The Integrated Clinical Education Strategic Initiatives Project—Development of Parameters to Guide Harmonization in Clinical Education: A Scoping Review

Abstract

Background

Clinical education curricular models specifically related to integrated clinical education (ICE) vary across physical therapist education programs. The interconnectedness of ICE to the advancement of a shared vision for clinical education in professional physical therapist education needs investigating.

Purpose

The purpose of this scoping review was to: (1) define ICE, (2) define baseline expectations and parameters of ICE, and (3) discern and describe current ICE models.

Data Sources

Databases accessed included Medline, MedlinePlus with Full, CINAHL, and CINAHL Plus with full text.

Study Selection

A multimodal data collection scoping review was completed. Data collection included survey research, a systematic review of the literature, and a series of focus groups. The McMaster Critical Appraisal Tool assessed methodological study quality. A qualitative, metasynthesis approach was used for data synthesis. Consensus agreement produced results.

Data Extraction

Twenty-two articles were included in the literature review from the health disciplines of medicine, nursing, physical therapy, occupational therapy, and speech-language pathology. Data synthesis produced 8 parameters defining the factors essential to categorizing clinical education experiences as ICE in physical therapist education. The 8 parameters and ICE definition are supported by a description of models of ICE that currently exist within health profession curricula.

Data Synthesis

Data synthesis followed a qualitative, metasynthesis approach. Themes emerged from the surveys, literature review, and focus group data. Patterns were compared, analyzed, and synthesized to generate the themes and ICE parameters.

Limitations

Selection bias from the literature search could have limited the richness of the model descriptions by unintentional exclusion of articles, and might limit the applicability of results beyond the United States. Sampling bias from survey and focus groups, although purposeful, might have limited a broader description of current viewpoints about ICE. However, the data sources, including multiple health profession perspectives coupled with consensus agreement, provide sound evidence in development of profession-based parameters.

Conclusions

The results of this scoping review provide the profession with a standard definition of ICE and parameters that can guide a program in designing a curriculum using ICE experiences as a foundation. A recommended next step is to design education research studies using reliable and valid outcome measures across programs to determine impact and effectiveness of ICE as an educational intervention.

Physical therapist education has historically included both didactic and clinical education (CE) course components in its curricular design. The didactic curriculum comprises the content, instruction, learning experiences, and assessment directed by the academic faculty, whereas the CE curriculum includes all part-time and full-time clinical education experiences.¹ Curricular models vary in educational patterns, including the overall curriculum design, the timing, and length of CE prior to graduation.² Although the clinical doctorate in physical therapy is the degree earned to enter the profession of physical therapy today in the United States, there are no model guidelines to which programs must abide related to didactic and clinical education curricula.^3,4

Scholars of education philosophy have found that early, authentic experiences enhance student learning.^2,5–7 These learning experiences provide students with a mechanism to attach a real-life experience with theoretical knowledge, resulting in more complex insight of basic concepts,⁸ such as designing an exercise program for children with disabilities. The inclusion of CE experiences throughout a student's academic program appears to provide an environment for transformative practice, where students can focus on actual experiences during immersion activities.⁹ Real-life experiences support the development of skills, reinforce academic knowledge, facilitate the clinical reasoning process, and develop self-confidence while providing services to community members.⁹

Historically, training of physical therapists involved an intricate balance of both didactic courses and CE experiences, with training programs evolving from societal need.¹⁰ Physical therapist education programs shifted to university-based programs, which require clinical affiliations with community-based physical therapist practices to provide the essential CE experiences.^10–13 As early as 1976, leaders of the profession recommended weekly CE experiences culminating with full-time blocks of CE toward the end of the curriculum.^10,11 As such, a variety of curricular models evolved with the advancement of the education requirements to enter the profession.

Currently, there are various views of the design of CE experiences within physical therapist education programs (PTEPs). CE models may include a combination of part-time and full-time experiences and a final CE experience of at least 7 weeks.³ It appears relocation of CE experiences to the end of the curriculum, following completion of all didactic coursework, might have been a trend with moving to the clinical doctorate degree⁸; however, data are not available to support this claim. Regardless of the design, it appears that no standardization in length, number, type, and practice-setting expectations exists, even after consensus conferences culminated in published reports that recommended standardization.^14,15

The lack of standardization has been in the forefront of national discussions within the profession. In particular, the topic of integrated clinical education (ICE) has been a debated topic due to a lack of professional guidelines related to curriculum development and CE. However, the Commission on Accreditation in Physical Therapy Education now requires programs to offer ICE experiences,¹⁶ and leaders within the profession argue in favor of early clinical learning experiences.² Concerning factors, nevertheless, are an anecdotal lack of understanding of what constitutes an ICE experience and a perceived lack of evidence supporting ICE as a valid curriculum design model. Because of the dissonance within the profession involving CE, action was needed.

The American Council of Academic Physical Therapy (ACAPT), in coordination with the American Physical Therapy Association (APTA), the Education Section of the APTA, the Federation of State Boards of Physical Therapy, and the Journal of Physical Therapy Education convened a Clinical Education Summit in 2014. The outcome of the Summit included both harmonization and innovation recommendations.¹⁷ The ACAPT Board of Directors selected the topic of ICE as an initial harmonizing recommendation to be investigated by a national workgroup, given the interconnectedness of this educational intervention to the advancement of a shared vision for CE. Therefore, the purpose of this project was to: (1) define ICE; (2) define baseline expectations and parameters for quality ICE in physical therapist education; and (3) discern and describe models of ICE that currently exist within physical therapist curricula.

Methods

This project was undertaken by a purposefully selected ACAPT work panel consisting of academic and clinical physical therapists, including education research physical therapists. Considerations in selecting the work panel members included: (1) previous experience and knowledge of professional education programs where an integrated model of clinical education was used; (2) academic or clinical position held; (3) geographic location; and (4) type of institution represented (public/private). The work panel consisted of the authors of this review.

The process to develop the definition, parameters, and explanatory models was developed by the work panel, because no previous procedures existed to guide our work. Initial workgroup consensus suggested that an evidenced-based, multimodal data collection method was needed to meet the goals of the workgroup charge. As such, a scoping review¹⁸ was completed to synthesize current knowledge and provide a consolidation of evidence to guide the development of baseline parameters and a definition for ICE for use by physical therapist education programs. A scoping review is:

A form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area of field by systematically searching, selecting, and synthesizing existing knowledge.^18p1292 Scoping reviews may also include an option of consulting with appropriate stakeholders to provide additional insights on what the literature may fail to highlight.^18,19

The methods of data collection included the development, distribution, and analysis of data from a descriptive survey, a review of the literature, and a series of purposeful focus groups. The survey and review of literature occurred concurrently. The focus groups occurred after the analysis of these data to offer transparency of the process to the members of ACAPT and other interested educators, and to seek additional data for consideration. The overall intent of these data collection methods was to examine current educational practices in physical therapist and other health profession programs from the viewpoint of various stakeholders. The results of these data collection methods guided the development of parameters to describe the foundations of ICE in PTEPs. Trustworthiness of this process was enhanced by development of a systematic process for data collection methods at the start of the project (credibility/dependability), the checks and balance system employed throughout the analysis process (credibility/transferability), and the establishment of decision strategies prior to the development of the results (confirmability).²⁰

Survey Research

Data collection and analysis

A descriptive survey tool was developed and distributed using Survey Monkey (SurveyMonkey, San Mateo, CA, USA) to the purposefully selected workgroup (n = 12). The survey consisted of 2 demographic questions; 3 global questions about the program's CE curriculum; and 10 questions related to each course considered as an ICE course, up to 5 courses (Appendix  1). The questions included 1 open-ended question and 9 closed questions with option for comment. Face validity was established by an education research reviewer and a pilot of the tool with 2 academic educators. Minor revisions were made based on this quality check. Data analysis used descriptive statistics, including frequencies and percent calculations. Qualitative common themes and patterns were generated from open comments.

Review of the Literature

Identification and selection of studies

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement guided the selection of the search-identified studies.²¹ A comprehensive search of the literature was completed in July/August 2016 and repeated in December 2016. Search terms included “integrated clinical education” in the literature of the health professions of physical therapy, occupational therapy, nursing, medicine, physician assistant, and speech language. CINAHL and Medline text subject headings were also included (Tab. 1).

Table 1.

Search Terms and Search Strategy

Physical Therapy	Occupational Therapy	Nursing	Physician Assistant	Speech Language	Medicine
Key Words Clinical education Clinical experience Experiential learning Integrated clinical experience Physical therapy Pro bono CINAHL Plus with Full Text and MEDLINE Plus with Full Text Subject Headings Clinical experience, physical therapy Experiential learning Integrated clinical experience Integrated clinical experience, physical therapy Patient experience, physical therapy Pro bono, physical therapy Standardized patients, physical therapy	Key Words Integrated clinical experience Integrated learning Level 1 field work Occupational therapy CINAHL Subject Headings Integrated clinical experience Integrated clinical experience in occupational therapy Integrated learning experience in level I field work Level I field work Level I field work in occupational therapy MEDLINE Subject Headings Level I fieldwork in occupational therapy	Key Words Experiential learning Integrated clinical experience Integrated learning Integrated learning experience Nursing CINAHL Subject Headings Experiential learning, nursing Integrated clinical experience, nursing Integrated learning, nursing Integrated learning experience	Key Words Clinical experience Physician assistant CINAHL and MEDLINE Subject Headings Clinical experience	Key Words Integrated clinical experience Speech language Speech language pathology Student experiential education Student integrated clinical experience CINAHL Subject Headings Speech language, integrated clinical experience Speech language pathology, student integrated clinical experience Speech language pathology student experiential education	Key Words Clinical education Clinical experience Integration Experiential learning Medicine CINAHL and MEDLINE Subject Headings Clinical experience Clinical experience Integration Experiential learning Medical students Medicine Medline (OVID) CINAHL Plus PubMed Medline Complete Integrated clinical experience Medicine

Databases accessed included Medline, MedlinePlus with Full, CINAHL, and CINAHL Plus with Full Text. Five researchers searched the databases for literature related to the identified health care professions. Results from each database search were intentionally tailored to include articles available in full text and abstracts. All literature citations and full-text articles were collected and organized using Google Drive Docs and Sheets (Google LLC, Mountain View, CA, USA). A referencing check and hand search complemented the database search. Figure 1 outlines the PRISMA study selection process.

Figure 1.

PRISMA flow diagram of systematic review.

Inclusion and exclusion

Empirical studies of any research design were included if available in full text in English and referenced an ICE experience. The period from 2000 through 2016 was the selected time frame, because we felt these years would reflect contemporary education practice. Studies were excluded when no clear purpose to the study was identified or if the study lacked clear education outcomes as a result of the ICE experience. Systematic reviews, dissertations, abstracts, and conference proceedings were also excluded based on consensus agreement. Likewise, simulation studies were excluded, as we focused on CE experiences that provided human interactions.²²

Data extraction

Descriptive data extracted included: the author(s), year of publication, discipline, type of course and/or CE experience, sequencing of the course(s) in respect to the entire education curriculum, objectives for the learning experience, frequency of the ICE experience(s), the location(s) of experience, methods and outcomes of assessments, and coordinator/facilitator of the experience. Other pertinent descriptive data about the structure, process, or outcome of the ICE experience were also extracted if available. Articles were categorized by research type/design.

Research design/quality assessment

The education research scale developed by the Institute of Education Sciences (US Department of Education) and the National Science Foundation was used to categorize research type.²³ Methodological quality was determined by 2 authors independently using a binary scoring system developed for the McMaster Critical Appraisal tools.^24,25 Any disagreements were resolved through consultation with another author. This tool was selected due to its use in other education research systematic reviews.^25,26 This 14-point scale offers a distributed quality measure counter to the risk of bias in the study results. Although methodological quality assessment is not required within a scoping review, we elected to complete this step to help guide the development of the ICE parameters and to be transparent about risk of bias within the selected studies.

Qualitative analysis

A descriptive thematic analysis²⁷ was used to identify, examine, and dichotomize key characteristics and trends in ICE experiences. Key elements of the structure, process, and outcomes of curriculum design were coded and thematically organized.¹⁰ Two authors analyzed the extracted data and developed 8 themes related to the education practices of programs or courses that offered CE experiences in an integrated manner within a health profession program. The themes were verified by 100% consensus from the work panel members. Once the themes were identified, descriptive summaries for each theme were generated. The summaries were reviewed, modified, and approved with 100% consensus.

Focus Groups

Two series of focus groups were conducted to gain perspective from stakeholders involved in CE. The first group included approximately 125 academic and clinical educators who attended an open-invitation educational session at the 2016 Educational Leadership Conference.²⁸ The second focus group included 15 student physical therapists interviewed either at the 2016 National Student Conclave in Miami, Florida, or through teleconference in November 2016. Facilitators led small group discussions using predetermined questions about issues related to current perceptions of ICE (Appendix  1). Comments were transcribed onsite during each focus group session. The transcribed data for each session were collated thematically and analyzed for content using key codes identified from the literature review.

Data Synthesis

A qualitative, metasynthesis approach²⁹ was followed. The primary themes were developed from the emerged patterns gleaned from the surveys, literature review, and focus groups. The patterns were compared, analyzed, and synthesized to generate the themes and ICE parameters. Data from the 3 methods of data collection converged,³⁰ indicating that a point of data saturation was achieved. As such, no further data were sought from other academic or clinical faculty through an expanded survey, additional focus groups, or review of additional literature. A meta-analysis of the literature data was not performed due to the heterogeneity of the outcomes studied.

The synthesis of all data resulted in the development of a set of educationally based parameters focused on a curriculum that uses ICE as an active learning pedagogy to support student learning. The parameters represent key characteristics of ICE within physical therapist education, and support sound curriculum design practices. The parameters developed denote general principles, rather than prescriptive requirements, to guide curriculum design. The parameters are not linear, but provide a loop for ongoing review, whereby one parameter can inform and provide justification for another. The model descriptions provide documented examples of curricula that support each key parameter. The parameters and model descriptions achieved 100% voting agreement by the work panel.

The definition of ICE was developed after consideration of the key parameter constructs. The literature that guided the development of each parameter was used to support the definition, coupled with accreditation standard considerations. The resulting definition achieved 100% voting agreement. The ICE parameters and definition were vetted, voted on, and approved at the 2017 ACAPT Annual Meeting.

Role of the Funding Source

This work was supported by the American Council of Academic Physical Therapy (ACAPT). Funds were used to support meetings of work panels. The funder played no other role in the design, conduct, or reporting of this study.

Results

Selection of Literature

A total of 3808 articles were retrieved. Articles were screened for title and abstract, yielding 83 articles. After full-text review, 19 articles were selected. Reference lists of these articles were reviewed resulting in an additional 3 articles for inclusion. A total of 22 articles were included in the final literature review. These articles represent the best available evidence about the topic of ICE in the selected health professions. The discipline distribution of the articles was: 55% (n = 12) physical therapy; 18% (n = 4) nursing; 9% (n = 2) occupational therapy; 9% (n = 2) speech-language pathology; 4.5% (n = 1) medicine; and 4.5% (n = 1) combined physical therapy/occupational therapy. Two studies originated in Australia^31,32 and 20 from the United States.^{2,7,8,33–48}

Design and Rigor of Literature

Table 2 describes research type, research design, and final methodological critical appraisal score. In the aggregate, 27% (n = 6) of the studies achieved a moderate to high quality, with a low risk of bias and a methodological quality score of 11 or higher²⁶; 73% (n = 16) had a low methodological quality and a high risk of bias score.²⁶ Items considered when scoring included literature review relevance, justification of sample size, use of reliable and valid outcome measures, contamination avoidance, educational importance reported, and appropriate conclusions (Appendix  2).

Table 2.

Description of Selected Studies by Discipline, Research Type, Design, and Methodological Critical Appraisal Score

Study	Discipline	Research Type21	Design	Critical Appraisal Score
Benson et al,9 2013	Occupational Therapy	Efficacy Study	Method/Model description with evaluation	8
Coker,43 2010	Occupational Therapy	Effectiveness Study	Cohort study-Quasi-experimental	11
Doucet and Seale,41 2012	Physical and Occupational Therapy	Early Stage or Explanatory Research	Model description/descriptive study	7
Faught et al44 (2013)	Nursing	Design and Development	Method/Model description with evaluation	6
Goldberg et al,45 2006	Speech Language Pathology	Design and Development	Method/Model description with evaluation	11
Hakim et al8 2014	Physical Therapy	Foundational Study	Position paper	3
Ingram and Hanks,35 2001	Physical Therapy	Effectiveness Study	Cohort study	8
Jensen et al,2 2015	Physical Therapy	Foundational Study	Qualitative	14
Mahendra et al,36 2013	Speech Language Pathology	Early Stage or Explanatory Research	Method/Model description with evaluation	9
Mai et al,37 2013	Physical Therapy	Early Stage or Explanatory Research	Method/Model description	13
Mai et al,46 2014	Physical Therapy	Efficacy	Cohort study-Quasi-experimental	7
O'Neil et al,38 2007	Physical Therapy	Early Stage or Explanatory Research	Method/Model description with evaluation	3
Reneker et al,49 2016	Physical Therapy	Effectiveness Study	Cohort study	9
Smith et al,48 2015	Nursing	Early Stage or Explanatory Research	Method/Model description	6
Stern and Rone-Adams,39 2006	Physical Therapy	Foundational	Model description	4
Stuhlmiller and Tolchard,33 2015	Nursing	Early Stage or Explanatory Research	Method/Model description	9
Weddle and Sellheim,7 2009	Physical Therapy	Foundational	Method/Model description	7
Weddle and Sellheim,40 2011	Physical Therapy	Early Stage or Explanatory Research	Method/Model description with evaluation	10
Williams-Barnard et al,47 2004	Nursing	Foundational	Method/Model description	6
Wilson42 (2006)	Physical Therapy	Early Stage or Explanatory Research	Model description	7
Wilson,50 2014	Physical Therapy	Foundational	Method/Model description with evaluation	6
Yardley et al,34 (2013)	Medicine	Foundational	Qualitative	14

Seventy-seven percent (n = 17) of published studies were designed to contribute to “core foundational knowledge”²³ that describes various models of ICE experiences. Twenty-three percent (n = 5) contributed to evidence of “impact,” designed to determine the reliability impact of ICE to achieve the intended outcomes.²³ Ninety-one percent (n = 20) were single-program designs that measured an assortment of outcomes.

Definition of ICE

The following definition was developed to define ICE. The numbers in brackets within the definition refer to the parameter that supports its inclusion:

Integrated clinical education is a curriculum design model whereby clinical education experiences are purposively organized within a curriculum.[3,4,7] In physical therapist education, these experiences are obtained through the exploration of authentic physical therapist roles, responsibilities, and values that occur prior to the terminal full-time clinical education experience.[1]

Integrated experiences are coordinated by the academic program and are driven by learning objectives that are aligned with didactic content delivery across the curricular continuum.[2,4,7,8] These experiences allow students to attain professional behaviors, knowledge, and/or skills within a variety of environments.[5] The supervised experiences also allow for exposure and acquisition across all domains of learning and include student performance assessment.[6]

For ICE experiences to qualify toward the minimum number of full-time clinical education weeks required by accreditation (Commission on Accreditation in Physical Therapy Education) standards, they must be full time and supervised by a physical therapist within a physical therapy workplace environment or practice setting.[5,8]

Parameters and Baseline Expectations of ICE/Model Descriptions of ICE

Eight parameters describe quality ICE (Fig. 2). The baseline expectation is that ICE is intentionally designed within a professional PTEP to meet the needs of the program and the learner, with consideration for site resources. Each parameter statement is explained by a model description (MD) gleaned from the collated results of the literature review (Appendix 3). Survey and focus group results that relate to the model descriptions are provided in Table 3.

• 1. ICE can occur in any academic term prior to the completion of the didactic coursework leading to the terminal full-time clinical education experience.

Figure 2.

The 8 parameters that describe integrated clinical education expectations. Copyright 2018 by the American Council of Academic Physical Therapy (ACAPT). Reprinted with permission.

Table 3.

Summary of Survey and Focus Group Data^a

Parameter	Survey Responses	Focus Group Responses
Occurrence within curriculum	100% (12/12) of programs provide ICE experiences.ICE experiences can occur anytime within a curriculum. Examples: A first academic year full-time clinical experience is 6-weeks in length, during which time students interact with patients in an acute care hospital environment. A second academic year full-time experience is an 8-week affiliation in an outpatient environment, where the primary patient/client populations are those with involvement of the musculoskeletal system. A part-time experience may include multiple observation courses, which occur during the fall and spring semesters of the second and third years of the curriculum.	ICE experiences should occur anytime within a curriculum based upon program needed. Ranges included in the first semester to any time before the final clinical education experience. Common words include: “early”, “as soon as possible”
Course/program objectives	100% programs report learning objectives are required for ICE. ICE experiences should have specific desired outcomes that correspond to course and/or programmatic objectives: Examples include: safe practice, communication, professional behaviors, and documentation skills.	The goals/objectives drive the experience, including location of where it is held. Examples of objectives include: inter-professional experience, basic/foundational skill development, exercise testing, affective behavior development, cultural competence, and observation of specialty areas.
Stand-alone course or component of a classroom course	83% (10/12) programs offer stand-alone ICE courses. These tended to be traditional full time CE experiences. Most part-time ICE experiences were embedded in classroom courses.	N/A
Time-frames	83% (10/12) programs provide full time and part-time ICE experiences; 2/12 programs provide only part-time ICE prior to final full time CE experiences. ICE experiences vary in frequency during a semester. Examples: 8 hours every other week, ½ day per week, or 1 day a week every other week, 2 weeks full time, 6–10 weeks full-time.	Most comments included part-time experiences; however, full time experiences were noted but no length was provided.
Location/learning sites	100% programs report full-time ICE experiences occur in traditional physical therapy practices. Other data varied by program. ICE experiences occur in a variety of learning sites, including campus or community based clinical or nonclinical settings, based upon the course and/or programmatic objectives. Example locations: ICU or LTAC setting, outpatient orthopedic practice, neurological rehabilitation setting, acute care setting, wound care specialty unit, total joint unit, OP in a university clinic, skilled nursing facility, pediatrics, outpatient practice in a hospital clinic, academic clinical practice setting, etc.	ICE could occur in a variety of settings. Settings could include: physical therapy clinics, community settings, nontraditional settings, or anywhere a student could have interaction with a patient/client. Examples provided: senior centers, radiology clinics, restorative services in skilled nursing centers.
Student assessment	100% programs report assessing student outcomes to learning objectives.Student assessments link to program or course objectives with student progression in professional behaviors, clinical knowledge, and/or skills. Examples: ability to perform foundational skills goniometry, mobility assessment, vitals screening, joint mobilizations, gait training, therapeutic exercise prescription/modalities applications.	Some form of student assessment is needed to evaluate if objectives met. Examples provided: CPI, professional behaviors, skill mastery.
Coordination of ICE	Qualitative data varied by program. Director of Clinical Education, other academic faculty were personnel noted.	N/A
Supervision	100% programs report students are supervised by either academic or clinical faculty. Other health care professionals were noted to supervise part-time clinical education experiences depending upon objectives of the experience.	Supervision required. Oversite by the academic program.

a

CE = clinical education; CPI = Clinical Performance Instrument; ICE = integrated clinical education; ICU = intensive care unit; LTAC =long-term acute care; N/A = not applicable; OP = outpatients. .

MD1: The placement and frequency of ICE within curricula is variable. ICE has been reported to occur as early as the first or second semester of year 1.^32–38 Although some programs incorporate ICE as late as the third year,^34,37,38 the majority of ICE models described experiences that occur in years 1 and 2.^{8,32,33,35–38,41–44} In some programs, ICE is not an isolated experience, but one in which students are afforded several opportunities to participate over the course of a professional program.^{8,32,35–38,45}

• 2. ICE experiences will have specific desired outcomes that correspond to course and/or programmatic objectives.

MD2: ICE experiences are part of the physical therapy curriculum that are designed to contribute to specific, desired outcomes for course and/or program objectives. Theoretical knowledge that students gain in the classroom can be reinforced with concrete experiences when ICE experiences are appropriately placed in the curriculum to augment the content being taught and designed to meet specific learning objectives.^2,38,40 As the curriculum progresses, ICE experiences can be structured so that students demonstrate a greater breadth and complexity of clinical skills.³⁸ Physical therapist students must experience all domains of learning (ie, cognitive, affective, and psychomotor) to be successful in clinical practice. The classroom setting does not always allow students to demonstrate skills in all the domains of learning as they would be used in professional settings.³⁵ ICE experiences afford students the opportunity to demonstrate these skills in situations that reflect the complexity of the health care delivery system.^9,46 In these situations, students prioritize care, demonstrate critical thinking,^35,46 and make decisions in an evidence-based manner.^34,43 ICE experiences can also be designed to include service activities,^35,36,46 which have the potential to influence students’ future behaviors related to the APTA Core Values and Code of Ethics.

Furthermore, ICE experiences can be designed as interprofessional activities so that students value the role of other members of the health care team.³⁶ It is important that academic institutions prepare student physical therapists to be clinical teachers, so ICE experiences can be designed in which students are given peer teaching and assessment opportunities to prepare them for future teaching roles.³⁵ Other examples of practice in which students can gain experience during ICE is with the management of patients who have highly specialized diagnoses,^39,45 are underserved,⁴³ are challenged with communication disorders,^34,43 have mental health disorders,^34,42 and convey divergent cultural values.³⁴

• 3. ICE experiences may be represented as a component of a didactic course or a stand-alone clinical course that that occurs in alignment with other academic coursework.

MD3: ICE has been found to occur as part of didactic content courses or as single or repeated stand-alone clinical education course(s). Most ICE experiences tend to be part time, although there are examples of full-time experiences.³² In current physical therapy literature, stand-alone ICE courses ranged from a single course⁴⁷ to as many as 3 separate courses.^32,35–38 Wide variability was found in clinical settings as well as in the courses in which ICE was a component, including neurological,^39,47 geriatrics,⁴⁷ and business courses.⁴⁰ One example threads integrated clinical experiences in a variety of community-based settings within a series of courses throughout a curriculum.³⁶ Literature from other health care disciplines (including medicine, nursing, occupational therapy, and speech pathology) reveals a slightly different picture in that most of the integrated experiences were part of didactic content courses.^{9,34,42,43,45,46} The similarity to the physical therapy literature was evident in the variability of the type of courses in which these experiences were housed and included pediatrics,⁹ mental health,⁴² dysphagia,⁴³ aging and dementia,³⁴ community health,⁴⁵ and a life span course.⁴⁶

• 4. ICE experience time frames are developed by the academic program based upon the course and/or programmatic objectives. ICE can include full-time and/or part-time experiences.

MD4: Similar to physical therapist education curricula, the time frames for ICE experiences are variable.^2,8,36 The time frames associated with ICE tend to be selected based on the course and/or programmatic objectives as well as what is most feasible for the academic program and clinical site. Several academic programs have embedded ICE into the curriculum as early as the first semester,^37,38 whereas a large majority of experiences are embedded at the end of or following the first year of the program.^33–35,41 ICE experiences may also span consecutive semesters^33,37,38,40 and are embedded as late in a curriculum as the second⁴³ or third years.⁴⁰ Such experiences can also be incorporated a few weeks into a course⁹ or during the last few weeks of a course.³⁴

Whether ICE experiences are embedded in a course or exist as a stand-alone course, there is also variability regarding the frequency and duration. The experiences range from a small number of hours that are primarily observation (2 h/wk or total of 2 hours in a semester), to several weeks that occur throughout years 1, 2, and perhaps 3, but prior to the full-time terminal experiences. ICE experiences can occur as infrequently as a quarter of a day twice weekly,³⁵ a half-day per week,³⁸ or a full day per week,⁸ and for longer durations of time, such as part time for up to 8 weeks⁴⁷ or full time for 1 to 4 weeks.³³ However, the experiences do not need to occur regularly, as students can still benefit from opportunities to participate in ICE experiences that occur multiple times (6–16 sessions) over the course of a semester³⁸ or several semesters.⁸

• 5. ICE experiences can occur in a variety of learning sites including campus- or community-based clinical or nonclinical settings, based on the course and/or programmatic objectives. Integrated full-time CE experiences that qualify for a program's minimum number of CE weeks shall be completed in a physical therapy workplace environment or practice setting.

MD5: Integrated clinical education can occur in a variety of clinical, nonclinical, and community settings. Campus pro bono clinics, pro bono programs such as exercise/wellness³⁵ or kids’ fitness,⁴¹ or more established campus facilities such as an outpatient clinic^37,40,48 or primary care clinic³¹ allow the integrated clinical experiences to be conducted at the convenience of the academic institution.

Other academic programs used off-campus community settings to conduct ICE with a wide range of clinical settings, including long-term care,³⁵ acute care,⁷ inpatient rehabilitation facilities,⁷ skilled nursing facilities,^35,37,44 outpatient orthopedic clinics,^33,38 adult day care,³⁷ Veterans Affairs Medical Center outpatient clinics,⁴⁷ pediatric inpatient and outpatient facilities,^35,37 and community health care centers.³⁶ Several ICE experiences capitalized on a combination of on- and off-campus settings^35,37 to meet their learning objectives. Integrated clinical education is also conducted in what are typically considered nonclinical settings that include senior living/community retirement homes,³⁵ child development centers or community-based preschools,⁹ residential homeless assistance centers or shelters,^36,37 community-based family fitness and aquatic programs,³⁶ or senior citizen programs.³⁵ The unifying factor with all of these locations is that the setting allows for human interactions.

• 6. ICE experiences shall include student assessments that are designed to link to the program or course objectives with student progression in professional behaviors, clinical knowledge, and/or skills.

  MD6: In order for ICE experiences to contribute to learning, there should be assessment of the learning outcomes and students should be given “direct and timely feedback.”⁸ Assessment can be provided by peers or clinical faculty, but academic faculty should be primarily responsible for students’ clinical behaviors and skills assessment.⁸ Assessments are chosen to determine the progression of the students’ learning; assessment and reflection can also serve as a catalyst for heightened engagement with the learning process.³⁴ When the objective of ICE is to prepare students for a future full-time clinical education experience, student assessment often included use of outcome measurement tools, such as the Clinical Performance Instrument (CPI),³³ May's Professional Behavior/Generic Abilities,^7,35 or a school tracking/assessment form or other selected standardized outcome measurement tool assessing clinical knowledge, skills, or professional behaviors.^7,34,44 For example, Mai et al³⁵ selected the Interpersonal Communication Questionnaire and the Medical Communication Behavior Scale to assess student learning of communication abilities, whereas Weddle and Sellheim⁷ used a program-developed online reporting form to track each ICE session.

Additional student assessment methods included faculty-led verbal debriefing and discussion sessions, whereby critical questions were asked and formal reflection papers were assigned to determine the level of the students’ critical thinking.^9,33–38,40 Peer-assisted learning was also beneficial, whereby first-year students were mentored by third-year students during ICE experiences.^35,40 It is recommended that reflection journals or papers incorporate students’ self-assessment of critical factors to determine learning and to develop reflective practitioners.^{9,34,39,41,43,45}

When the ICE experience was more focused on a novel practice environment, student assessments were concentrated on the understanding of the health care system and determination of the ability to compare and contrast sites, to identify clinical and social benefits, or to demonstrate interprofessional skills.^{31,36,40,42,46}

Student assessments varied according to the type of course, the purpose of the experience, and the specific objectives. Student assessments included faculty review of student documentation including patient examinations, evidence-based treatment plans,⁹ or onsite assessment of the treatment session, and evaluation of the therapeutic manner of student performance in establishing the relationship formed between the student and the patient.^9,41 In addition, some academic programs used student feedback and standardized assessment to determine if the curricular-designed experience was the best approach to accomplish this learning.^9,41–43

• 7. ICE experiences are coordinated by a faculty member of the academic program, in partnership with a coordinator from the clinical education site.

MD7: ICE experiences are coordinated by a faculty member of the academic program and individuals from clinical/community-based education sites. Although some educators have suggested that the academic program be the responsible party for facilitating a partnership, building relationships, and sharing in the educative element,⁸ several authors have described the role of the academic faculty member or the directors of clinical education in developing and sustaining the clinical partnerships.^{8,31,34,35,40,45,46}

The academic program selects clinical education sites with which to partner based upon factors such as geographical proximity to the academic institution, the availability of the patient population desired, the availability of an onsite representative to organize logistics, and the availability of onsite preceptor supervision.^9,42,43 Regardless of the locality of the ICE experience or the identity of the onsite supervisor, the academic faculty member is responsible for assessment and grading of student success in achieving the course or program objectives.⁹

• 8. ICE experiences are typically supervised by a course instructor and a preceptor. The preceptor can be an academic course faculty member, a clinical instructor, or other health care professional at the site where the student is engaged in the experience, depending upon the course and/or programmatic objectives. Integrated full-time clinical education experiences that qualify for a program's minimum number of clinical education weeks shall be supervised by a licensed physical therapist.

MD8: Students who participate in ICE must be supervised, at some level, dependent on the objective(s) of the experience. Three models of supervision were identified in the literature. Onsite supervision was provided either by: (1) an academic faculty member^{2,35–37,39,46}; (2) an academic faculty member plus a community-based clinician or other representative^9,39; or (3) a community-based clinician or other health care professional.^{2,7,33,36,39,43,46,48} At times, the course instructor also served as the clinical preceptor during the ICE experience.⁴⁷ Regardless of who serves as the onsite preceptor, a faculty course instructor oversees the course management and grading of student outcomes.^9,31

Discussion

The purpose of this project was to address a highly prioritized concern identified from the APTA Clinical Education Summit, namely on PTEPs “offering goal oriented, diverse, active learning experiences that are developed in collaboration with invested stakeholders and embedded within the didactic curriculum, and which occur prior to terminal internships.”¹⁷ The ACAPT Board of Directors determined that ICE could be a mechanism to offer these active learning experiences for students. As such, it required a process to clearly define ICE and to develop professional parameters to guide curricular designers as they develop, refine, and revise PTEP curricula.

The ACAPT Board of Directors developed a work panel representative of national academic and clinical educators to carry out the process. The work panel, in turn, undertook a scoping review strategy using various data collection methods and a triangulated analysis and synthesis process to meet its intended purpose. The results of this project provide an evidence-based outcome that outlines model descriptions and parameters to guide the design of ICE experiences within PTEPs.

Our results reveal a body of knowledge that supports the efficacy of student learning in authentic workplace environments, offered at various time points throughout a health profession program, prior to a final full-time CE experience. Evidence supports the use of various curricular models to integrate CE experiences, when clear program and/or course objectives are provided to guide the teaching and learning process. Common to all the experiences was the human element: the important interaction between a learner and a patient/client. Our data indicate that the purpose of ICE experiences appears to focus on 4 “Cs”: improving student confidence, communication skills, clinical reasoning, and/or clinical skill development. These findings are similar to medical literature that supports early student interactions with people to ease the transition into clinical practice, increase student motivation and confidence, and contextualize theoretical knowledge with practical knowledge.^22,49 In essence, the reason to provide authentic learning experiences prior to a terminal full-time CE experience is to guide development of student behaviors required to enter practice in all domains of learning.

The ICE parameters and definition provide a harmonization framework from which PTEPs can build an integrated curriculum focusing on both didactic learning and CE. Each of the 8 parameters provides a key recommendation that should be met to “label” a clinical experience as integrated within a curriculum. We offer parameters to consider not only where or when ICE experiences should occur, but also why and how. Figure 3 provides a framework for consideration in the development and implementation of ICE experiences.

Figure 3.

Framework for developing and implementing integrated clinical education (ICE).

An unintended outcome of our project was the realization that further research is needed for the advancement of knowledge about the outcomes of ICE in physical therapy education. Most of the studies identified were foundational, describing single program outcomes, with few studies providing evidence of ICE impact on a core set of professional outcomes. No comparative data were available, and no evidence demonstrated that one ICE model was superior to another. For this reason, our synthesis and parameter recommendations did not address specific requirements for ICE experiences, such as what “early” means in the context of a curricular model. Rather, the collective parameters are the first to define guidelines for curriculum development related to CE experiences offered in an integrated manner. The outcomes of this project lend support to APTA's Best Practice in Clinical Education Report,⁵⁰ which endorsed the need to further advance clinical education research.

Limitations

It is important to recognize the plausibility of limitations that might have affected the results. Although intentional methodological procedures were used throughout our process, selection or response bias could have influenced results. First, selection bias from the literature search might have limited the richness of the model descriptions by exclusion of articles. The search for literature was systematic and comprehensive, but the unintended absence of international CE models outside Australia might limit applicability of the results to physical therapist education beyond the United States. There could also be concern about the inclusion of studies with a wide range of methodological quality scores; however, the selected studies offer the best available evidence at the present time. Second, sampling bias in the survey and focus groups, though purposeful, could have limited a broader description of current viewpoints about ICE. As such, the work panel members used a checks-and-balance system to counter any unintended bias. The ICE parameters and definition were developed using multiple triangulated data sources, including 22 articles from multiple health professions and interviews with more than 135 stakeholders, and consensus agreement among the work panel. We believe the synthesized evidence provides sound evidence for the professional parameters about ICE.

Conclusion

The results of this project provide the physical therapy profession with a standard definition of ICE and a set of parameters to guide program curriculum design integrating clinical education. Designing a professional education curriculum is challenging to ensure students master the expected knowledge, skills, and behaviors of the profession. It is even more challenging to design CE experiences that are integrated in a purposeful manner throughout an academic program because of the need for a flexible curricular design, the need for administrative support, and the need to stay abreast of the dynamics of the health care environment.² It is an educator's responsibility, however, “to provide students with learning opportunities that develop the ability to engage in complexities of client-centered practice.”^51p47 Educators must attend to critical components of curriculum design in order to ensure effective learning opportunities for students. The development of professionally based ICE parameters and a common definition is a positive step in understanding the foundations from which PTEPs are built. A next step is to design education research studies using reliable and valid outcome measures across programs to determine impact and effectiveness of ICE as an educational intervention.

Author Contributions and Acknowledgments

Concept/idea/research design: C. McCallum, J. Bayliss, K. Nixon-Cave, Y. Colgrove, J. Kucharski-Howard, D. Stern, K. Evans, V. Strunk, B. Russell, T. Legar

Writing: C. McCallum, J. Bayliss, E. Becker, K. Nixon-Cave, Y. Colgrove, J. Kucharski-Howard, K. Evans, E. Wetherbee, B. Russell

Data collection: C. McCallum, J. Bayliss, E. Becker, K. Nixon-Cave, Y. Colgrove, J. Kucharski-Howard, D. Stern, K. Evans, V. Strunk, E. Wetherbee, B. Russell, T. Legar

Data analysis: C. McCallum, J. Bayliss, E. Becker, K. Nixon-Cave, Y. Colgrove, J. Kucharski-Howard, D. Stern, K. Evans, E. Wetherbee, T. Legar

Project management: C. McCallum, J. Kucharski-Howard

Providing participants: E. Wetherbee

Providing facilities/equipment: C. McCallum

Consultation (including review of manuscript before submitting): Y. Colgrove, J. Kucharski-Howard, D. Stern, V. Strunk, E. Wetherbee.

The ICE work panel acknowledge Dr Shawne Soper for her guidance and assistance throughout this process.

Funding

The American Council of Academic Physical Therapy (ACAPT) sponsored this work.

Disclosures

The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

The work described in this review was presented at the Education Leadership Conference (ELC), American Council of Academic Physical Therapy business meeting, in October 2017. This work also was presented at the ELC in October 2018.

Appendix 1. Survey and Focus Group Questions

Instructions: The ACAPT Integrated Clinical Experience (ICE) work panel is reaching out to determine the scope of integrated clinical education experiences in entry-level physical therapy program curriculums. We ask that the person completing the survey consult with their faculty to gauge the comprehensiveness of clinical experiences that are offered throughout your curriculum.

1. Name of your institution.

2. Name/role of person completing the survey

3. Provide a brief description of integrated clinical education experiences (ICE) within your curriculum (overall program).

4. Does your program offer full time integrated clinical education experiences? (Traditional clinical education experiences that are not at the end of your curriculum? Yes/No Comments:

5. Does your program offer integrated clinical education experiences other than full-time experiences (clinical education experiences that are offered concurrently with didactic courses)? Yes/No Explain:

For ICE #1-5, please provide a brief description of the specific integrated clinical education experience.

For ICE #1-5, is the experience

• □ Full-time?

• □ Less than full-time?

• □ For ICE #1-5 within your curriculum, is the ICE:

• □ A stand-alone course?

• □ A component of course?

• □ Other?

For ICE #1-5, where does the experience take place (select all that apply)?

• □ Onsite at the academic institution-clinical practice

• □ At a traditional clinical practice setting

• □ In a nonclinical setting

• □ Other

In ICE #1-5, where does it occur within the curriculum?

• □ First year

• □ Second year

• □ Third year

• □ Other

How often are students participating in ICE #1?

• □ Half day a week (or less)

• □ One day a week

• □ One day every other week

• □ One full week

• □ Multiple full weeks

• □ Other

For ICE #1-5, who supervises students (select all that apply)?

• □ Academic faculty

• □ Clinical faculty (instructors)

• □ Members of other disciplines

• □ Peer members

• □ Other

For ICE #1-5, do students have objectives that must be met?

• □ Yes

• □ No

For ICE #1-5, are students assessed during the experience?

• □ Yes

• □ No

For ICE #1-5, are results of the experience linked to programmatic outcomes?

• □ Yes

• □ No

Focus/Small Group Discussion Facilitator Guide

Objectives

To gather feedback from participants on the work of the panels.

To submit comments and suggestions for compilation and subsequent use by the panels.

Integrated Clinical Experience (ICE)  

• □ In what settings should ICE occur?

• □ What thoughts do you have about education experiences in nontraditional settings being classified as an ICE (examples: ophthalmology practice, radiology department visit, soup kitchen)?

• □ When during the curriculum should an ICE occur?

• □ Who should supervise ICE experiences?

Appendix 2.

Methodological Quality Critical Appraisal Scores^a

Study	Score
	1	2	3	4	5	6	7	8	9	10	11	12	13	14	Total Score
Benson, Provident, and Szucs (2013)	√	√				√	√		√		√	√		√	8
Coker (2010)	√	√	√		√	√	√		√	√	√	√		√	11
Doucet and Seale (2012)	√	√	√	√			√		√			√			7
Faught, Gray, DiMeglio, Meadows, and Menzies (2013)	√	√	√			√	√					√			6
Goldberg, Richburg, and Wood (2006)	√	√	√	√		√	√		√	√	√	√		√	11
Hakim, Moffat, Becker et al (2014)	√	√										√			3
Ingram and Hanks (2001)	√	√	√		√	√	√					√		√	8
Jensen, Mostrom, Gweyer, Hack, and Nordstorm (2015)	√	√	√	√	√	√	√	√	√	√	√	√	√	√	14
Mahendra, Fremont, and Dionne (2013)	√	√	√	√		√	√		√		√	√			9
Mai et al (2013)	√	√	√	√	√	√	√	√	√	√	√	√		√	13
Mai et al (2014)	√	√				√	√	√				√		√	7
O'Neil, Rubertone, and Villanueva (2007)	√						√					√			3
Reneker, Weems, and Scaia (2016)	√	√	√		√	√	√			√	√			√	9
Smith, Lutenbacher, and McClure (2015)	√	√	√				√					√		√	6
Stern and Rone-Adams (2006)	√	√	√									√			4
Stuhlmiller and Tolchard (2015)	√	√			√	√	√			√	√	√		√	9
Weddle and Sellheim (2009)	√	√					√			√	√	√		√	7
Weddle and Sellheim (2011)	√	√	√	√			√		√		√	√	√	√	10
Williams-Barnard, Sweatt, Harkness, and DiNapoli (2004)	√	√	√				√					√		√	6
Wilson (2006)	√	√			√	√					√	√		√	7
Wilson and Collins (2011)	√	√	√				√				√			√	6
Yardley, Brosnan, Richardson, and Hays (2011)	√	√	√	√	√	√	√	√	√	√	√	√	√	√	14

a

Critical Appraisal Category Scoring Key

1 = Study purposes stated clearly (quantitative and qualitative)

2 = Relevant literature reviewed (quantitative and qualitative)

3 = Sample described in detail (quantitative)/theoretical perspective identified (qualitative)

4 = Sample size justified (quantitative)/purposeful sample selection described (qualitative)

5 = Outcome measures reliable (quantitative)/sampling until redundancy in data reached (qualitative)

6 = Outcome measures valid (quantitative)/informed consent obtained (qualitative)

7 = Intervention described in detail (quantitative)/procedural rigor used in data collection (qualitative)

8 = Contamination avoided (quantitative)/analytical preciseness (qualitative)

9 = Co-intervention avoided (quantitative)/findings consistent with and reflective of data (qualitative)

10 = Results reported in terms of statistical significance (quantitative)/auditability (decision trail developed and rules reported) (qualitative)

11 = Analysis methods appropriate (quantitative)/transformation of data described (qualitative)

12 = Educational importance reported (quantitative)/theoretical connections described (qualitative)

13 = Dropouts reported (quantitative)/trustworthiness (triangulation reported for methods) (qualitative)

14 = Conclusions appropriate (quantitative and qualitative)

Appendix 3.

Model Descriptions of Integrated Clinical Education that Currently Exist in the Literature: Organized by the 8 Parameters^a

Author(s)	Year	Discipline	Placement	Course/Program Objectives	Frequency	Type of course	Occurrence during course	Locality	Assessment and Outcomes	Coordination	Supervision
Benson, Provident, and Szucs	2013	Occupational Therapy	Four intervention courses, experiential lab in all, ICE in first neurological course	Course lab objectives: (1) selecting, administering and interpreting results of assessment instruments and techniques, for use with clients with performance, deficits related to neurological, sensory, motor, cognitive, and perceptual dysfunction; (2) designing and implementing intervention plans to remediate and/or rehabilitate occupational performance deficits in the birth-to-adolescent population; (3) evaluating and using current research in the design and implementation of intervention; and (4) producing appropriate documentation supporting evaluation findings and delineating intervention activities and plans and progress notes	Not clearly presented, first 4 wk in classroom-then in community	Experiential learning lab within a course with pediatric content	First experiential lab occurred after week 4 of the course	Community site-private school delivering services to children and adolescents; needed services not available in public school system	Observation of student performance, written and oral feedback of performance, review/assessment of/feedback about intervention plans, student choice of evidence and ability to apply to intervention plan, and patient evaluation report; final course assessment—mastery testing of clinical skills to ensure readiness for fieldwork	Course instructor; partnered with 5 OTs from school	Instructor of course and/or community clinician
Coker	2010	Occupational Therapy	After first year in program—part of 2-y program	Course/program objectives not discussed	1 wk (5 d, 6 h/d)	Stand-alone course	After first year in the program	1-wk day-camp for children with CP	Use student feedback and standardized assessment using Self-Assessment of Clinical Reflection and Reasoning (SACRR) and California Critical Thinking Skills Test (CCTST) to determine if their designed experience is the best approach to accomplish this learning	OT faculty member; OT clinician at camp	Licensed OT including the faculty who coordinated the experience
Doucet and Seale	2012	Physical Therapy and Occupational Therapy	Second or third year of physical therapy/OT programs	Course/program objectives not discussed	1 wk in length for clinic	Stand-alone course	Embedded in educational course	On-campus clinic	Written questionnaire consisting of multiple questions with responses based on a 5-point Likert scale; patients rated their perception of the student intern(s) assigned, the treatment given, and the organization of the clinic. Students rated their perception of the clinic experience, whether clinic prepared them for field work/clinical rotations, connection to didactic knowledge, and overall benefit. Supervisors rated student interns on their ability to interact with patients, demonstration of knowledge, and application of appropriate interventions, along with their overall perception of the effectiveness and organization of the clinic	2 faculty members (1 occupational therapist, 1 physical therapist)	Faculty and community clinicians (clinical instructors)
Faught, Gray, DiMeglio, Meadows, and Menzies	2013	RN	Unsure	Goal that students could (1) gain skill in providing integrated physical and mental health care to their patients, (2) become aware of and possibly improve perceptions regarding mental health/mental illness, and (3) expand their understanding of the critical importance of the therapeutic nurse-patient relationship in caring for all patients	24 h	Part of mental health course	Unsure	Inpatient health care unit	Quantitative end-of-semester evaluations of the clinical rotations, qualitative evaluations of the modified clinical experience (nothing specific identified)	Faculty members	Two clinicians with educator experience who were employed on inpatient medical units, had psychiatric nursing clinical expertise
Goldberg, Richburg, and Wood	2006	SLP	Second-year course	To facilitate reflective problem-based learning and decision-making, integration of theoretical and clinical knowledge, and student awareness of the importance of evidence-based practice in the area of dysphagia	15 h	Part of a dysphagia course	Second-year course in spring semester (15 h)	Community partners with dysphasia management program	Competencies on the students’ analysis, synthesis, and evaluation of the following: ethical behavior; ASHA policies and guidelines, and local, state, and national legislation; normal and disordered swallowing; effective prevention and assessment; research principles and evidence-based treatment; effective speaking and listening and written reports; treatment plans; professional correspondence; reflective journals	Faculty member places student with community supervisor (goal to be placed with externship partner)	Community supervisor
Ingram and Hanks	2001	Physical Therapy	First year of the program	Course/program objectives not discussed	Full time weeks; varying points in time during the first year	MPT students—stand-alone course; BS students—part of course	MPT students—7-wk course end of first year; BS students—integrated 7 wk (1 wk end of fall semester, 2 wk end of spring semester, and 4 wk end of summer semester)	Variety of traditional physical therapy clinics	Clinical Performance Instrument	Faculty coordinated	Clinical faculty
Jensen, Mostrom, Gwyer, Hack, and Nordstrom	2015	Physical Therapy	Variety—highlights early integrated	Course/program objectives not discussed	Variety	Variety (both stand-alone and parts of courses)	Variety	Academic-community partners (faculty practice)	Variety—written pre-work, post debriefing	Faculty coordinated and supervised	Variety (clinical faculty and academic faculty)
Mahendra, Fremont, and Dionne	2013	SLP	Elective course over 2 y (SLP)	Learning outcomes for the course were derived from student self-reflections but the actual objectives were not described	Last 4 wk of course	Part of a course	Last 4 wk of course	Local dementia unit	Quiz on dementia, personal reflection before and after the service learning (SL), ethnographic interview, screening of individuals (for cognition, affect, hearing, and vision), collaborative interpretation of results, research and development of a diagnosis plan, and actual participation in SL	Not explicitly stated—faculty and site personnel	Not specified
Mai et al	2013	Physical Therapy	3 courses—successive semesters, starts first year	Specific course/program objectives not mentioned	Semester-long courses	Stand-alone courses	Begin in first year of DPT program—2 h twice weekly (Clarke University); winter semester of year 1 (Nova Southeastern University)	On-campus wellness clinic: patients referred from community health clinics and local dialysis center; and senior living centers, community wellness centers, or long-term care centers	Generic abilities and CPI; group debriefings, service learning papers	Faculty coordinated and supervised	Licensed physical therapy faculty
Mai et al	2014	Physical Therapy	First year of program	Course/program objectives not discussed	Variety—2 h twice weekly and 40 h/wk	Stand-alone courses and integrated	First year	Community clinics, wellness activities	Interpersonal Communication Questionnaire (ICQ) and Medical Communication Behavior Scale (MCBS); standardized outcome tool for assessment	Course coordinator; other faculty as assigned, including DCE	Community clinical supervisors
O'Neil, Rubertone, and Villanueva	2007	Physical Therapy	Early, present at 3 different points throughout curriculum	Course objectives that create service learning experiences include engagement (a service component meeting community needs), reflection (a mechanism for students to link service experiences to course content), reciprocity (teacher and learner roles for all participants in the experience), and public dissemination (sharing outcomes among participants)	Three phases	Part of courses	See Table 3 of article—variety of times dependent upon specific SL activity	Community workplaces	Outcomes are reported through class discussion, reflection exercises, and course evaluations	Faculty coordinated with community partners	Faculty members, lab instructors, nursing assistant
Reneker, Weems, and Scaia	2016	Physical Therapy	Second year of curriculum	Course/program objectives not discussed	8 wk, once per week	Part of a neuro course	Not specified, only that occurrence was for 8 wk	Veterans Affairs outpatient clinic	Pre- and post-ICE student perceptions about the geriatric population	Faculty coordinated, physical therapist supervised	Two licensed physical therapists
Smith, Lutenbacher, and McClure	2015	RN	Unsure	Using guidelines from the American Association of Colleges of Nursing Public Health Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing, the following objectives were determined: students were required to develop, implement, and evaluate an individualized plan based on their assessment of the patient and their community	Three semesters	Part of clinical community health course	Unsure	Transitional care environment	Peer evaluation tool, clinical performance evaluation tool was used to assess clinical competencies and interprofessional collaboration; students also wrote a weekly journal reflection about their experiences	ACPs (academic-clinical partnerships) developed before, during, and after courses	Nursing faculty
Stern and Rone-Adams	2006	Physical Therapy	First and second year of the program	Primary learning objectives for the first year students included evaluation, examination, assessment skills, and development of professional behaviors as defined by the Generic Abilities behaviors; learning objectives for second-year students included cognitive, psychomotor, and affective skills practiced the first year of the program	One day per week every other week	Stand-alone course	Not specified—did begin during the second month of the curriculum and continued for 3 consecutive semesters	Clinical practices (SNF, adult day care, homeless shelter, outpatient clinics)	Generic Abilities self-assessment, student-faculty clinical instructor self-assessment discussion with feedback, student reflective journal that was discussed at the end of each rotation	Clinical education team coordinated; faculty oversight in areas with prior experience	Faculty clinical instructors
Stuhlmiller and Tolchard	2015	RN	Unsure	Course objectives: (1) effectively engage with the community, its leaders, and other stakeholders in assessing and responding to health and social well-being needs; (2) increase provision of evidence-based integrated health help that promotes collaborative learning, self-determination, and responsibility; and (3) demonstrate positive health outcomes as determined by standardized measures	Ongoing clinic: range 80-120 h attached to a unit of study	Not explicitly stated	Unsure	Student-led clinic (Australia), partnered with an existing community clinic	None reported	Principal investigator from academic side partnered with community supervisors; supervisors onsite provided day-to-day supervision	No reference to who provided specific supervision
Weddle and Sellheim	2009	Physical Therapy	Begins first semester, extends into the second semester of second year	Course/program objectives not discussed	1/2 day	Part of courses	Not specific, but second week of the curriculum until the second semester of year 2	Physical therapist practice settings	Direct outcomes and measures related to ICE not reported, NPTE pass rates of students who participated in the new model were 94% and 100% over the 2 y discussed, 1-y graduate survey and alumni survey both indicated students and employers felt the new grad was well prepared for practice	Faculty and clinical faculty coordinated	Clinical faculty
Weddle and Sellheim	2011	Physical Therapy	First semester	Objectives of ICE are to have students practice components of patient/client management; begin to apply basic, medical, and behavioral sciences to clinical science; and to deepen their understanding of the breadth and complexities of physical therapist practice	75 h before first FT experience	Part of courses	Not specific, but 2 experiences occur during first semester year 1, and 6 experiences occur during second semester year 1	Physical therapist practice settings	Learning activity check off form, skills competency—patient management—and documentation checks throughout model learning units, online reporting forms, once a semester professional behaviors meeting between student and faculty advisor to go over student self-assessment and performance, 10 item professional behaviors assessment of student by the clinical faculty	Faculty coordinated-clinical faculty supervised	Clinical faculty
Williams-Barnard, Sweatt, Harkness, and DiNapoli	2004	RN	Unsure	Vague objectives: (1) engage in health promotion and disease prevention strategies; (2) provide new avenues for secondary and tertiary care; and (3) offer innovative treatment approaches in the community setting to care for people throughout their lives	Part of a course	Part of parent-child health and mental health course	Unsure	Community-based partners	Unsure, possibly focus groups to assess student perception of the experience	Faculty-led community supervisors	Faculty and community supervisors
Wilson	2006	Physical Therapy	Three consecutive semesters in second/third year of curriculum	ICE I: Become familiar with clinic environment, observe and assist with patient care, practice documentation and interviewing skills, prescribe exercise for a healthy population; ICE II: Develop patient-professional interaction skills, develop documentation skills, develop skill in patient handling and treatment interventions, develop critical clinical reasoning and clinical decision-making skills; ICE III: Refine patient-professional interaction skills, assume responsibility for all aspects of patient management, refine documentation skills, refine clinical reasoning and clinical decision-making skills, begin to develop peer mentoring and supervisory skills	1 d/wk	Stand-alone course	N/A as it is a stand-alone course; begins in the fall semester of year 2 for 3 consecutive semesters	Campus onsite clinic	ICE I: written evaluations of student performance from both peer mentors in the onsite clinic and from CIs in the exercise/wellness group; ICE II: written midterm and evaluations of the CI's assessment of the student's performance in the areas of safety, professional behavior, communication, examination and intervention skills, and clinical reasoning; ICE III: written midterm and final evaluations of the CI's assessment of the student's performance in the areas of safety, professional behavior, communication, examination and intervention skills, and clinical reasoning	Faculty coordinated and supervised	Core faculty and physical therapy clinicians from the local community
Wruble Hakim, Moffat, Becker et al	2014	Physical Therapy	Early in curriculum (authentic early experiences)—year 1	Course/program objectives not discussed	Variety	Variety	Variety	Academic-community partnerships	Not described	Faculty led-placement providers (DCE)	Clinical faculty; master clinicians
Yardley, Brosnan, Richardson, and Hays	2014	Medicine	Early in curriculum (authentic early experiences)—year 1	Learning outcomes for individual episodes were generic rather than context specific and related to the title of each experience	Part of a course	Incorporated into medical school activities	Incorporated into medical school activities	Workplaces (health, social, voluntary community services)	Reflective summaries within a portfolio that was graded for presentation of work, depth of reflection, and self-awareness	Faculty led-placement providers	Observational experiences with “some supervision”
Wilson and Collins	2011	Physical Therapy	First year of program	Leadership and management principles were primary focus	Part of a course: 4-8 h/wk	Clinical course coordinated with management course	Clinical course coordinated with management course	On campus and off campus	Student satisfaction, surveys, course evaluations,  reflection discussions, graduate surveys 1 y post-graduation; key themes: delegation, communication, giving and receiving feedback; role as manager; development of fundamental business skills	Course coordinator; other faculty as assigned, including DCE	Course coordinator

a

ASHA = American Speech-Language-Hearing Association; BS = bachelor of science; CI = clinical instructor; CPI = clinical performance instrument; DCE = director of clinical education; DPT = doctor of physical therapy; FT = fulltime; ICE = integrated clinical education; MPT = masters in physical therapy; NPTE = national physical therapy exam; OT = occupational therapist; RN = registered nurse; SL = service learning; SLP = speech-language pathology; SNF = skilled nursing facility.