Competencies of undergraduate physiotherapy education: A scoping review

Background In recent years, the need for competency-based medical education has been emphasised. Each country needs a defined set of physiotherapy competencies from the associations and governing bodies. Objectives Our review aimed to map competencies of undergraduate physiotherapy education and propose a context-specific competency framework for Namibia. Method This scoping review was conducted following the Joanna Briggs Institute framework and was reported using the Preferred Reporting for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. Qualitative direct content analysis utilising the five main competency domains from the WHO Rehabilitation Competency Framework was adapted. Results Five main competency domains were proposed: practice, professional growth and involvement, learning and development, management and leadership, and research. Nineteen potential competencies were identified, and each competency has a set of knowledge and skills activities that is expected of each student. Conclusion The proposed competencies still need to undergo expert consensus and content validation before they can be adopted and implemented in Namibia. Future studies can explore the perspectives and experiences of the faculty, students and clinicians on the current status of competency-based education of undergraduate physiotherapy programme in Namibia. Similarly, future studies can focus on possible assessment strategies that can be used for each competency and an evaluation framework for assessing milestones in student competencies from entry into clinical education to graduation. Clinical implications The review proposed a context-specific competency framework for Namibia with a set of knowledge and skills activities that is expected of each student. The faculty can adopt these competencies and improve on their competency-based physiotherapy education.


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Introduction Rationale
In recent years, the need for competency-based medical education (CBME) has been emphasised.This shift to CBME has shortcomings of existing assessment (Harris et al. 2010), including strategies to assess the clinical competencies in the ever-changing medical education, characterised by the multidisciplinary approach among healthcare professionals, requiring patient safety, transparency and accountability (Lockyer et al. 2017).
Two key rationales for assessment are assessment of learning and assessment for learning.Competency-based medical education has shifted the rationale for assessment from assessment of learning to assessment for learning (Lockyer et al. 2017).In assessment for learning, active engagement of the learner forms the central role.Assessment should be performed by and with the learner (Sargeant et al. 2010).On the other side, assessment of learning focuses on the acquisition of knowledge or the demonstration of certain competencies in controlled settings.Given that these two rationales for assessments are different and the recent shift to CBME, our thinking should be on developing assessment rubrics that consider the effect of trainees' competence on the quality of patient treatment outcomes (Kogan & Holmboe 2013).
Background: In recent years, the need for competency-based medical education has been emphasised.Each country needs a defined set of physiotherapy competencies from the associations and governing bodies.
Objectives: Our review aimed to map competencies of undergraduate physiotherapy education and propose a context-specific competency framework for Namibia. http://www.sajp.co.za Open Access There are many inconsistencies regarding the definition of competency (Kurunsaari et al. 2018).In 2010, following a systematic review by a group of educators (Frank et al. 2010), a more comprehensive definition of competence was provided: The array of abilities across multiple domains or aspects of physician performance in a certain context.Statements about competence require descriptive qualifiers to define the relevant abilities, context, and stage of training.Competence is multidimensional and dynamic.It changes with time, experience, and setting.(p.641) Further, in 2020, a group of rehabilitation experts proposed a more recent definition: 'Competencies are the observable abilities of a person, integrating knowledge and skills, as well as core values and belief in their performance of tasks' (World Health Organization 2020:4).
Competency-based medical education is outcomes-based and is designed using a framework of competencies that drive its implementation, assessment and evaluation (Frank et al. 2010).To this end, it is important to identify the competencies expected in an undergraduate student during the development of the curriculum and assessment rubrics.
The University of Namibia has an undergraduate physiotherapy programme in its infancy, with its first cohort of graduates produced in May 2022.Further, the University of Namibia is the only institution in Namibia training physiotherapists.The undergraduate programme was developed through benchmarking against South African universities.There are many contextual factors influencing the application of competency-based physiotherapy education.Some factors that hinder the application of competency-based education include the number and type of accredited clinical settings for student rotations, the number of speciality clinicians in hospitals to assist with clinical supervision, and the number and frequency of clinical assessments.
The current physiotherapy education system has the consequence of producing a graduate who is likely to lack clear-cut competencies that are responsive to the Namibia and international rehabilitation standards.This may run the risk of having a clinician who is not adequately ready for delivering quality physiotherapy services responsive to the Namibian population, thus compromising patient safety and treatment outcomes.Further, there is a consequence of breeding a lack of common assessment language among Namibia's students, faculty, clinicians, external examiners and licensing bodies.To this end, this practice can lead to a lack of cohesion among professionals, thus hampering teamwork in patient care.
Globally, various physiotherapy associations and governing bodies have set contextual competencies expected from each physiotherapy graduate.In Namibia, most of the regulations and guidelines were developed prior to this physiotherapy programme and have not yet been reviewed to include contextual competencies required for physiotherapy education.
Having practised physiotherapy in Namibia for over 15 years in Namibia, the authors believe that the lack of a defined set of competencies from the associations and governing bodies has led to trial and error practice when it comes to structuring clinical blocks and finding the best-fit formula for assessments.

Objectives
The main aim of our review was to map the undergraduate physiotherapy education competencies and propose a context-specific competency framework for Namibia.There is no evidence of any scoping or systematic literature review on undergraduate physiotherapy competencies in Africa.Thus, our review aims to answer the main research question: what evidence is available on undergraduate physiotherapy education competencies?Further, the review intends to answer the secondary question: what are the contextually relevant competencies for physiotherapy education in Namibia?However, the competencies will require to undergo expert consensus and content validation before physiotherapy educators can use them to review the learning outcomes for their curriculum (World Physiotherapy 2021).Moreover, the Allied Health Professions Council of Namibia can adapt them as an evaluation of physiotherapists for registration.

Research methods and design
This scoping review followed the Joanna Briggs Institute (2015) methodology for scoping reviews.The Preferred Reporting for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) (Tricco et al. 2018) was followed for reporting the findings.

Protocol and registration
The review protocol was registered with the Open Science framework and can be accessed at the following link: https:// osf.io/4r6tm/.

Type of participants
All studies reporting on the general competencies and physiotherapy domain-specific competencies for undergraduate and entry-level physiotherapy programmes will be included.

Concept
The concept of this study is undergraduate physiotherapy competencies.For this study, 'Competencies are the observable abilities of a person, integrating knowledge and skills, as well as core values and belief in their performance of tasks' (World Health Organization 2020:4).This study adopted the structure and adapted the contents of the WHO Rehabilitation Competency Framework (RCF).This WHO RCF 'is a model that communicates the expected or aspired performance of the rehabilitation workforce across professions, specialisations and settings to enable quality care and service delivery' (World Health Organization 2020:1).This framework was chosen as it resonates with the vision of the Rehabilitation 2030 Initiative.

Context
All studies reporting competencies for undergraduate physiotherapy at the global level in a rehabilitation centre, healthcare setting and community setting were considered.
Understanding the competencies required of a physiotherapy student in any setting is important.

Types of sources
All types of primary studies, all types of reviews, grey literature (websites, guidelines, theses) and books from electronic databases were included in our review.

Time frame
The time frame chosen was from January 1990 to May 2023.

Exclusion criteria
The exclusion criteria include the following: • All articles with titles and abstracts not in English.This is because English was used in the first step for screening titles.

Information sources
The

Selection of sources of evidence
The Joanna Briggs Institute methodology (The Joanna Briggs Institute 2015) guided the search selection of sources.
The selection was based on title, abstract and full-text screening.
The first author (T.S.) screened the titles of the retrieved studies.Further, T.S. and A.T. independently screened the abstracts against the inclusion criteria.The studies retained for full text were then independently assessed for eligibility by two reviewers (T.S. and A.T.).The reference lists from all the full-text studies were searched for potential additional study.Full-text studies not meeting the inclusion criteria were excluded and reasons were provided (Appendix 2).Disagreements in the selection process were resolved through discussions.

Data charting process
Two reviewers extracted data using an adapted data extraction tool from the Joanna Briggs Institute (The Joanna Briggs Institute 2015).The following headings were used on the data extraction sheet: author(s), year of publication, place of publication, process followed in identifying competencies, type of competencies and list of competencies.The first reviewer (T.S.) initiated the data extraction and the second reviewer (A.T.) conducted independent verification.Discussions were held to resolve any disputes.

Data items
The following comprise a list and definitions of all variables for which data were sought and any assumptions and simplifications made.
• Author(s): It indicates the author(s) who published the document.A document may mean a peer-reviewed article, a framework, a guideline and a report.• Year of publication: It indicates the year the document was published.• Place of publication: This is the place where the document was published.This was sought by country and later by region.• Process followed in identifying competencies: This identifies the methodology followed, the stakeholders or participants involved and the completion time frame.We assumed that the process indicated the results' validity and reliability.• Type of competencies: This defined the competencies including general competencies for physiotherapists, competencies for physiotherapy registration and licensing, physiotherapy exit competencies, and domainspecific competencies (e.g.pain management).• List of competencies: This is a pool of competencies that were identified across the documents.

Synthesis of results
Firstly, descriptive statistical analysis was conducted on the number of studies, trend of studies, geographical locations, process followed in identifying competencies and type of competencies.Secondly, conventional content analysis (Namey et al. 2008) was employed to analyse the competencies.This was conducted by reviewing the documents and highlighting text describing competence.These data were extracted verbatim and added to an Excel http://www.sajp.co.zaOpen Access sheet for coding.The final subthemes represented the competencies and the codes indicated activities.
Finally, direct content analysis utilising the WHO RCF (World Health Organization 2020) was adopted for its structure and adapted for its content.Thus, the domains of the WHO RCF were adopted as the main themes which included practice, professionalism, learning and development, management and leadership, and research.
The content was determined by the results from convectional content analysis where the subthemes represented the competencies and the codes indicated skills and knowledge-specific activities of that competence.

Ethical considerations
The Ethical Clearance Certificate was issued by the University of Namibia Decentralized Ethics Committee (DEC) in accordance with the University of Namibia's Research Ethics Policy and Guidelines (SAH08/22 -24/07/2022).

Selection of sources of evidence
The initial search from electronic databases identified 495 publications.A total of 30 duplicates were removed and 256 were found to be ineligible before screening.After the abstract screening of 201 articles, 188 were excluded and 13 were retained for full text screening.A total of four articles were finally included.A search of websites and hand searching in organisations retrieved a total of 13 documents (frameworks [10], scope of practice [1], regulation for licensing [1], curriculum [1]).The study finally included 16 documents for analysis.This is depicted in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Peters et al. 2015) (Figure 1).

Characteristics of individual sources of evidence
The types of publication were competence frameworks (10), peer-reviewed articles (4), scope of practice (1), regulations for licensing (1) and curriculum (1).Summary of the documents extracted is shown in Table 1.

Year of publication
Figure 2 indicates there has been a growing interest in competency-based education and practice with a peak in the year 2020.

Geographical location
Most of the documents retrieved were from Oceania (5).None were retrieved from Asia and South America (Table 2).

Process followed in identifying competencies
Most of the global competencies were developed using country consultations, technical working groups and delphi consensus studies (Table 3).

Synthesis of results
Our review aimed to map the competencies of undergraduate physiotherapy education and propose a context-specific   competency framework for Namibia.Five domains were adopted from the WHO RCF (World Health Organization 2020).Nineteen potential competencies were identified from various frameworks and studies globally.Each competency has a set of activity-specific knowledge and skills expected of each student.A sample of how the competencies were identified and aligned to the domains of the WHO RCF is shown in Table 4 and the proposed contextspecific competency framework for Namibia is shown in Appendix 3.

Discussion
Competency frameworks have the potential of providing a shared language, unifying and harmonising rehabilitation professionals (World Health Organization 2020).Our review aimed to map the competencies of undergraduate physiotherapy education and propose a context-specific competency framework for Namibia.The study synthesised several global entry-level physiotherapy competencies enshrined in competency frameworks, scope of practice, regulation for licensing and curriculum.The WHO RCF (World Health Organization 2020) underpinned the data analysis and the subsequent development of the proposed context-specific competency framework for Namibia (Appendix 3).Thus, five domains of the WHO RCF were adopted as the main themes which included practice, professionalism, learning and development, management and leadership, and research.Nineteen competencies were identified from convectional content analysis of the final included documents, and they represented the subthemes.The codes indicated skillsspecific activities and knowledge-specific activities of that competence.Notably, the proposed competencies are intended to supplement the current competencies and to add clarity, strength and content.
It is critical to track the student's progress from entry to graduation based primarily on competency acquisition, where time becomes a resource for education and not a determinant for graduation.There is a need for guidance on a student's observable behaviours and other attributes at a significant point in development to be a physiotherapist (Edgar et al. 2020).Notably, adopting a competency-based undergraduate physiotherapy education has the potential of de-emphasising a time-based credentialing system where graduation to physiotherapist would be hinged on the acquisition of skills rather than time frames (Frank et al. 2010).
The adopted five domains allowed for the thematic grouping of the synthesised competencies and their accompanying knowledge and skill statements.The most prominent domain of practice entails competencies hinged on the interaction between the undergraduate physiotherapy student and the patient and family (World Health Organization 2020).

Process Frequency of documents
Multi-country consultation 3 Regional country consultation (four countries) 1

Country consultation 9
Technical working groups 7 Delphi consensus studies 6 Policy reviews 3 Importantly, leadership and management can enable the students to acquire competencies in managing a rehabilitation team, service delivery, monitoring and evaluation.In Namibia, physiotherapy graduates must be deployed in remote areas where they need to demonstrate these competencies.To this end, physiotherapy education is required to equip the students with the competencies that will enable them to independently manage a rehabilitation department upon graduation (World Physiotherapy 2021).
Central to any profession is evidence-based practice which is driven by research.Physiotherapists are required to apply clinical reasoning underpinned by evidence-based practice (Wijbenga et al. 2018).Understanding the research process is critical at the undergraduate level.To advance the profession through evidence generation, dissemination and integration, entry-level physiotherapists are required to have a fair understanding of designing basic operational research and to be able to disseminate through various platforms (World Health Organization 2020).
Competency-based education emphasises a learner-centred approach, where learners take charge of their learning, and deemphasises a time-based approach (Frank et al. 2010).Most medical education programmes are time-bound and thus defeat the ideology of allowing students to achieve their competency at their own pace (Frank et al. 2010).However, students can acquire competencies at different times, and it is thus important for the education system to be flexible to adjust the time spent on some tasks to accommodate these learners (Carraccio et al. 2008).For example, the competency of clinical reasoning should be approached with caution as it also follows the normal developmental pattern of a baby from learning to crawl and then progressing to standing and walking.The academic supervisors and clinicians must understand that their role involves nurturing the student's growth by facilitating the process using new teaching methods and assessment techniques to be utilitarian and efficient.
Our review is a first step towards a competency framework for physiotherapy education in Namibia.It is expected that the physiotherapy educators, clinicians, examiners, students and registration bodies can reflect on their practice and identify areas that need improvement regarding competency-based education.The proposed competency framework will require expert consensus and content validation before adoption.

Limitations
Firstly, the reviewer only has access to databases hosted by the University of Namibia.Secondly, articles that had abstracts not in English were not included in the review.This could have potentially missed some crucial studies in other languages.

Conclusion
To advance physiotherapy education in Namibia, our review synthesised various global physiotherapy competency frameworks, scope of practice, regulation for licensing and original studies to propose a contextually specific competency framework for Namibia.The proposed competencies still need to undergo expert consensus and content validation before they can be adopted and implemented in Namibia.Significantly, this contextualised framework can be utilised in several ways, including proposing to the Allied Health Professions Council of Namibia to guide the competencies required for physiotherapy registration; the University of Namibia physiotherapy programme can use it to convey their courses' learning outcomes so that they are responsive to the needs of the population, and the Ministry of Health and Social Services can use it to plan human resource recruitments and evaluation.

TABLE 1 :
Summary of documents selected.

TABLE 4 :
Competence identification and alignment to the domains of WHO Rehabilitation Competency Framework.

TABLE 3 :
Process followed in identifying competencies.

TABLE S1 :
Search strategies for the electronic databases, date of the last search: 20 May 2023.Timing for which interventions relevant to scope of practice should be conducted to achieve desired outcomes Frequency and duration of an intervention relevant to scope of practice to achieve desired outcomes Reasons for noncompliance with rehabilitation plans and methods of maximising compliance Correctly prescribe and control physical exercise in its different modalities (isometric, concentric and eccentric isotonic, functional, motor control, conscious movement, etc.), adequately selecting among them to achieve the best result according to the objective set in a musculoskeletal dysfunction Prescribe, perform and/or control the proprioceptive and neuromuscular re-education techniques in their different phases, adequately selecting the techniques according to the evolutionary phase of the patient to achieve the best result based on the objective Correctly propose coherent physiotherapeutic objectives in the short, medium and long term, considering the pathology and the individuality of the user and his/her expectations and preferences Plan the treatment based on the objectives set, attending to the criteria of adequacy, validity and efficiency, considering risks and contraindications and efficiently managing the treatment time Correctly perform a bandaging (functional, neuromuscular, compressive), knowing the best choice among the different materials and techniques to achieve the best result according to the objective set Correctly carry out an application of electrotherapy (motor electrostimulation, TENS, galvanic current, magnetotherapy, laser, shock waves), selecting among the different parameters, and establishing dosimetries and application times, etc., to achieve the best result according to the objective set Correctly carry out the different techniques of manual therapy: massage therapy (decontraction, bowel evacuation, cicatrisation massage, Cyriax), adequately selecting among them and correctly executing them to achieve the best result according to the objective set Correctly carry out an application of thermotherapy (paraffin baths, MW, PSWT, radiofrequency, etc.), selecting among the different parameters, and establishing dosages and application times, etc., to achieve the best result according to the objective set Carry out the procedure of progressive loading and gait reeducation in patients who require so due to the lower limbs injuries Correctly carry out the following techniques of manual therapy: neuromuscular techniques, adequately selecting among them to achieve the best result according to the objective set Correctly carry out the following techniques of manual therapy: articulatory techniques, adequately selecting among them to achieve the best result according to the objective set Correctly carry out the following techniques of manual therapy: neurodynamic techniques, adequately selecting among them to achieve the best result according to the objective set Demonstrate management of pain -how is pain relieved?Demonstrate an understanding and implementation of pain management in a specific context/environment Referring to other providers Range of appropriate providers relevant to scope of practice and considerations for referral Typical eligibility criteria of providers relevant to scope of practice Potential costs and logistical requirements for accessing providers Referral pathways and procedures relevant to scope of practice, including information handover requirements Referring to other providers Managing handovers Writing referrals Evaluating progress towards desired outcomes Expected trajectory of functioning with implementation of the rehabilitation plan relevant to scope of practice Range of outcome measures relevant to scope of practice and considerations for selection Intervals for evaluating progress towards desired outcomes Non-standardised approaches to determining progress towards desired outcomes, such as observation, self-report and family or caregiver perceptions Methods and techniques for using outcome measurement instruments relevant to scope of practice How to interpret and report outcome measures relevant to scope of practice Evaluating progress towards desired outcomes Setting up and using equipment and consumables relevant to scope of practice Implementing inspecting, measuring and testing techniques Scoring standardised outcome measures Interpreting the results of outcomes measures Assessing body functions, activities and participation through observation and interview Evaluating outcomes Develop a working prognosis Discharging and ensuring appropriate continuity of care Information required and methods for determining discharge readiness, including typical indications and contraindications for discharge relevant to scope of practice Methods for determining the need for, and degree of, ongoing support and follow-up that a person and their family may require Approaches to facilitating self-management following discharge Potential logistical requirements for discharge or transition of care How to construct a discharge report, including key information points How to ensure successful transfer and/or storage of information on discharge Discharging and ensuring appropriate continuity of care Managing handovers Closing relationships with a person and their family Physiotherapy Board of New Zealand (https://www.physioboard.org.nz/)Framework European Region of WCPT website (https://www.erwcpt.eu/file/251)Framework Physiotherapy Advisory Group website (https://peac-aepc.ca/pdfs/Resources/Competency%20Profiles/Competency%20Profile%20for%20PTs%202017%20EN.pdf)Framework American Physical therapy Association Website (https://www.apta.org/for-educators/core-competencies-pt-resident)Framework AHPCN website (https://www.hpcna.com/images/councils/allied/http://www.sajp.co.zaOpen Access