Disability and Rehabilitation: Assistive Technology
ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: http://www.tandfonline.com/loi/iidt20
A description of manual wheelchair skills training curriculum in entry-to-practice occupational and physical therapy programs in Canada Krista L. Best, William C. Miller & François Routhier To cite this article: Krista L. Best, William C. Miller & François Routhier (2015) A description of manual wheelchair skills training curriculum in entry-to-practice occupational and physical therapy programs in Canada, Disability and Rehabilitation: Assistive Technology, 10:5, 401-406 To link to this article: http://dx.doi.org/10.3109/17483107.2014.907368
Published online: 07 Apr 2014.
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Date: 05 November 2015, At: 22:39
http://informahealthcare.com/idt ISSN 1748-3107 print/ISSN 1748-3115 online Disabil Rehabil Assist Technol, 2015; 10(5): 401–406 ! 2014 Informa UK Ltd. DOI: 10.3109/17483107.2014.907368
ORIGINAL RESEARCH
A description of manual wheelchair skills training curriculum in entry-to-practice occupational and physical therapy programs in Canada Downloaded by [Texas A & M International University] at 22:39 05 November 2015
Krista L. Best1,2, William C. Miller1,2,3, and Franc¸ois Routhier4,5 1
Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, 2GF Strong Rehabilitation Research Lab, Vancouver Coastal Research Institute, Vancouver, BC, Canada, 3Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, 4Department of Rehabilitation, Universite´ Laval, Que´bec City, QC, Canada, and 5Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Institut de Re´adaptation en De´ficience Physique de Que´bec, Que´bec City, QC, Canada Abstract
Keywords
Purpose: To describe the curriculum for manual wheelchair (MWC) skills training in entry-topractice occupational (OT) and physical therapy (PT) programs in Canada. Methods: An online survey was sent to 28 directors of entry-to-practice OT and PT programs in Canadian universities. Responses were solicited from individuals who could report about wheelchair skills training. Fourteen survey questions asked about: (1) demographic information, (2) specific curriculum content for MWC skills training, (3) teaching methods used, (4) instructional methods and estimated time used to teach MWC skills and (5) whether validated wheelchair skills training programs were used in curriculum development. Results: Responses received from 21/28 programs, (OT-11/14; PT-10/14). About 16 of 21 programs included curriculum for MWC skills training. Informal hands-on instruction was the most common method used for teaching wheelchair skills (13/21), while multiple lectures were used the least (5/21). Only 8/21 used a validated wheelchair skills training program in curriculum development. Conclusion: Despite the public availability of a validated wheelchair skills program, there is little use of the program in entry-to-practice curriculum. Integrating online training programs into existing curricula or the development of post-professional training modules may help clinicians to better accommodate the mobility needs of the substantially increasing population with disabilities.
Entry-to-practice curriculum, manual wheelchair skills training, occupational therapy, physical therapy History Received 4 December 2013 Revised 4 March 2014 Accepted 18 March 2014 Published online 7 April 2014
ä Implications for Rehabilitation
Current clinical curriculum includes basic wheelchair skills training, but not necessarily training in the advanced wheelchair skills that are needed for optimal wheelchair mobility. There is evidence for a standardized approach for providing wheelchair skills training, that may be administered through curriculum, online or through post-graduate training modules.
Introduction Wheelchairs provide mobility options for 4264 000 Canadians, 90% of whom are adults and older adults [1]. Given that the number of older adults is projected to double by 2026, it is likely that the number of manual wheelchair (MWC) users will also increase [2]. However, wheelchair procurement alone does not guarantee independent and safe use. According to the World Health Organization (WHO), wheelchair provision should include
Address for correspondence: William C. Miller, PhD, FCAOT, Department of Occupational Science and Occupational Therapy, University of British Columbia, T325 – 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada. Tel: +604 714 4107. Fax: +604 714 4168. E-mail: [email protected]
referral and appointment, client assessment, prescription, funding and ordering, product preparation, fitting, user training, and follow-up, maintenance and repairs [3]. The WHO guidelines were included in a recent systematic review on wheelchair-service provision models, which identified user training as a common factor among all models [4]. User training has also been identified as an important component in a conceptual framework for wheelchair mobility developed by Routhier et al. [5]. Within this framework, successful mobility outcomes depend on the optimal interaction of the user’s profile (e.g. physical characteristics, personality and cultural influence), the environment, the wheelchair, daily activities and social roles, and training [5]. Acknowledging that wheelchair skills training is a single factor, it may be deemed as one of the most important for maximizing the capacity for individuals to participate in meaningful activities in challenging environments [6].
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There is growing evidence that a validated MWC skills training program [7] improves the wheelchair skills capacity and safety of MWC users in rehabilitation [8] and the community [9–11], as well as in caregivers [12], students [13–15] and clinicians [16]. After completion of standardized MWC skills training students have also demonstrated increased knowledge and retention of MWC skills, as well as the ability to teach MWC skills to other students 1 year later [15]. Without proper training there may be increased risk of injury for wheelchair users [17–19], higher likelihood of mobility dependence, reduced social participation [6,20,21] and decreased quality of life [22,23]. In Canada, occupational (OT) and physical therapists (PT) are responsible for wheelchair provision and training. Although OT and PT students are required to complete entry-to-practice university programs to obtain certification for practice, the program structure is quite variable across the country. Thus, it is plausible that the curriculum specific to MWC skills training may also be inconsistent. Previous studies describe MWC curriculum in OT to be predominantly focussed on seating and positioning [24,25], suggesting that content for MWC skills training may be limited. This may be problematic, as less than optimal training of professionals is associated with unsuccessful wheelchair outcomes, including abandonment or non-use, poor comfort and client dissatisfaction with the wheelchair [26]. Given the projected increased in MWC users in Canada [1,2] and advancing wheelchair technologies, standardized wheelchair skills training for OTs and PTs is becoming increasingly important [27]. Implementing standardized approaches into entry-to-practice clinical curriculum would support the ‘‘best practice’’ principles for which accredited university programs advocate. It has been suggested that evidence-based practices (i.e. the best available external clinical evidence from systematic research) [28], should replace traditional approaches in health care and this change should be reflected in entry-to-practice curriculum for health professionals, including OT and PT [29]. To date, there is relatively little systematic understanding of the MWC skills training curriculum provided in entry-to-practice OT and PT programs [13,14]. The purpose of this study was to describe the current entry-topractice MWC skills training curriculum in OT and PT programs. Specifically, we examined the following objectives across professions and Canadian regions: (1) methods used for integrating MWC skills training into curriculum, (2) amount of time allocated to MWC skills training, (3) instructional approaches used for delivering the MWC skills training content and (4) whether validated programs were used in curriculum development.
survey. A reminder email with the web link to the survey was sent to non-responders at 2 and 4 weeks later. The study was approved by the Research Ethics Board at the University of British Columbia.
Methods
Instructional approaches used for MWC skills training
Design and sample
We then asked which instructional approaches were used for MWC skills training, from a list which included ‘‘mandatory or elective courses’’, ‘‘part of a course’’, ‘‘part of a lecture’’ or ‘‘self-directed learning’’. To capture the various instructional approaches, we developed a checklist with five commonly used methods, including ‘‘multiple formal lectures’’, ‘‘single formal lecture’’, ‘‘demonstration’’, ‘‘informal hands-on approach’’ and ‘‘additional education outside of curriculum’’. Respondents were asked to indicate the frequency that each method of teaching was used through a dropdown list of items that included ‘‘never’’, ‘‘rarely’’, ‘‘sometimes’’ and ‘‘always’’.
In Canada there are 28 entry-to-practice programs, 14 OT (9 English; 5 French) and 14 PT (10 English; 4 French), which are accredited by a national association that governs and regulates practice across the country. A cross-sectional survey was used to collect data from entryto-practice OT and PT programs in Canada. The head of each OT and PT program, identified through an internet search, was contacted by email with a letter of information and asked to either respond to the survey or identify an appropriate faculty member who could answer questions about the curriculum related to wheelchair training. The tailored design method was used to maximize response rate [30], which began by emailing a letter of information about the survey. One week later a follow-up email was sent, which summarized the study and included a web link to the electronic
Measurement The survey was initially developed in English based on our areas of interest and existing literature. We posed closed-ended questions about the type and amount of MWC skills training provided, the instructional approaches used for delivering MWC content, and whether an existing validated program was used to develop the MWC skills training curriculum. Initial iterations of the survey were sent to 10 wheeled mobility researchers, 6 of whom were also licensed OTs, who provided feedback to improve the content and clarity of questions. Demographic and descriptive information Demographic information was collected to describe the sample, including discipline, province, type of degree program, academic position and location of clinical training. Descriptive information was collected to describe the MWC curriculum, including education about wheelchair components, wheelchair seating, maintenance and repair, modifying the environment for wheelchair use, transfers, wheelchair skills training for mobility and community transportation. Response options for each item were ‘‘yes’’, ‘‘no’’ or ‘‘not sure’’. Respondents were then informed the remainder of the survey would focus on the curriculum specific to wheelchair skills training for mobility. Integration of MWC skills training into program curriculum We asked respondents to indicate whether MWC skills training was included in the education and evaluation for each of the following components: (1) theory, defined as subjective guiding principles for practice, (2) practical competence, defined as demonstrated ability to perform a specific task and (3) clinical competence, defined as a standardized evaluation of capability to perform a given task in a clinical setting, such as a structured objective examination. Response options were ‘‘yes’’, ‘‘no’’ or ‘‘not sure’’. Time allocated for teaching MWC skills Respondents were asked to estimate the total number of hours spent on MWC skills training, based on the following categorical variables: ‘‘less than 1 hour’’; ‘‘1–2 hours’’; ‘‘3–5 hours’’; ‘‘6–10 hours’’; ‘‘greater than 10 hours’’ and ‘‘not sure’’.
Use of validated program To capture information about the use of an existing validated program in curriculum development, we asked respondents to indicate sources that were used. Response options were based on
Wheelchair skills training in OT and PT therapy programs
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an extensive search of the literature which identified two standardized wheelchair skills programs, the Wheelchair Skills Training Program (Halifax, Canada) and Whizz-Kids (London, UK). We asked respondents to indicate whether either of the standardized wheelchair training programs were used in whole or in part in the curriculum development. Respondents were also given the option to select ‘‘other’’, where they could provide free text about other sources, or to select ‘‘no formal sources were used in the development of the curriculum’’. We also asked respondents to estimate the number of years that MWC skills training had been included as part of the standard curriculum.
PT ¼ 3) and 5/21 from Western provinces (OT ¼ 2, PT ¼ 3). The respondents were primarily at the professorial level (8/21) or were Curriculum/Program Coordinators (9/21). Most of the respondents were trained in Canada (17/21). The educational components of the MWC curriculum included wheelchair skills training, transfers, wheelchair components, wheelchair seating, modifying the environment, maintenance and repair and ‘‘other’’ (community transportation, loading wheelchair in car and pressure management). There were no significant differences in educational components between professions or across regions as shown in Table 1.
French translation
Integration of MWC skills training into program curriculum
The survey was developed in English and then it and all relevant documentation were translated to French by a bilingual research assistant. Translations were reviewed and refined by two bilingual researchers.
Manual wheelchair skills training was integrated into program curriculum through the inclusion of theoretical information, the description of practical competencies for MWC skills and the evaluation of clinical competencies. There were no statistically significant differences in how education on MWC skills training was integrated into program curriculum between professions or across regions as summarized in Table 2.
Analyses We used descriptive statistics (i.e. frequencies, proportions and cross-tabulations) to address the study questions. Statistical differences between professions and Canadian regions were analyzed using chi-squared ( 2) distributions. Based on geography and location of universities, Canadian regions were defined as Atlantic provinces/Quebec (Nova Scotia and Quebec), Ontario and Western provinces (Manitoba, Saskatchewan, Alberta, BC). Due to the small number of responses, the categorical response options for frequency (always, rarely, sometimes, never) were collapsed into three categories (always, sometimes, never). The survey was created and managed online using Fluid Survey software (http://www.fluidsurveys.com, Ottawa, Canada). Survey responses were collected online and raw data were exported into Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA) and coded. SPSS 19 (SPSS Inc., Chicago, IL) was used for all data analyses.
Time allocated for teaching MWC skills While 5/21 respondents indicated that the program had no specific curriculum for MWC skills training (OT ¼ 4, PT ¼ 1), 8/21 reported delivering 46 h of training (OT ¼ 3, PT ¼ 5). The remaining eight respondents specified that wheelchair skills training comprised 55 h of the total curriculum (OT ¼ 4, PT ¼ 4). There were no significant differences in the estimated time spent on MWC skills training between disciplines ( 2 ¼ 6.43, p ¼ 0.17) or across regions ( 2 ¼ 7.23, p ¼ 0.51). Instructional approach to teaching MWC skills Manual wheelchair skills training curriculum was administered through mandatory course content, component of a course, guest lecturers, self-directed studies and ‘‘other’’ approaches (i.e. field trips to labs where MWC skills were demonstrated in a clinical setting). Using guest lecturers to teach MWC skills content was the only instructional approach that was significantly different between professions ( 2 ¼ 3.83, p ¼ 0.05), with PT using this approach slightly more than OT. There were no significant differences between professions or across regions in other
Results Demographic and descriptive information Responses were received from 21/28 (75%) entry-to-practice OT (11, 52.4%) and PT (10, 47.6%) programs. We had representation from all Canadian regions, including 9/21 from Atlantic provinces/Quebec (OT ¼ 5, PT ¼ 4), 7/21 from Ontario (OT ¼ 4, Table 1. MWC curriculum content in Canada by profession and region. Atlantic/QC MWC curriculum content
Ontario
Western
Professional 2
OT (n ¼ 5)
PT (n ¼ 4)
OT (n ¼ 4)
PT (n ¼ 3)
OT (n ¼ 2)
PT (n ¼ 3)
3 3 4 – 1 4 –
4 4 4 1 4 4 1
3 4 4 2 3 4 2
2 2 2 – 2 2 –
1 2 2 1 2 2 1
3 3 3 1 2 3 –
2.01 0.29 0.01 0.15 1.53 0.01 1.01
MWC skills Seating MWC components Maintenance/repair Modify environ. Transfers Other
Regional
p
2
p
0.16 0.59 0.94 0.70 0.22 0.94 0.31
0.14 1.30 0.74 1.61 0.97 0.74 0.78
0.93 0.52 0.69 0.45 0.62 0.69 0.68
Table 2. Inclusion of MWC skills training in theoretical, practical and clinical competencies by profession and region. Atlantic/QC Competence component Theory Practical Clinical
Ontario
Western
Professional 2
OT (n ¼ 5)
PT (n ¼ 4)
OT (n ¼ 4)
PT (n ¼ 3)
OT (n ¼ 2)
PT (n ¼ 3)
2 3 2
3 2 3
3 3 2
1 1 2
1 1 1
1 1 1
0.64 2.01 1.76
Regional
p
2
p
0.80 0.16 0.42
0.14 0.03 0.14
0.93 0.99 0.93
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Table 3. Instructional approaches used to teach MWC skills content by profession and region. Atlantic/QC Instructional approach
Ontario
Western
Professional
Regional
OT (n ¼ 5)
PT (n ¼ 4)
OT (n ¼ 4)
PT (n ¼ 3)
OT (n ¼ 2)
PT (n ¼ 3)
p
2
p
2 1 1 – 1
4 1 3 – 1
2 2 1 1 –
– 1 2 1 –
1 – 1 1 –
2 2 2 1 –
0.44 0.38 3.83 0.01 0.01
0.51 0.54 0.05 0.92 0.94
2.44 0.87 0.41 3.95 0.78
0.30 0.64 0.82 0.14 0.68
Mandatory course Course component Guest lecturer Self-directed study Other
2
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Table 4. Frequency of use of various delivery methods used to teach MWC skills content by profession, with professional and regional differences summarized. Always
Rarely
Never
Professional
Regional
Teaching method OT (n ¼ 11); PT (n ¼ 10)
OT
PT
OT
PT
OT
PT
p
p
Multiple formal lectures Single formal lecture Demonstration Hands-on instruction Extra-curricular
3 5 4 6 1
2 4 6 7 3
– – 1 – 2
3 3 3 2 2
8 6 6 5 8
5 3 1 1 5
3.85 4.07 7.94 4.71 1.65
0.28 0.25 50.05 0.95 0.65
12.71 7.75 8.20 3.77 8.48
50.05 0.26 0.22 0.44 0.21
Table 5. Frequency of use of various combinations of teaching methods used to teach manual wheelchair skills training content by discipline. Combined teaching methods 0 methods 1 method 2–3 methods 4–5 methods
OT
PT
5 1 2 3
1 – 2 7
instructional approaches used to teach MWC skills as shown in Table 3. The most common method used by both professions to deliver MWC skills training content was informal hands-on instruction. Other methods included demonstration, lectures and extracurricular activity, which were described as exposure during clinical placements and spending a day in a wheelchair. There was a significant difference between professions in the use of demonstration to teach MWC skills curriculum ( 2 ¼ 7.94, p50.05), such that six PT programs reported always using this method, while six OT programs reported never using it. The only significant difference in teaching methods used across regions was for the use of multiple formal lectures ( 2 ¼ 12.71, p50.05), where the Atlantic/Quebec region reported using this method less frequently than the other two regions. Teaching methods are summarized in Table 4. The majority of programs used a combination of two or more methods to teach MWC skills as displayed in Table 5. Use of validated program The following results pertain to the 16 respondents who reported the inclusion of MWC skills training in curriculum. When asked about the length of time that wheelchair skills training was included in the curriculum, 5/16 respondents indicated 1–4 years (OT ¼ 3, PT ¼ 2), 4/16 replied 5–10 years (OT ¼ 1, PT ¼ 3) and 7/16 reported 410 years (OT ¼ 4, PT ¼ 3). Only 8/16 reported using a standardized MWC skills training program, in whole or in part, in the development of the MWC curriculum (OT ¼ 2, PT ¼ 6).
Discussion We surveyed representatives from the entry-to-practice programs who provide training for future OTs and PTs in Canada and
2
2
achieved a 75% response rate. Our results demonstrated that the majority of OT and PT programs in Canada included specific curriculum for MWC skills training, but less than half used an existing validated program when implementing MWC content into curriculum. Without the use of a validated program, it is speculated that the curriculum specific to wheelchair skills training does not exceed beyond fundamental skills, such as transfers, propulsion and basic manoeuvring [13]. While the fundamental skills may address some accessibility and safety issues, being trained in intermediate and advanced wheelchair skills is important for enabling wheelchair mobility and increasing community participation [6,31]. Improved independent wheelchair skills capacity may also alleviate some of the burden that is often placed on caregivers to provide mobility and to facilitate engagement in social activities for wheelchair users [12]. Optimal wheelchair skills training may also have economic influence. For example, wheelchair skills training could reduce the risk of wheelchair accidents associated with tips and falls, which is the leading cause of wheelchair related injuries and deaths [32]. Reducing the number of wheelchair-related accidents could alleviate some of the burden on the healthcare system, which was estimated to be 100 K in 2006 in USA due to emergency room admittances alone [17]. Basic training on weight shifting combined with proper seating may also reduce the healthcare costs associated with the treatment of pressure ulcers, which can cost over $9000 per month to treat [33]. There are currently no compulsory curricular standards for MWC skills for OT and PT students. While it is promising that half of the programs reported six or more hours of MWC skills training in curriculum, it is speculated that the most commonly used informal hands-on approach would be inconsistent and variable. Previous findings suggest that wheelchair skills training according to a standardized wheelchair skills training program may offer guidelines for curricular standards. When 1 h of a validated Wheelchair Skills Training Program (WSTP) was added to existing curriculum, students in an entry-to-practice OT program improved their MWC skills by 25%, retained the skills for 1 year and were able to teach other students [13,15]. Kirby et al. [14] demonstrated similar findings in a group of medical students, whose wheelchair skills and wheelchair knowledge significantly improved after a 4-h workshop that included the WSTP. This suggests that a validated wheelchair skills training
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program could be effectively implemented into existing OT and PT curriculum using minimal time. Albeit important for effective wheelchair use, wheelchair skills training is a single factor within the wheelchair provision process. Since clinician expertise influences every component of wheelchair service delivery [34], it is imperative that curriculum provides a broad understanding of all factors. Although our results show that curriculum included education on the wheelchair, seating and fit and environmental considerations for wheelchair use, we did not examine these components in detail. Nor did we investigate curriculum on the other key components of wheelchair provision. It is critical that wheelchair-related curriculum be scrutinized to ensure quality wheelchair service delivery. For example, curriculum should also include education on standardized methods for wheelchair service provision [35], including key intervention approaches to optimize function of individuals with disabilities [36]. This supports the need for the acceptance of a standardized approach for wheelchair provision [4], which may also assist with consistent education and training across disciplines and geographical regions. Furthermore, a universal approach could help to establish clearly defined roles and responsibilities for clinicians and wheelchair suppliers. Continuing education is critical for obtaining advanced training in specialized fields, such as wheelchair provision, which requires an understanding of the dynamic interface between the wheelchair and the user, in addition to an appreciation of the user’s needs, abilities, preferences, available technologies and environmental demands [25]. The knowledge and skills required to successfully provide wheelchairs include the application of biomechanics and ergonomics for specialty seating, and the integration of advancing technologies with environmental considerations and personal characteristics [37,38]. Even the selection of the best seat cushion requires considerable knowledge [39]. Some organizations provide continuing education certifications to recognize expertise in specialized skill sets, such as Assistive Technology Professional and Seating Mobility Specialist [40]. However, there are no requirements to obtain specialized MWC training certifications for national or provincial practice in Canada, thus providing little incentive for Canadian OTs and PTs. Interestingly, clinicians in Quebec are encouraged to not develop their knowledge outside of what is practiced in their clinical milieus, possibly because post-professional certifications are rarely, if ever, offered in French. However, the WSTP may also provide an evidence-based framework for the development of continuing education modules in French, as healthcare professionals who completed the WSTP-French version significantly improved their wheelchair skills capacity and their perception of their actual skill level. One participant commented that the WSTP could lead to changes in professional practice [16]. Although we would not necessarily advocate for creating a new category of a wheelchair training specialist, we would encourage the use of standardized basic training for students in entry-to-practice programs, as well as standardized continuing education modules. The WSTP may provide an evidence based approach for teaching students and professionals, which would fit within the educational philosophies of both the Canadian Association of Occupational Therapy (CAOT) and the Canadian Physiotherapy Association (CPA). The WSTP would also fit within the recent recommendations for an Assistive Technology Service Method (ATSM), which aims for a service method that is consistent with key guidelines, models and systems. For example, the WSTP provides a standardized approach for education, professional development, continuing education and certification, as required by the Rehabilitation and Engineering Society of North America (RESNA) guidelines [40]. Further, the WSTP provides a validated intervention for assistive technology
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users (i.e. the wheelchair), which is an essential component of the IMPACT2 model [36]. Finally, wheelchair skills can be categorized within the ‘‘activities’’ sub-domain of the International Classification of Functioning, Health and Disability (ICF) framework, and the WSTP uses a common language that can be used across disciplines [35]. Future studies could examine the time and financial efficiencies of basic standardized training according to the WSTP in entry-to-practice programs to ensure all clinicians enter the field with the same education. The WSTP could be further explored as a framework for the development of intermediate and advanced wheelchair skills training modules for post-graduate OTs and PTs who practice specifically in rehabilitation. A description of current clinical practices for wheelchair skills training for new wheelchair users could also provide insight into the use of validated programs by practicing professionals, which may provide suggestions for future knowledge translation efforts. Study limitations Despite a 75% response rate, we were pleased to have representation from all Canadian regions. Since responses came from all levels and respondents may or may not have been responsible for teaching the content we surveyed about, we suspect that there may be some variability in the knowledge of the respondents with regard to the specific content about MWCs. It is also possible that specificity of wheelchair skills taught may have been missed, as the survey questions did not ask for specific details about particular skills. Survey question comprehension may have imposed another limitation and despite our efforts to operationalize survey questions, self-reports are prone to misinterpretation. Finally, we discussed accreditation and post-professional training from a national perspective, which is not applicable for clinicians in the province of Quebec where clinical practice is regulated by provincial associations. However, a validated program for teaching MWC skills is available and effective in French and may also be used for curriculum and post-professional training in Quebec.
Conclusion The findings from our study suggest wheelchair curriculum is consistently included in OT and PT programs, but the content and teaching methods specific to wheelchair skills training are not standardized and limited in time. Program curriculum may benefit by integrating validated programs for MWC skills training. Validated MWC training programs may also provide a structure for the development of intermediate and advanced wheelchair skills training and certification after graduation. As with all assistive technology devices and services, procurement of training to effectively use a wheelchair is incumbent upon professional associations for inclusion in core educational curriculum.
Acknowledgements The authors would like to thank all participants for their contributions. We would also like to thank Karine Boily, Emilie Lacroix and Claudine Auger for assistance with translating study documents and members of the ‘‘Rehabilitation Research Lab productivity club’’ for research and clinical input when editing the manuscript.
Declaration of interest The authors report no conflicts of interest.
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19. Akbar M, Balean G, Brunner M, et al. Prevalence of rotator cuff tear in paraplegic patients compared with controls. J Bone Joint Surg Am 2010;92:23–30. 20. Hoenig H, Landerman LR, Shipp KM, et al. A clinical trial of rehabilitation expert clinician versus usual care for providing manual wheelchairs. J Am Geriatr Soc 2005;53:1712–20. 21. van Zeltzen JM, de Groot S, Post MWM, et al. Return to work after spinal cord injury. Am J Phys Med Rehabil 2009;88:47–56. 22. Walker KA, Morgan KA, Morris CL, et al. Development of a community mobility skills course for people who use mobility devices. Am J Occup Ther 2010;64:547–54. 23. Inkpen P, Parker K, Kirby RL. Manual wheelchair skills capacity versus performance. Arch Phys Med Rehabil 2012;93:1009–13. 24. Powell NJ. Content for educational programs in school-based occupational therapy from a practice prospective. Am J Occup Ther 1994;48:130–7. 25. Kanny EM, Anson DK. Current trends in assistive technology education in entry-level occupational therapy. Am J Occup Ther 1998;52:586–91. 26. DiMarco A, Russell M, Masters M. Standards for wheelchair prescription. Aust Occup Ther J 2003;50:30–9. 27. Hammel J, Angelo J. Technology competencies for occupational therapy practitioners. Assist Technol 1996;8:34–42. 28. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. Brit Med J 1996;312: 71–2. 29. Nelson A, Baptiste AS. Evidence-based practices for safe patient handling and movement. Clin Rev Bone Miner Metab 2006;4:55–69. 30. Dillman DA. Mail and internet surveys: the tailored design method. New York: John Wiley and Sons, Inc; 2000. 31. Hosseini SM, Oyster ML, Kirby RL, et al. Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury. Arch Phys Med Rehabil 2012;93: 2237–43. 32. Kirby RL, Ackroyd-Stolarz SA, Brown MG, Kirkland SA. Wheelchair-related accidents caused by tips and falls among noninstitutionalized users of manually propelled wheelchairs in Nova Scotia. Am J Phys Med Rehabil 1994;73:319–30. 33. Allen J, Houghton P. A case study for electrical stimulation on a stage three pressure ulcer. Wound Care Canada 2004;2:34–6. 34. Eggers SL, Myaskovsky L, Burkitt KH, et al. A preliminary model of wheelchair service delivery. Arch Phys Med Rehabil 2009;90: 1030–8. 35. Elsaesser L-J, Bauer SM. Provision of assistive technology services method (ATSM) according to evidence-based information and knowledge management. Disabil Rehabil Assist Technol 2011;6: 386–401. 36. Smith RO. IMPACT2 Model. Rehabilitation Research Design and Disability Center. 2005. Available from: http://www.r2d2.uwm.edu/ archive/impact2model.html [last accessed 17 Feb 2014]. 37. Trefler E, Taylor SJ. Prescription and positioning: evaluating the physically disabled individual for wheelchair seating. Prosthet Orthot Int 1991;15:217–24. 38. Samuelsson K, Larsson H, Thyberg M, Gerdle B. Wheelchair seating intervention. Results from a client-centred approach. Disabil Rehabil 2001;23:677–82. 39. Ferguson-Pell M. Seat cushion selection. J Rehabil Res Dev 1990; (suppl 2):49–73. 40. Rehabilitation Engineering and Assistive Technology Society of North America [Internet]. Virginia: RESNA; c2013 [updated 2013 May 24]. Available from: www.RESNA.org [last accessed 21 Mar 2013].
ISSN: 1748-3107 (Print) 1748-3115 (Online) Journal homepage: http://www.tandfonline.com/loi/iidt20
A description of manual wheelchair skills training curriculum in entry-to-practice occupational and physical therapy programs in Canada Krista L. Best, William C. Miller & François Routhier To cite this article: Krista L. Best, William C. Miller & François Routhier (2015) A description of manual wheelchair skills training curriculum in entry-to-practice occupational and physical therapy programs in Canada, Disability and Rehabilitation: Assistive Technology, 10:5, 401-406 To link to this article: http://dx.doi.org/10.3109/17483107.2014.907368
Published online: 07 Apr 2014.
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http://informahealthcare.com/idt ISSN 1748-3107 print/ISSN 1748-3115 online Disabil Rehabil Assist Technol, 2015; 10(5): 401–406 ! 2014 Informa UK Ltd. DOI: 10.3109/17483107.2014.907368
ORIGINAL RESEARCH
A description of manual wheelchair skills training curriculum in entry-to-practice occupational and physical therapy programs in Canada Downloaded by [Texas A & M International University] at 22:39 05 November 2015
Krista L. Best1,2, William C. Miller1,2,3, and Franc¸ois Routhier4,5 1
Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, 2GF Strong Rehabilitation Research Lab, Vancouver Coastal Research Institute, Vancouver, BC, Canada, 3Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, 4Department of Rehabilitation, Universite´ Laval, Que´bec City, QC, Canada, and 5Center for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Institut de Re´adaptation en De´ficience Physique de Que´bec, Que´bec City, QC, Canada Abstract
Keywords
Purpose: To describe the curriculum for manual wheelchair (MWC) skills training in entry-topractice occupational (OT) and physical therapy (PT) programs in Canada. Methods: An online survey was sent to 28 directors of entry-to-practice OT and PT programs in Canadian universities. Responses were solicited from individuals who could report about wheelchair skills training. Fourteen survey questions asked about: (1) demographic information, (2) specific curriculum content for MWC skills training, (3) teaching methods used, (4) instructional methods and estimated time used to teach MWC skills and (5) whether validated wheelchair skills training programs were used in curriculum development. Results: Responses received from 21/28 programs, (OT-11/14; PT-10/14). About 16 of 21 programs included curriculum for MWC skills training. Informal hands-on instruction was the most common method used for teaching wheelchair skills (13/21), while multiple lectures were used the least (5/21). Only 8/21 used a validated wheelchair skills training program in curriculum development. Conclusion: Despite the public availability of a validated wheelchair skills program, there is little use of the program in entry-to-practice curriculum. Integrating online training programs into existing curricula or the development of post-professional training modules may help clinicians to better accommodate the mobility needs of the substantially increasing population with disabilities.
Entry-to-practice curriculum, manual wheelchair skills training, occupational therapy, physical therapy History Received 4 December 2013 Revised 4 March 2014 Accepted 18 March 2014 Published online 7 April 2014
ä Implications for Rehabilitation
Current clinical curriculum includes basic wheelchair skills training, but not necessarily training in the advanced wheelchair skills that are needed for optimal wheelchair mobility. There is evidence for a standardized approach for providing wheelchair skills training, that may be administered through curriculum, online or through post-graduate training modules.
Introduction Wheelchairs provide mobility options for 4264 000 Canadians, 90% of whom are adults and older adults [1]. Given that the number of older adults is projected to double by 2026, it is likely that the number of manual wheelchair (MWC) users will also increase [2]. However, wheelchair procurement alone does not guarantee independent and safe use. According to the World Health Organization (WHO), wheelchair provision should include
Address for correspondence: William C. Miller, PhD, FCAOT, Department of Occupational Science and Occupational Therapy, University of British Columbia, T325 – 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada. Tel: +604 714 4107. Fax: +604 714 4168. E-mail: [email protected]
referral and appointment, client assessment, prescription, funding and ordering, product preparation, fitting, user training, and follow-up, maintenance and repairs [3]. The WHO guidelines were included in a recent systematic review on wheelchair-service provision models, which identified user training as a common factor among all models [4]. User training has also been identified as an important component in a conceptual framework for wheelchair mobility developed by Routhier et al. [5]. Within this framework, successful mobility outcomes depend on the optimal interaction of the user’s profile (e.g. physical characteristics, personality and cultural influence), the environment, the wheelchair, daily activities and social roles, and training [5]. Acknowledging that wheelchair skills training is a single factor, it may be deemed as one of the most important for maximizing the capacity for individuals to participate in meaningful activities in challenging environments [6].
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There is growing evidence that a validated MWC skills training program [7] improves the wheelchair skills capacity and safety of MWC users in rehabilitation [8] and the community [9–11], as well as in caregivers [12], students [13–15] and clinicians [16]. After completion of standardized MWC skills training students have also demonstrated increased knowledge and retention of MWC skills, as well as the ability to teach MWC skills to other students 1 year later [15]. Without proper training there may be increased risk of injury for wheelchair users [17–19], higher likelihood of mobility dependence, reduced social participation [6,20,21] and decreased quality of life [22,23]. In Canada, occupational (OT) and physical therapists (PT) are responsible for wheelchair provision and training. Although OT and PT students are required to complete entry-to-practice university programs to obtain certification for practice, the program structure is quite variable across the country. Thus, it is plausible that the curriculum specific to MWC skills training may also be inconsistent. Previous studies describe MWC curriculum in OT to be predominantly focussed on seating and positioning [24,25], suggesting that content for MWC skills training may be limited. This may be problematic, as less than optimal training of professionals is associated with unsuccessful wheelchair outcomes, including abandonment or non-use, poor comfort and client dissatisfaction with the wheelchair [26]. Given the projected increased in MWC users in Canada [1,2] and advancing wheelchair technologies, standardized wheelchair skills training for OTs and PTs is becoming increasingly important [27]. Implementing standardized approaches into entry-to-practice clinical curriculum would support the ‘‘best practice’’ principles for which accredited university programs advocate. It has been suggested that evidence-based practices (i.e. the best available external clinical evidence from systematic research) [28], should replace traditional approaches in health care and this change should be reflected in entry-to-practice curriculum for health professionals, including OT and PT [29]. To date, there is relatively little systematic understanding of the MWC skills training curriculum provided in entry-to-practice OT and PT programs [13,14]. The purpose of this study was to describe the current entry-topractice MWC skills training curriculum in OT and PT programs. Specifically, we examined the following objectives across professions and Canadian regions: (1) methods used for integrating MWC skills training into curriculum, (2) amount of time allocated to MWC skills training, (3) instructional approaches used for delivering the MWC skills training content and (4) whether validated programs were used in curriculum development.
survey. A reminder email with the web link to the survey was sent to non-responders at 2 and 4 weeks later. The study was approved by the Research Ethics Board at the University of British Columbia.
Methods
Instructional approaches used for MWC skills training
Design and sample
We then asked which instructional approaches were used for MWC skills training, from a list which included ‘‘mandatory or elective courses’’, ‘‘part of a course’’, ‘‘part of a lecture’’ or ‘‘self-directed learning’’. To capture the various instructional approaches, we developed a checklist with five commonly used methods, including ‘‘multiple formal lectures’’, ‘‘single formal lecture’’, ‘‘demonstration’’, ‘‘informal hands-on approach’’ and ‘‘additional education outside of curriculum’’. Respondents were asked to indicate the frequency that each method of teaching was used through a dropdown list of items that included ‘‘never’’, ‘‘rarely’’, ‘‘sometimes’’ and ‘‘always’’.
In Canada there are 28 entry-to-practice programs, 14 OT (9 English; 5 French) and 14 PT (10 English; 4 French), which are accredited by a national association that governs and regulates practice across the country. A cross-sectional survey was used to collect data from entryto-practice OT and PT programs in Canada. The head of each OT and PT program, identified through an internet search, was contacted by email with a letter of information and asked to either respond to the survey or identify an appropriate faculty member who could answer questions about the curriculum related to wheelchair training. The tailored design method was used to maximize response rate [30], which began by emailing a letter of information about the survey. One week later a follow-up email was sent, which summarized the study and included a web link to the electronic
Measurement The survey was initially developed in English based on our areas of interest and existing literature. We posed closed-ended questions about the type and amount of MWC skills training provided, the instructional approaches used for delivering MWC content, and whether an existing validated program was used to develop the MWC skills training curriculum. Initial iterations of the survey were sent to 10 wheeled mobility researchers, 6 of whom were also licensed OTs, who provided feedback to improve the content and clarity of questions. Demographic and descriptive information Demographic information was collected to describe the sample, including discipline, province, type of degree program, academic position and location of clinical training. Descriptive information was collected to describe the MWC curriculum, including education about wheelchair components, wheelchair seating, maintenance and repair, modifying the environment for wheelchair use, transfers, wheelchair skills training for mobility and community transportation. Response options for each item were ‘‘yes’’, ‘‘no’’ or ‘‘not sure’’. Respondents were then informed the remainder of the survey would focus on the curriculum specific to wheelchair skills training for mobility. Integration of MWC skills training into program curriculum We asked respondents to indicate whether MWC skills training was included in the education and evaluation for each of the following components: (1) theory, defined as subjective guiding principles for practice, (2) practical competence, defined as demonstrated ability to perform a specific task and (3) clinical competence, defined as a standardized evaluation of capability to perform a given task in a clinical setting, such as a structured objective examination. Response options were ‘‘yes’’, ‘‘no’’ or ‘‘not sure’’. Time allocated for teaching MWC skills Respondents were asked to estimate the total number of hours spent on MWC skills training, based on the following categorical variables: ‘‘less than 1 hour’’; ‘‘1–2 hours’’; ‘‘3–5 hours’’; ‘‘6–10 hours’’; ‘‘greater than 10 hours’’ and ‘‘not sure’’.
Use of validated program To capture information about the use of an existing validated program in curriculum development, we asked respondents to indicate sources that were used. Response options were based on
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an extensive search of the literature which identified two standardized wheelchair skills programs, the Wheelchair Skills Training Program (Halifax, Canada) and Whizz-Kids (London, UK). We asked respondents to indicate whether either of the standardized wheelchair training programs were used in whole or in part in the curriculum development. Respondents were also given the option to select ‘‘other’’, where they could provide free text about other sources, or to select ‘‘no formal sources were used in the development of the curriculum’’. We also asked respondents to estimate the number of years that MWC skills training had been included as part of the standard curriculum.
PT ¼ 3) and 5/21 from Western provinces (OT ¼ 2, PT ¼ 3). The respondents were primarily at the professorial level (8/21) or were Curriculum/Program Coordinators (9/21). Most of the respondents were trained in Canada (17/21). The educational components of the MWC curriculum included wheelchair skills training, transfers, wheelchair components, wheelchair seating, modifying the environment, maintenance and repair and ‘‘other’’ (community transportation, loading wheelchair in car and pressure management). There were no significant differences in educational components between professions or across regions as shown in Table 1.
French translation
Integration of MWC skills training into program curriculum
The survey was developed in English and then it and all relevant documentation were translated to French by a bilingual research assistant. Translations were reviewed and refined by two bilingual researchers.
Manual wheelchair skills training was integrated into program curriculum through the inclusion of theoretical information, the description of practical competencies for MWC skills and the evaluation of clinical competencies. There were no statistically significant differences in how education on MWC skills training was integrated into program curriculum between professions or across regions as summarized in Table 2.
Analyses We used descriptive statistics (i.e. frequencies, proportions and cross-tabulations) to address the study questions. Statistical differences between professions and Canadian regions were analyzed using chi-squared ( 2) distributions. Based on geography and location of universities, Canadian regions were defined as Atlantic provinces/Quebec (Nova Scotia and Quebec), Ontario and Western provinces (Manitoba, Saskatchewan, Alberta, BC). Due to the small number of responses, the categorical response options for frequency (always, rarely, sometimes, never) were collapsed into three categories (always, sometimes, never). The survey was created and managed online using Fluid Survey software (http://www.fluidsurveys.com, Ottawa, Canada). Survey responses were collected online and raw data were exported into Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA) and coded. SPSS 19 (SPSS Inc., Chicago, IL) was used for all data analyses.
Time allocated for teaching MWC skills While 5/21 respondents indicated that the program had no specific curriculum for MWC skills training (OT ¼ 4, PT ¼ 1), 8/21 reported delivering 46 h of training (OT ¼ 3, PT ¼ 5). The remaining eight respondents specified that wheelchair skills training comprised 55 h of the total curriculum (OT ¼ 4, PT ¼ 4). There were no significant differences in the estimated time spent on MWC skills training between disciplines ( 2 ¼ 6.43, p ¼ 0.17) or across regions ( 2 ¼ 7.23, p ¼ 0.51). Instructional approach to teaching MWC skills Manual wheelchair skills training curriculum was administered through mandatory course content, component of a course, guest lecturers, self-directed studies and ‘‘other’’ approaches (i.e. field trips to labs where MWC skills were demonstrated in a clinical setting). Using guest lecturers to teach MWC skills content was the only instructional approach that was significantly different between professions ( 2 ¼ 3.83, p ¼ 0.05), with PT using this approach slightly more than OT. There were no significant differences between professions or across regions in other
Results Demographic and descriptive information Responses were received from 21/28 (75%) entry-to-practice OT (11, 52.4%) and PT (10, 47.6%) programs. We had representation from all Canadian regions, including 9/21 from Atlantic provinces/Quebec (OT ¼ 5, PT ¼ 4), 7/21 from Ontario (OT ¼ 4, Table 1. MWC curriculum content in Canada by profession and region. Atlantic/QC MWC curriculum content
Ontario
Western
Professional 2
OT (n ¼ 5)
PT (n ¼ 4)
OT (n ¼ 4)
PT (n ¼ 3)
OT (n ¼ 2)
PT (n ¼ 3)
3 3 4 – 1 4 –
4 4 4 1 4 4 1
3 4 4 2 3 4 2
2 2 2 – 2 2 –
1 2 2 1 2 2 1
3 3 3 1 2 3 –
2.01 0.29 0.01 0.15 1.53 0.01 1.01
MWC skills Seating MWC components Maintenance/repair Modify environ. Transfers Other
Regional
p
2
p
0.16 0.59 0.94 0.70 0.22 0.94 0.31
0.14 1.30 0.74 1.61 0.97 0.74 0.78
0.93 0.52 0.69 0.45 0.62 0.69 0.68
Table 2. Inclusion of MWC skills training in theoretical, practical and clinical competencies by profession and region. Atlantic/QC Competence component Theory Practical Clinical
Ontario
Western
Professional 2
OT (n ¼ 5)
PT (n ¼ 4)
OT (n ¼ 4)
PT (n ¼ 3)
OT (n ¼ 2)
PT (n ¼ 3)
2 3 2
3 2 3
3 3 2
1 1 2
1 1 1
1 1 1
0.64 2.01 1.76
Regional
p
2
p
0.80 0.16 0.42
0.14 0.03 0.14
0.93 0.99 0.93
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Table 3. Instructional approaches used to teach MWC skills content by profession and region. Atlantic/QC Instructional approach
Ontario
Western
Professional
Regional
OT (n ¼ 5)
PT (n ¼ 4)
OT (n ¼ 4)
PT (n ¼ 3)
OT (n ¼ 2)
PT (n ¼ 3)
p
2
p
2 1 1 – 1
4 1 3 – 1
2 2 1 1 –
– 1 2 1 –
1 – 1 1 –
2 2 2 1 –
0.44 0.38 3.83 0.01 0.01
0.51 0.54 0.05 0.92 0.94
2.44 0.87 0.41 3.95 0.78
0.30 0.64 0.82 0.14 0.68
Mandatory course Course component Guest lecturer Self-directed study Other
2
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Table 4. Frequency of use of various delivery methods used to teach MWC skills content by profession, with professional and regional differences summarized. Always
Rarely
Never
Professional
Regional
Teaching method OT (n ¼ 11); PT (n ¼ 10)
OT
PT
OT
PT
OT
PT
p
p
Multiple formal lectures Single formal lecture Demonstration Hands-on instruction Extra-curricular
3 5 4 6 1
2 4 6 7 3
– – 1 – 2
3 3 3 2 2
8 6 6 5 8
5 3 1 1 5
3.85 4.07 7.94 4.71 1.65
0.28 0.25 50.05 0.95 0.65
12.71 7.75 8.20 3.77 8.48
50.05 0.26 0.22 0.44 0.21
Table 5. Frequency of use of various combinations of teaching methods used to teach manual wheelchair skills training content by discipline. Combined teaching methods 0 methods 1 method 2–3 methods 4–5 methods
OT
PT
5 1 2 3
1 – 2 7
instructional approaches used to teach MWC skills as shown in Table 3. The most common method used by both professions to deliver MWC skills training content was informal hands-on instruction. Other methods included demonstration, lectures and extracurricular activity, which were described as exposure during clinical placements and spending a day in a wheelchair. There was a significant difference between professions in the use of demonstration to teach MWC skills curriculum ( 2 ¼ 7.94, p50.05), such that six PT programs reported always using this method, while six OT programs reported never using it. The only significant difference in teaching methods used across regions was for the use of multiple formal lectures ( 2 ¼ 12.71, p50.05), where the Atlantic/Quebec region reported using this method less frequently than the other two regions. Teaching methods are summarized in Table 4. The majority of programs used a combination of two or more methods to teach MWC skills as displayed in Table 5. Use of validated program The following results pertain to the 16 respondents who reported the inclusion of MWC skills training in curriculum. When asked about the length of time that wheelchair skills training was included in the curriculum, 5/16 respondents indicated 1–4 years (OT ¼ 3, PT ¼ 2), 4/16 replied 5–10 years (OT ¼ 1, PT ¼ 3) and 7/16 reported 410 years (OT ¼ 4, PT ¼ 3). Only 8/16 reported using a standardized MWC skills training program, in whole or in part, in the development of the MWC curriculum (OT ¼ 2, PT ¼ 6).
Discussion We surveyed representatives from the entry-to-practice programs who provide training for future OTs and PTs in Canada and
2
2
achieved a 75% response rate. Our results demonstrated that the majority of OT and PT programs in Canada included specific curriculum for MWC skills training, but less than half used an existing validated program when implementing MWC content into curriculum. Without the use of a validated program, it is speculated that the curriculum specific to wheelchair skills training does not exceed beyond fundamental skills, such as transfers, propulsion and basic manoeuvring [13]. While the fundamental skills may address some accessibility and safety issues, being trained in intermediate and advanced wheelchair skills is important for enabling wheelchair mobility and increasing community participation [6,31]. Improved independent wheelchair skills capacity may also alleviate some of the burden that is often placed on caregivers to provide mobility and to facilitate engagement in social activities for wheelchair users [12]. Optimal wheelchair skills training may also have economic influence. For example, wheelchair skills training could reduce the risk of wheelchair accidents associated with tips and falls, which is the leading cause of wheelchair related injuries and deaths [32]. Reducing the number of wheelchair-related accidents could alleviate some of the burden on the healthcare system, which was estimated to be 100 K in 2006 in USA due to emergency room admittances alone [17]. Basic training on weight shifting combined with proper seating may also reduce the healthcare costs associated with the treatment of pressure ulcers, which can cost over $9000 per month to treat [33]. There are currently no compulsory curricular standards for MWC skills for OT and PT students. While it is promising that half of the programs reported six or more hours of MWC skills training in curriculum, it is speculated that the most commonly used informal hands-on approach would be inconsistent and variable. Previous findings suggest that wheelchair skills training according to a standardized wheelchair skills training program may offer guidelines for curricular standards. When 1 h of a validated Wheelchair Skills Training Program (WSTP) was added to existing curriculum, students in an entry-to-practice OT program improved their MWC skills by 25%, retained the skills for 1 year and were able to teach other students [13,15]. Kirby et al. [14] demonstrated similar findings in a group of medical students, whose wheelchair skills and wheelchair knowledge significantly improved after a 4-h workshop that included the WSTP. This suggests that a validated wheelchair skills training
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program could be effectively implemented into existing OT and PT curriculum using minimal time. Albeit important for effective wheelchair use, wheelchair skills training is a single factor within the wheelchair provision process. Since clinician expertise influences every component of wheelchair service delivery [34], it is imperative that curriculum provides a broad understanding of all factors. Although our results show that curriculum included education on the wheelchair, seating and fit and environmental considerations for wheelchair use, we did not examine these components in detail. Nor did we investigate curriculum on the other key components of wheelchair provision. It is critical that wheelchair-related curriculum be scrutinized to ensure quality wheelchair service delivery. For example, curriculum should also include education on standardized methods for wheelchair service provision [35], including key intervention approaches to optimize function of individuals with disabilities [36]. This supports the need for the acceptance of a standardized approach for wheelchair provision [4], which may also assist with consistent education and training across disciplines and geographical regions. Furthermore, a universal approach could help to establish clearly defined roles and responsibilities for clinicians and wheelchair suppliers. Continuing education is critical for obtaining advanced training in specialized fields, such as wheelchair provision, which requires an understanding of the dynamic interface between the wheelchair and the user, in addition to an appreciation of the user’s needs, abilities, preferences, available technologies and environmental demands [25]. The knowledge and skills required to successfully provide wheelchairs include the application of biomechanics and ergonomics for specialty seating, and the integration of advancing technologies with environmental considerations and personal characteristics [37,38]. Even the selection of the best seat cushion requires considerable knowledge [39]. Some organizations provide continuing education certifications to recognize expertise in specialized skill sets, such as Assistive Technology Professional and Seating Mobility Specialist [40]. However, there are no requirements to obtain specialized MWC training certifications for national or provincial practice in Canada, thus providing little incentive for Canadian OTs and PTs. Interestingly, clinicians in Quebec are encouraged to not develop their knowledge outside of what is practiced in their clinical milieus, possibly because post-professional certifications are rarely, if ever, offered in French. However, the WSTP may also provide an evidence-based framework for the development of continuing education modules in French, as healthcare professionals who completed the WSTP-French version significantly improved their wheelchair skills capacity and their perception of their actual skill level. One participant commented that the WSTP could lead to changes in professional practice [16]. Although we would not necessarily advocate for creating a new category of a wheelchair training specialist, we would encourage the use of standardized basic training for students in entry-to-practice programs, as well as standardized continuing education modules. The WSTP may provide an evidence based approach for teaching students and professionals, which would fit within the educational philosophies of both the Canadian Association of Occupational Therapy (CAOT) and the Canadian Physiotherapy Association (CPA). The WSTP would also fit within the recent recommendations for an Assistive Technology Service Method (ATSM), which aims for a service method that is consistent with key guidelines, models and systems. For example, the WSTP provides a standardized approach for education, professional development, continuing education and certification, as required by the Rehabilitation and Engineering Society of North America (RESNA) guidelines [40]. Further, the WSTP provides a validated intervention for assistive technology
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users (i.e. the wheelchair), which is an essential component of the IMPACT2 model [36]. Finally, wheelchair skills can be categorized within the ‘‘activities’’ sub-domain of the International Classification of Functioning, Health and Disability (ICF) framework, and the WSTP uses a common language that can be used across disciplines [35]. Future studies could examine the time and financial efficiencies of basic standardized training according to the WSTP in entry-to-practice programs to ensure all clinicians enter the field with the same education. The WSTP could be further explored as a framework for the development of intermediate and advanced wheelchair skills training modules for post-graduate OTs and PTs who practice specifically in rehabilitation. A description of current clinical practices for wheelchair skills training for new wheelchair users could also provide insight into the use of validated programs by practicing professionals, which may provide suggestions for future knowledge translation efforts. Study limitations Despite a 75% response rate, we were pleased to have representation from all Canadian regions. Since responses came from all levels and respondents may or may not have been responsible for teaching the content we surveyed about, we suspect that there may be some variability in the knowledge of the respondents with regard to the specific content about MWCs. It is also possible that specificity of wheelchair skills taught may have been missed, as the survey questions did not ask for specific details about particular skills. Survey question comprehension may have imposed another limitation and despite our efforts to operationalize survey questions, self-reports are prone to misinterpretation. Finally, we discussed accreditation and post-professional training from a national perspective, which is not applicable for clinicians in the province of Quebec where clinical practice is regulated by provincial associations. However, a validated program for teaching MWC skills is available and effective in French and may also be used for curriculum and post-professional training in Quebec.
Conclusion The findings from our study suggest wheelchair curriculum is consistently included in OT and PT programs, but the content and teaching methods specific to wheelchair skills training are not standardized and limited in time. Program curriculum may benefit by integrating validated programs for MWC skills training. Validated MWC training programs may also provide a structure for the development of intermediate and advanced wheelchair skills training and certification after graduation. As with all assistive technology devices and services, procurement of training to effectively use a wheelchair is incumbent upon professional associations for inclusion in core educational curriculum.
Acknowledgements The authors would like to thank all participants for their contributions. We would also like to thank Karine Boily, Emilie Lacroix and Claudine Auger for assistance with translating study documents and members of the ‘‘Rehabilitation Research Lab productivity club’’ for research and clinical input when editing the manuscript.
Declaration of interest The authors report no conflicts of interest.
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