RESEARCH REPORT - Joyce Maring, PT, DPT, EdD, Ellen Costello, PT, PhD, Margaret Ulfers, PhD, and Elisa Zuber, PT, PhD

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1 RESEARCH REPORT - Curriculum, Faculty, and Cohort Variables Predicting Physical Therapist Assistant Program Graduate Success on the National Physical Therapy Examination Joyce Maring, PT, DPT, EdD, Ellen Costello, PT, PhD, Margaret Ulfers, PhD, and Elisa Zuber, PT, PhD Background and Purpose. Evidence for curriculum, faculty, and student cohort factors associated with success on the National Physical Therapy Examination (NPTE) for physical therapist assistant (PTA) program graduates is important to inform decisions about designing and implementing a quality education program. The purposes of this study were the following: (1) to examine relationships among PTA curriculua, faculty, and cohort factors, as defined by variables available in annual reports submitted to the Commission on Accreditation on Physical Therapy Education (CAPTE), and program first-time and ultimate pass rates; and (2) to develop logistic regression models that best predict success on the PTA licensure exam using those factors. Joyce Maring is an associate professor and program director of the Program in Physical Therapy, The George Washington University, rd Street, Washington, DC (maringj@gwu. edu). Please address all correspondence to Joyce Maring. Ellen Costello is an associate professor and associate director of the Program in Physical Therapy, The George Washington University, Washington, DC. Margret Ulfers is an adjunct faculty in the Department of Epidemiology and Biostatistics in the School of Public Health and Health Services at The George Washington University, Washington DC. Elisa Zuber is an associate professor and program chair of physical therapist assistant programs, and program director of the Physical Therapist Assistant Program at South University in High Point, North Carolina. This study was approved by the Institutional Review Board of The George Washington University. Received June 2, 2011, and accepted January 31, Subjects. De-identified retrospective data from 178 accredited PTA programs in the United States in 2005 were included. Methods. Descriptive statistics were used to summarize curricula, faculty, and cohort variables. Associations between first-time and ultimate pass rates and the variables were quantified using Spearman rank correlations. The odds of either firsttime or ultimate pass rates of program graduates on the NPTE were examined using logistic regression models. Results. Significant bivariate relationships were found between first-time success on the NPTE and increased laboratory contact hours, academic clinical coordinator of education (ACCE) program experience, decreased graduation rate, and no required CAPTE progress report. Significant bivariate relationships were found between ultimate NPTE success and laboratory contact hours, decreased graduation rates, and institutional status (public versus private). Program graduates completing curricula with increased laboratory hours and decreased clinical education hours, and graduating from programs with lower graduation rates had significantly increased odds of both first time and ultimate NPTE success. Graduates from programs with a higher minority enrollment percentage were less likely to pass the NPTE on the first or subsequent attempt. Graduates from programs required to submit progress reports 2 or more years following an onsite accreditation review were less likely to pass the NPTE on the first attempt. Graduates from programs placed on probation in the last 8 years were significantly less likely to ultimately pass the NPTE. Lower student/faculty ratios increased the odds of ultimate NPTE success. Discussion and Conclusion. Understanding the optimal ratio of clinical and laboratory experiences requires more prospective investigation; however, our findings suggest programs should consider including sufficient laboratory experiences in the curriculum that model the range of physical therapist assistant entry-level data collection and intervention skills. Increasing the number of faculty per student to provide instruction also may be an important consideration. Rigorous graduation standards may positively influence NPTE success. Program compliance with accreditation standards appears also to increase the success of program graduates on the licensing exam. Understanding the factors that contribute to the NPTE success of graduates from programs with higher minority enrollment is critical to meeting the goal of enhanced diversity in the profession. Key Words: National Physical Therapy Examination, Physical therapist assistant, Educational outcomes. BACKGROUND AND PURPOSE As we move into the 21st century and the average age of the United States population continues to increase, the need for qualified physical therapists and physical therapist assistants continues to grow. Schools need to graduate qualified students to meet this demand. Therefore, finding prediction models that identify student and program characteristics associated with success of licensure and work-readiness is key. Although nursing educators have a long history of investigating factors that predict student academic success, 1-4 the literature reveals few studies that address physical therapist (PT) student success and fewer still that address physical therapist assistant (PTA) Vol 27, No 2, Spring 2013 Journal of Physical Therapy Education 33

2 student success. Given that research that explores PTA student success is scarce, the literature reviewed in this article draws upon student success in PT programs, as it more closely approximates the educational experiences of PTA students compared to other health care professionals. Student success has been defined in a variety of ways in PT programs: successful completion of a PT program, grade point average (GPA) in the professional program, passing the National Physical Therapy Examination (NPTE), etc. Cognitive characteristics associated with student success in PT programs, as well as on the NPTE, include preadmission criteria such as standardized tests, 5, 6 preprofessional grade point average (GPA), 5-11 Graduate Record Examination (GRE) scores, 8,11 and standardized reading tests. 12 A recent investigation including 72 PTA graduates indicated that PTA GPA was significantly correlated with NPTE scores. 13 Demographic characteristics such as ethnicity and age also have been cited in the literature when examining student success. Physical therapist students of an ethnic minority were less likely to be successful on licensing exams 14 and were more likely to experience academic difficulty. 10 Age as a predictor of academic success has had mixed results. Utzman et al, 10 Dockter, 7 and Thieman and colleagues 8 all demonstrated a negative association between age and physical therapist student academic success. In contrast, Beeson and Kissling, 1 in a study of nursing students, found that nontraditional college age students (> 23 years) had higher passing rates on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) than those of traditional age. Beeson and Kissling 1 attributed their findings to a more disciplined older student who was able to handle multiple roles; Utzman and colleagues 10 postulated that other factors, such as responsibilities in the home, may impact the older students outcomes. Although student characteristics play a significant role in predicting future academic success, these factors can only partially explain the variability in physical therapist student outcomes. Therefore, the association between education program characteristics and student success also has garnered interest. Institutional geographic region has been associated with performance on the NPTE and likelihood of experiencing academic difficulty. Students from southern institutions had 1.8 times the odds of NPTE failure when compared with students from northeastern institutions. 10 Mohr and colleagues 15 examined the relationship between physical therapist education program characteristics and performance on the NPTE and found that accreditation status (probation versus nonprobation), along with other faculty and program characteristics, accounted for 30.2% of the variance in pass rate scores on the NPTE. Only 1 published study has investigated the relationship between institutional characteristics and physical therapist assistant student outcomes. Maring and Costello 16 found that PTA graduate pass rates were positively correlated with newer, public programs, with more clinical education credits. The authors noted that the relationship between clinical education credits and contact hours in clinical education was inconsistent among programs. To be licensed as a PTA in most jurisdictions within the United States, candidates must graduate from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) and pass the NPTE, constructed and administered by the Federation of State Boards of Physical Therapy (FSBPT). 17 One of the standards required of programs by CAPTE criteria is an ultimate NPTE pass rate average of at least 80% for the most recent 3 years. 18 Ultimate pass rate is defined as the total number of candidates who pass the licensing exam, regardless of the number of attempts. Accreditation serves 2 primary functions: (1) institutional or program quality improvement among its members, and (2) an assurance of quality to the public. 19 Investigations examining the association between licensure pass rate and program accreditation mostly are limited to professions where accreditation is voluntary and program graduates from unaccredited programs are permitted to take the licensing exam. Thus, the studies compare graduate pass rates from accredited versus nonaccredited programs. 20,21 In these studies, graduates from accredited programs scored significantly higher on the national certification examinations. Only 1 study was found that examined the impact of accreditation on physical therapist licensure pass rates. Mohr et al 15 found that pass rates of graduates from programs placed on probation by CAPTE were significantly lower than programs not placed on probationary accreditation. Given the mission of CAPTE to apply standards that assure quality, 22 it appears reasonable that graduates of programs judged to be noncompliant with quality standards as indicated by a probationary status or required progress reports for 2 or more years following an onsite visit are at higher risk for failing the NPTE. The purposes of this study are the following: (1) to examine relationships among characteristics of PTA curricula, faculty, and student cohorts with program first-time and ultimate pass rates for PTA programs, using data available from the Annual Accreditation Reports (AARs) required by CAPTE; and (2) to develop logistic regression models that best predict first-time and ultimate pass rate success on the PTA licensure exam. METHODS Sample Retrospective data from all accredited PTA programs in the United States in 2005 were included in this study. Following institutional internal review board approval, CAPTE provided the investigators with de-identified summaries of program variables and licensure pass rates based on annual accreditation reports submitted by all 217 accredited PTA programs. Programs were included in our study if more than 50% of its graduates completed the NPTE in 2005, or if they had complete information for the variables under consideration. All of the data is at the program-level only. The FSBPT posts first-time pass rates 1 year following graduation and ultimate pass rates approximately 2 years following graduation in order to allow students sufficient time to re-test. At the time the data was requested, the most current ultimate pass rates were for the 2005 graduates. Data Analysis Descriptive statistics and data analyses were generated using SAS Version In order to quantify the relative weight of the technical education in the curriculum, as well as facilitate comparisons across institutions, credits were expressed as a percentage of the total credits required to complete the program. 16 Technical education is defined by CAPTE as the courses in the technical education portion of the PTA curriculum generally open to and taken only by students accepted into the PTA program. 24 Given that data were not normally distributed, Spearman rank correlations 25 were used to quantify associations between first-time and ultimate pass rates for the student, faculty, and program characteristics. To take into account the large differences in the size of the programs (ie, the number of students attempting the exam) and the nominal nature of the outcome (passing or failing), logistic regression models with an events per trial type of outcome were used. 26 This approach also takes into consideration that the available data were at the institutional program level as opposed to an individual student level. Therefore in the model, the trials are the number of examinations per educational institution, and the events are the number of examinations passed in each educational institution. All variables are held 34 Journal of Physical Therapy Education Vol 27, No 2, Spring 2013

3 constant at the level of the educational institution. This is a small modification to the more standard logistic regression model; however, it still yields the odds of an individual passing the NPTE given the educational program variables included in the model. 26 Both the odds of first-time and ultimate passing of students at each program were modeled. For each of these outcomes (firsttime and ultimate passing), bivariate models for each independent variable and models including all independent variables were generated. The choice of variables was restricted to those believed to be of greatest interest based on the relevant literature as well as available data, and to keep the number from exceeding the ratio of 10 subjects to each independent variable as recommended by Norman and Streiner. 27 To further assist interpretation, the odds ratios (OR) were reported for changes that would be most meaningful given the particular variable under consideration. For example, the OR is reported for curriculum contact hours for changes of 20 hours as opposed to a change of 1 hour. For some proportions, the reported ORs are for a change of 10 percentage points as opposed to comparing a value of 0 to 1, which unrealistically suggests either a 0% or 100% proportion in the variable under investigation. 28 Student Variables The following student variables were considered in the logistic regression: the percent of students identified as ethnic minorities, the percent of applicants accepted, and the proportion of students who graduated. Average student age was not considered, as many programs did not include this information in the AAR. Faculty Variables The total number of years of experience of the program directors and the academic clinical coordinators of education (ACCEs) in their faculty roles at their current program were considered. The ratio of students to core faculty also was included. Program and Curriculum Variables The percent of the program total credits devoted to the technical education phase was included as an independent variable, as were the numbers of contact hours for lecture, laboratory experiences, and clinical education. Total contact hours were considered a more reliable measure of student effort than credit hours given the lack of consistency among institutions in assigning credits per contact hour. In addition, the status (public versus private) of the institution in which the program was located was included as a variable. Table 1. Summary of Annual Report Data (N = 178) Curriculum Accreditation Variables Dichotomous variables (yes/no) were included to indicate whether or not a program was placed on a probationary status by CAPTE in the previous accreditation cycle and whether or not a program was required to submit a progress report 2 or more years following its most recent accreditation visit. RESULTS The sample consisted of 217 PTA programs for which we had data. Thirty-nine of these programs did not meet the inclusion criteria for data analysis. These programs reported no graduates taking the 2005 NPTE exam (n = 13) or that less than 50% of the graduates took the NPTE exam (n = 15), or they had missing information (n = 11) for some of the variables under consideration. Of the remaining 178 programs, 19 (11%) were located in private institutions. Twentyfour (13.5%) of the programs were placed on probation by CAPTE sometime in the previous 8 years, and 72 (40%) of the programs were required to submit a progress report to Mean Standard Deviation (SD) Lecture Contact Hours Lab Contact Hours Clinical Education Hours Percent Technical Credits Program Faculty Program Director: Years of Program Experience ACCE: Years of Program Experience Student Faculty Ratio Cohort Information Percent Accepted Percent Minority Enrollment Graduation Rate Student Pass Rates in 2005 First-Time Pass Rate Ultimate Pass Rate Abbreviation: ACCE, academic clinical coordinator of education. CAPTE 2 or more years following the onsite visit. Table 1 summarizes the descriptive data for the remaining variables. Bivariate Correlations Variables significantly and positively associated with program graduates passing the NPTE on the first attempt included the number of laboratory contact hours and the years of program experience of the ACCE. Variables significantly and inversely associated with passing the NPTE on the first attempt included submission of progress reports 2 or more years following the most recent accreditation visit and program graduation rates. Program ultimate success rate positively correlated with laboratory contact hours; as laboratory contact hours increased, so did the likelihood of the program s ultimate NPTE success. Graduation rates also significantly inversely correlated with ultimate NPTE success in addition to first-time NPTE success, as noted earlier (ie, as the graduation rate increased, NPTE ultimate success decreased). There also was an inverse correlation between Vol 27, No 2, Spring 2013 Journal of Physical Therapy Education 35

4 private (versus public) institutions and ultimate NPTE success (Table 2). First-Time NPTE Success The results of the logistic regressions indicated that significant predictors of firsttime NPTE success included the following: number of laboratory and clinical education hours, technical credit percentages, graduation rate, minority enrollment percentages, student-to-faculty ratio, ACCEs program experience, institutional status, and whether the program was required to submit progress reports 2 or more years following its accreditation visit. However, in the full model which adjusts for the influence of the other variables in the model 4 of the 9 variables drop out, with the following remaining variables significantly contributing to the model: laboratory hours, clinical education hours, graduation rate, minority enrollment percentages, and the need for a progress report more than 2 years following an onsite visit (Table 3) The adjusted odds ratio indicated that as laboratory contact hours increased by 20 hours and the clinical education hours decreased by 20 hours, the odds of first-time NPTE success increased 4.6% and 2.6%, respectively. As program graduation rates decreased by 10 percentage points, the odds of NPTE success increased by 8.7%; as the minority enrollment percentage increased 10 percentage points, the odds of NPTE success decreased by 10.1% (Table 3). Ultimate NPTE Success Eight unadjusted variables included in the logistic regression significantly predicted ultimate success on the NPTE: number of laboratory and clinical education hours, graduation rate, minority enrollment percentages, student-to- faculty ratio, ACCEs program experience, institutional status, and whether the program was required to submit progress reports 2 or more years following its accreditation visit. When variables were adjusted in the full model, 2 variables dropped out, leaving 7 predictors of NPTE ultimate success: number of laboratory and clinical education hours, minority student enrollment percentage, graduation rate, acceptance rate, probation history, and student to faculty ratio (Table 4). The adjusted odds ratio indicated that as laboratory hours increased by 20 hours and clinical education hours decreased by 20 hours, the odds of ultimate NPTE success increased 6.9% and 4.2%, respectively. As program graduation rates decreased by 10 percentage points, the odds of NPTE success increased by 6.6%. When the minority enrollment percentage increased 10 percentage Table 2. Correlations Between Progran Variables and NPTE Success Variable Lecture Contact Hours Clinical Education Hours Lab Contact Hours Graduation Rate Percent Accepted Percent Minority Enrollment Percent Technical Credits Student Faculty Ratio Program Director: Years of Program Experience ACCE: Years of Program Experience Progress Report Required > 2 years (no report = 0; report required = 1) Probation History (no probation = 0; probation = 1) Institutional Status (public = 0; private = 1) Abbreviation: NPTE, National Physical Therapy Exam. a Spearman rank correlation. b P <.05. points, the odds of NPTE success decreased by 12.2%. As the acceptance rate increased by 10 percentage points, the odds of NPTE ultimate success increased 8.0%. A decrease in the student-to-faculty ratio increased the odds of ultimate success by 4.6%. Additionally, if the program had a history of probation, the odds of ultimate NPTE success decreased 43.2%. First-Time or Ultimate NPTE Success r a P First Time Ultimate First Time Ultimate First Time b Ultimate b First Time b Ultimate b First Time Ultimate First Time Ultimate First Time Ultimate First Time Ultimate First Time Ultimate First Time b Ultimate First Time b Ultimate First Time Ultimate First Time Ultimate b DISCUSSION Graduates of programs with more laboratory contact hours and less clinical education hours had an increased likelihood of success on the first and ultimate NPTE attempt. The study described previously 16 explored the relationship of clinical education credits with program pass rates, but the sample size of the investigation was small and programs/institutions used different formulas for assigning credits to contact hours. Our study used the total number of clinical education contact hours in the curriculum, which is a more reliable measure of the clinical education intensity or effort requirement. There is little information in the literature supporting the influence of either laboratory practice or clinical practice on licensure examination outcomes for health care students. One study compared cohort outcomes for European medical students who participated in intensive skills laboratory training versus a group who practiced the required skills primarily in clinical internships. 29 The cohort completing laboratory training significantly outperformed the clinical internship group on the objective-structured clinical examination. The authors noted that the laboratory 36 Journal of Physical Therapy Education Vol 27, No 2, Spring 2013

5 Table 3. First Time Pass Rate Logistic Regression Model Predictor β SE β χ 2 df P Lecture Contact Hours b Clinical Education Hours b d AdjustedOdds Ratio a (95% CI).991 (0.964, 1.018).974 (0.949, 0.999) Lab Contact Hours b d (1.025, ) Graduation Rate c d (0.870, ) Acceptance Rate c d (0.996, ) Percent Minority Enrollment c d Percent Technical Credits c Student Faculty Ratio Program Director: Years of Program Experience ACCE: Years of Program Experience Progress Report Required > 2 Years d Probation History Institutional Status a Statistics reported based on the full model (df = 13), which included all listed variables. b Odd ratio (OR) given for comparing differences of 20 hours (e^[beta x 20]). c OR given for comparing differences of 10 percentage points (e^[beta/10]). d P <.05 Abbreviations: SE, standard error; df, degrees of freedom; CI, confidence interval..899 (0.857, 0.944) (0.921, 1.222).983 (0.995, 1.012) (0.980, 1.026) (0.996, 1.044).766 (0.622, 0.944).896 (0.659, 1.218).888 (0.655, 1.205) group was more likely to focus on required skills and set up a learning environment conducive to skill mastery, leading to more rigorous monitoring for mastery. Other investigations with medical students report that clinical practice without adequate training enhances confidence but not necessarily competence. 30,31 Although caution needs to be exercised in relating the experiences of medical students to physical therapist assistant students, PTA programs also design and implement laboratory experiences that model the breadth of specific data collection and intervention skills required for entry-level practice. On the other hand, the physical therapist and physical therapist assistant student clinical experiences are facility-specific and are likely not consistent or uniform across different students in the program. Additionally, studies found that PT and PTA student scores on APTA s PT/PTA Clinical Performance Instrument 32,33 were not related to NPTE scores. 8,13 Clinical practice is clearly complex and caution must be exercised when generalizing findings from this study or considering curricular changes that include alterations in laboratory and clinical education contact hours. The findings of this study do suggest, however, that programs should ensure that the curriculum includes adequate laboratory hours with structured activities modeling entry-level practice expectations. Vol 27, No 2, Spring 2013 Journal of Physical Therapy Education 37

6 Table 4. Ultimate Pass Rate Logistic Regression Model Predictor β SE β χ 2 df P Lecture Contact Hours B a Statistics reported based on the full model (df = 13), which included all listed variables. b Odd ratio (OR) given for comparing differences of 20 hours (e^[beta x 20]). c OR given for comparing differences of 10 percentage points (e^[beta/10]). d P <.05 Abbreviations: SE, standard error; df, degrees of freedom; CI, confidence interval. Adjusted Odds Ratio a (95% CI) (0.946, 1.017) Clinical Education Hours b d (0.926, ) Lab Contact Hours b d (1.041, ) Graduation Rate c d (0.877, ) Acceptance Rate c d (1.021, ) Percent Minority Enrollment c d (0.829, ) Percent Technical Credits c (0.811, 1.155) Student Faculty Ratio d (0.919, ) Program Director: Years of Program Experience ACCE: Years of Program Experience Progress Report Required > 2 years , 1.035) , 1.059) (0.660, 1.135) Probation History d (0.390, ) Institutional Status , 1.258) Similar to the findings of Mohr and colleagues, 15 we also found a negative association between probationary accreditation and ultimate NPTE success of PTA programs. First-time NPTE failure was more strongly associated with programs required to submit a progress report 2 or more years following their onsite visit. These findings appear to support compliance with accreditation criteria as an indicator of program quality. As no further information is available in the deidentified data, we were not able to determine what specific citations by CAPTE prompted the required progress reports or probationary status. Although NPTE success was negatively associated with program probationary status and required progress reports, when adjusting for other factors in the models probationary status was more strongly correlated with ultimate pass rate success and ongoing progress report as compared to first-time pass rate success. Judgment related to program quality performed in an accreditation review is both comprehensive and complex, and the data available to us only permitted a dichotomous representation of the accreditation reviews. It is likely that the reasons for the probationary status and the required progress report are diverse and could, if available, explain the differential impact on NPTE success. Graduates from programs with lower 38 Journal of Physical Therapy Education Vol 27, No 2, Spring 2013

7 graduation rates were more successful on the NPTE. Although graduation rates as a predictor of NPTE success has not been previously reported in the literature, it appears probable that program dismissal of underperforming students is related to the program s improved success on the licensure examination. The proportion of students accepted into the program also was a significant predictor of ultimate NPTE success. The results in this case were not easy to interpret as graduates from programs with higher acceptance rates were more likely to pass the exam. Many community colleges, however, have criterionbased admission processes and, therefore, acceptance rate may not reflect a competitive selection process. Lack of a competitive or potentially selective admission process also may explain the relationship of a decreased graduation rate to an improved likelihood of passing the NPTE, but the qualifications of the program applicants were not available to us in the data provided by CAPTE. Increased minority enrollment as a predictor of lower success rates on the NPTE was consistent with other findings described in the literature for physical therapist students. 10,14 Clearly this is an area that requires more indepth and prospective investigation. Unfortunately, the retrospective data set did not provide any insight into possible covariates or other explanations for the finding. Enhancing the diversity of the physical therapy workforce is an important goal adopted by the American Physical Therapy Association 34 and is consistent with improving the quality of services to a diverse population of prospective patients. Understanding factors contributing to success of underrepresented minorities enrolled in physical therapy programs and completing the licensure examination is critical to meeting the goal of enhanced diversity in the profession. Finally, the ratio of students to core faculty also significantly predicted first-time success on the licensing exam. Programs with fewer students per core faculty member experienced greater first-time success on the NPTE. This suggests that students receiving more individualized attention may experience improved outcomes. Research addressing student faculty ratios and licensure success is generally lacking in health-related literature and appears limited to nursing research. Lower student to faculty ratios were associated with improved success of nursing students on the National Council Licensure Examination. 35,36 Although the similarities between nursing and PTA education have not been described, PTA students may benefit from more individualized faculty attention in a similar manner experienced by the nursing students reported in these studies. This study offers insight into institutional factors and practices that may affect student outcomes and ultimately impact the success of a PTA program. Data presented in this study may be used by programs and institutions when considering curricular revisions or modifications to current program policies and procedures. For instance, a program may want to consider using an adjusted odds-ratio threshold score, such as the one reported in this study, in their overall program evaluation plan. For example, if at least a 5% increased likelihood of NPTE success is considered valuable to a program, then certain factors (eg, laboratory contact hours, student faculty ratio, graduation rates, history of probation) would come under closer scrutiny by program faculty and administration. Limitations There are several important limitations in our study. The reliability and validity of the AAR data provided by the PTA programs in this study has not been investigated. Retrospective data also is frequently difficult to interpret, and the de-identified data set did not permit us to ask follow-up clarification questions to better understand and interpret the data. For example, understanding the relationship of compliance with accreditation standards and success on the NPTE would require a more in-depth understanding of the programs areas of noncompliance. Finally, it is important to highlight the exploratory nature of our investigation. For example, additional data is needed to understand the curriculum design that represents the optimal combination of factors such as laboratory hours and clinical hours. CONCLUSION Our study, using retrospective data provided by the AAR for 178 PTA programs, suggests a number of variables that may be significantly related to the odds of program graduates success on the NPTE. 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