future research should investigate all modalities of CE, including nonformal CE (eg, mentorship, self-study). Future research also should investigate the amount of accumulated CE that relates directly to current or future work, because it has been demonstrated that nurses who practice under a mandate take more course work that is unrelated to their current or future work.⁴⁷

We believe that the percentages of physical therapists not attending CE and physical therapists with minimal attendance (5.9% and 10.8%, respectively) are probably conservative estimates and that the actual percentages of therapists not attending CE or with minimal attendance actually may be higher. We had a lower rate of return from therapists in states without a mandate than from therapists in states with a mandate; this result may have been attributable, in part, to therapists' reluctance to report something that would reflect negatively on them or their state or both (stakeholder response bias). In addition, it is also possible that some respondents were strongly motivated (or not) by the topic or questions and that this factor may have skewed not only responses but also response rates. It is possible that the lower response rate from states without a mandate was attributable to a lack of regular CE record keeping, which not only may have skewed therapists' answers but also may have discouraged some from answering for fear of reporting inaccurate information. Additionally, therapists who pursue CE may be more likely to have responded to the questionnaire. It is also possible that therapists were more likely to answer the questionnaire if they were unhappy or disagreed with mandatory CE.

	Conclusion

Top Abstract Introduction Method Results Discussion Conclusion References

 
The results of our study suggest that most physical therapists are intrinsically motivated to pursue formal CE. However, therapists reported 28.3 hours of CE per year over the preceding 5 years in states without mandatory CE compared with 33.8 hours of CE per year over the preceding 5 years in states with mandatory CE. On the basis of our results, it appears that mandatory CE does have a significant, yet small, association with the number of formal CE hours taken by physical therapists.

	Footnotes

 
The Biomedical Sciences Institutional Review Board of the University of Nevada, Las Vegas, approved the testing procedure of this study.

This work was supported by a New Investigator Award from the Office of Research Services, University of Nevada, Las Vegas.

This research was presented, in part, at the Combined Sections Meeting of the American Physical Therapy Association; February 4–8, 2004; Nashville, Tenn.

^* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.

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Top Abstract Introduction Method Results Discussion Conclusion References

 

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