Torres-Narváez et al.

BMC Medical Education (2018) 18:280

https://doi.org/10.1186/s12909-018-1377-x

RESEARCH ARTICLE Open Access

Validity and reproducibility of a tool for

assessing clinical competencies in physical
therapy students
Martha-Rocío Torres-Narváez1*, Olga-Cecilia Vargas-Pinilla2 and Eliana-Isabel Rodríguez-Grande3

Abstract
Background: The evaluation of competencies in the clinical field is essential for health professionals, as it allows
the acquisition of these competencies to be tracked. The objective of this study was to create and evaluate the
validity and reliability of a tool for measuring clinical competencies in physical therapy (PT) students to assess the
quality of their performance in a professional context.
Methods: A descriptive study was designed. The Measurement Tool for Clinical Competencies in PT (MTCCP) was
developed based on the evaluation of 39 experts: 15 clinicians and 24 instructors. The content validity was evaluated
using the Content Validity Index (CVI). Three professors were invited to apply the tool to 10 students. Cronbach’s alpha,
exploratory factor analysis, and the intraclass correlation coefficient were used to determine the reliability and validity
of the scale.
Results: The CVI was positive—higher than 0.8. Principal component analysis confirmed the construct validity
of the tool for two main factors: clinical reasoning (first factor) and professional behavior (second factor). With
regard to reliability, the MTCCP achieved an internal congruence of 0.982. The inter-evaluator reproducibility
for clinical reasoning, professional behavior, and the total MTCCP score was almost perfect; the ICCs were 0.984,
0.930, and 0.983, respectively.
Conclusions: The MTCCP is a valid and reliable instrument for assessing the performance of PT students in hospital
settings and can be used to determine what skills students feel less confident using and what additional training/
learning opportunities could be provided. Further research is needed to determine whether the MTCCP has similar
validity and reproducibility in other Spanish-speaking national and international PT programs.
Keywords: Clinical competencies, Physical therapy, Student performance, Clinical education, Professionalism

Background evidence-based practice, quality improvement approaches,

The goal of university education is to expand, broaden, and informatics [3].
and transform the mind and to prepare students to ef- Competency-based education has thus been proposed
fectively address problems [1]. Higher education should as a means to optimize the preparation of health profes-
be centered on students and should contribute to their sionals [4]. The competency-based approach is focused
personal growth and to their intellectual, psychological, on outcomes related to the skills, knowledge, and atti-
and moral development [2]. For the health professions, tudes of graduates [5] that will allow them to work as
the Institute of Medicine has proposed a set of core competent professionals at the national or international
competencies for all health disciplines that will allow cli- level [6, 7]. Competence-based learning is based on the
nicians to deliver patient-centered care as members of capacity and responsibility of each student and on the
an interdisciplinary team; these competencies emphasize development of the student’s autonomy [2]; it requires
specific learning methodologies, monitoring, and tutoring
* Correspondence: [email protected]
as well as competency-based assessment methods [8].
1
Universidad del Rosario, Bogotá, Colombia
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Torres-Narváez et al. BMC Medical Education (2018) 18:280 Page 2 of 8

At the entry level, educational programs in physical validity and reliability of the Measurement Tool for Clin-
therapy (PT) integrate theory, evidence, and practice with ical Competencies in PT (MTCCP).
the aim of producing knowledgeable, helpful, confident,
adaptable, and reflective professionals who can practice
independently and autonomously to meet their patients’ Methods
or clients’ needs, as supported by evidence [9, 10]. To Development of the MTCCP
achieve this end, the curriculum must ensure that gradu- This was a descriptive study of the validity and reproduci-
ates will be able to demonstrate the established entry-level bility of the MTCCP. To establish the theoretical basis for
(undergraduate) competencies based on the priorities of the development of the MTCCP, we reviewed and analyzed
the educational program, institution, and country while technical documents produced by the WCPT, APTA, and
conforming to the national and international standards of the Commission on Accreditation in Physical Therapy
the PT profession [4]. Education (CAPTE). These documents describe the per-
Due to the competencies’ focus on performance, the formance evaluation of PT students and tools such as the
formal assessment of students should be modified ac- Clinical Performance Instrument (CPI) and the Clinical In-
cording to the practice setting. The evaluation of compe- ternship Evaluation Tool (CIET). We also considered the
tencies in clinical areas is essential for PT: it allows the professional competencies established by the ASCOFI.
acquisition of competencies to be supervised, thus help- This document analysis allowed us to identify conceptual
ing to improve competency levels and practice standards references for competencies, constructs, criteria, items,
for new graduates [11]. The evaluation of clinical com- and evidence that could guide our design of the MTCCP.
petencies takes into account the performance of profes- The MTCCP assesses the knowledge, attitudes, skills,
sionals during patient or client interaction with respect and abilities of PT students at clinical practice sites dur-
to the clinical reasoning that is applied to decision mak- ing decision making, i.e., clinical competency. Within
ing. This evaluation includes the conceptual commands, this process, the clinical instructor (CI) plays the funda-
expert judgment, team work, communication, motor mental role of the judge who verifies the students’ learn-
skills, and professionalism that are necessary for provid- ing achievements. Therefore, instructors must have the
ing health services [11–13]. conceptual and methodological ability to evaluate the ac-
The current research on educational evaluation is ori- quisition of clinical competencies [24].
ented toward the way knowledge acquisition is integrated The MTCCP defines two assessment dimensions: pro-
with strategies for the measurement and quantification of fessional behavior and clinical reasoning. Each dimension
capacities in technology and science. To comprehensively has 10 items (Additional file 1: Appendix). We defined
evaluate students in a specific time and context, the professional behavior as a set of attitudes and behaviors
process of evaluating clinical competencies needs to be el- reflecting a physical therapist’s ethical commitment in
evated to a more formal and complex level [14–17]. providing health services. Professional behavior involves
Current evaluation tools follow the recommendations the consistent demonstration of values, including altruism,
of the World Confederation for Physical Therapy excellence, care, ethics, respect, communication, and ac-
(WCPT) and the American Physical Therapy Associ- countability, related to professional performance [8].
ation (APTA) for assessing the competencies of physical Clinical reasoning refers to the critical thinking
therapists at the undergraduate level (commonly referred process that physical therapists engage in when making
to as the entry level) [18, 19]. These tools group compe- decisions. This reasoning is reflected in a set of cognitive
tencies into professional training, patient management, and psychomotor skills used in decision making, includ-
and resource scheduling and management. The grading ing examination, evaluation, diagnosis, prognosis, and
of the performance level is carried out using numerical, intervention [25–27]. Clinical reasoning includes a stu-
ordinal, or interval scales; a PT student must reach a dent’s skills in gathering information from patients, in-
pre-determined performance level to graduate from an cluding their medical history, and in conducting physical
undergraduate program [8, 20–23]. examinations. In addition, clinical reasoning involves the
We conducted a review of the literature and found that following: the ability to prepare clinical reports based on
no studies have examined the tools for measuring clinical knowledge and understanding of pathology; the inter-
competence in a Spanish-speaking context. In addition, pretation of complementary clinical tests; and the assess-
the tools that have been created for an English-speaking ment of the impact that a particular condition has on
context have not been validated in Spanish. Therefore, movement and functioning capabilities [28]. Further-
there is a need to create and evaluate a tool that assesses more, clinical reasoning includes the ability to make
student competencies and the quality of student perform- clinical judgments and solve problems and to combine
ance in a professional Spanish-speaking context. Based on various elements to provide a diagnosis and design a
the above discussion, this study seeks to determine the treatment plan.
Torres-Narváez et al. BMC Medical Education (2018) 18:280 Page 3 of 8

In its structure, the MTCCP follows the guidelines of Finally, to evaluate reliability, we estimated the sample
an evidence-based model that establishes the method- size for three evaluators with a reliability of 95% and a
ology for determining the competencies to be evaluated power of 80%. We established that a sample of 10 stu-
and describes the aspects to be included in the evalu- dents would allow inter-evaluator reproducibility. Three
ation: statements or items and evidence [29]. An item is instructors (with over 10 years of clinical experience and
defined as a general statement about the facts that stu- over 5 years of teaching experience) assessed 10 students
dents should master with regard to clinical reasoning engaged in clinical practice in two tertiary and quater-
and professional behavior. Evidence represents behaviors nary care institutions in the areas of hospitalization, in-
or observable products that allow the verification of stu- tensive care, and outpatient visits.
dents’ performance levels in relation to expected levels
with regard to actions, conceptual background, and Psychometric properties
motor and cognitive abilities. Clinical instructors exam- Content validity
ine each piece of evidence and then assign a score to This study was conducted between September 2014 and
each item to obtain an overall grade. March 2016. Thirty-nine experts agreed to participate
The student evaluation conducted with the MTCCP is and accordingly signed a confidentiality agreement. The
based on a competency-based analysis. This analysis is a evaluators received via e-mail the tool and conceptual
dynamic longitudinal process that monitors a person’s framework to evaluate the relevance, sufficiency, coher-
use of the knowledge, skills, attitudes, and sound judg- ence, and clarity of each item. Their evaluations were
ment relevant to the profession with the aim of becom- based on a Likert scale from 1 to 4, where 1 was the
ing completely professionalized [30]. lowest grade for each item and 4 the highest. The evalu-
The MTCCP employs a discrete measurement scale from ators were also able to suggest any other items they con-
1 to 5. The tool includes key aspects that determine stu- sidered necessary. To improve clarity and prevent bias,
dents’ autonomy: the required monitoring level and the de- we summarized these suggestions to determine whether
gree of fulfillment of their competencies or functions at a our items should be revised or adjusted in terms of co-
practicum site [29]. The CIs evaluate each item separately herence, length, or redundancy.
based on the evidence pertaining to it. The instructors In the second stage, 11 experts, using the Delphi tech-
score their students’ performance, taking into account each nique [31], assessed the structure and content of each
student’s level of compliance with the expected profile of a item, the evidence of the tool, and the guidelines. They
recent PT graduate in relation to the evidence proposed for used the following scale to evaluate each item: 2, essen-
each item and the degree of supervision required. tial; 1, useful but not essential; and 0, unnecessary. We
The maximum MTCCP score is 100 points, which calculated an agreement index with a cut-off point of
equates to a grade of 5.0, the highest possible grade for a 90%; items below the cut-off point were adjusted or
student. To determine a student’s performance grade, eliminated by consensus. On applying this consensus ap-
the CIs take the average score for the items in each di- proach, we determined that 60% of the final grade would
mension and multiply them by the factor corresponding correspond to the clinical reasoning dimension and 40%
to clinical reasoning and professional behavior; this fig- to the professional behavior dimension.
ure is then added to the total for each dimension to ob-
tain the final grade. Reliability
We trained three instructors in the standardized imple-
Participants mentation of the tool. The instructors evaluated 10 stu-
To determine the measurement properties, three distinct dents at two different times, with a one-week interval
convenience samples were used. To evaluate the content between the evaluations. The instructors’ evaluations
validity, we calculated the sample size for a minimum were not disclosed to the others when all three instruc-
concordance of 0.80, a reliability of 95%, and a power of tors were simultaneously evaluating student perform-
99%; we established that a sample of 32–40 people ance during the consultation process of a previously
would allow the tool’s content to be validated. assigned patient. We observed the evaluations at each
The evaluation of the content validity was carried out practicum site to verify the proper implementation of
by a group of 39 experts who were classified as clinical the evaluation protocol.
(15) or academic (24) and selected from the ASCOFI
and PT training programs in Colombia. Statistical analysis
In the second stage of the content validation, we se-
lected 11 experts from the group of 39 evaluators ac- Content validity We evaluated the relevance, sufficiency,
cording to their affiliation, geographical location, and pertinence, coherence, and clarity of each item using the
availability to travel to the consensus meeting. content validity index (CVI). The CVI varies between + 1
Torres-Narváez et al. BMC Medical Education (2018) 18:280 Page 4 of 8

and − 1, where higher positive scores indicate higher con- performance of physiotherapy students in the South
tent validity. American context is limited. This is the first known
study conducted in a Spanish-speaking country to de-
Construct validity We assessed the construct validity velop a tool for assessing PT students in clinical practice
by means of exploratory factor analysis. Bartlett’s test of and to measure its psychometric properties. In this
sphericity and the Kaiser-Meyer-Olkin (KMO) measure study, the MTCCP has two categories: professional be-
of sampling adequacy were used to confirm the appro- havior and clinical reasoning. Our results showed that
priateness of the factor analysis. A KMO value > .8 is items 1 (minimizes the actual risk of damage itself and
considered good, indicating the strength of the correl- in the population served) and 4 (has assertive verbal,
ation between items. Next, Bartlett’s test of sphericity nonverbal, and written communication) may be consid-
was conducted. Finally, principal component analysis ered factorially complex, because they showed similar
using Varimax rotation was used as a dimension reduc- loadings in both the professional behavior and clinical
tion technique [32]. reasoning categories. Indeed, these components are
strongly associated, as suggested by the significant and
Reliability We assessed the MTCCP’s internal consistency large correlation coefficient between these two factors.
using Cronbach’s alpha coefficient: α ≥ 0.9 was considered In the original validation studies [25], these items were
excellent; 0.8–0.9 good; 0.7–0.8 acceptable; 0.6–0.7 doubt- assigned to the professional behaviors category. In our
ful; and 0.5–0.6 poor [33]. We evaluated the inter-evaluator context, these items were also assigned to the profes-
reproducibility for the scores obtained from each dimen- sional behavior category. These results reinforce our
sion and the total MTCCP score using the intraclass correl- concept of professional behavior: a set of attitudes and
ation coefficient (ICC). The ICC results were interpreted behaviors that reflect the physical therapist’s ethical
according to the Landis and Koch classification as follows: commitment in providing health services.
values of 0.81–1.00 indicated almost perfect agreement; Earlier studies have described assessment instruments
values of 0.61–0.80 indicated considerable agreement; for measuring the clinical performance of PT students in
values of 0.42–0.60 indicated moderate agreement; values specific settings, such as Blue MACS [22], the CIET
of 0.21–0.40 indicated fair agreement; values of 0.00–0.20 [25], or the CPI [20]. The CPI was found to be a valid
indicated low agreement; and values < 0 indicated poor and reliable instrument for assessing clinical competence
agreement [34]. in three areas: “Professional Practice,” “Patient Manage-
ment,” and “Practice Management.” The MTCCP takes a
Results different approach in that some items related to practice
In terms of content validity, the CVI indexes were posi- management are included in the professional behavior
tive—higher than 0.8 (Table 1). With regard to construct category according to our conceptual reference
validity, the KMO analysis yielded an index of 0.9 (p < framework.
0.001), indicating the appropriateness of the data for The MTCCP achieved internal congruence, with a Cron-
PCA. Two factors with eigenvalues ≥1 were extracted by bach’s alpha coefficient of 0.982. The inter-evaluator repro-
PCA and accounted for 80.69% of the overall variance. ducibility for clinical reasoning, professional behavior, and
As shown in Table 2, the first factor (denoted clinical the total MTCCP score was almost perfect; the ICCs were
reasoning) accounted for 44.7% of the total variance and 0.984, 0.930, and 0.983, respectively. These findings are in
included 10 items with factor loadings ≥0.70. The sec- line with the CPI Cronbach’s alpha values of 0.99 and 0.97
ond factor (professional behavior) accounted for 35.9% [20, 36]. These results have important implications for PT
of the variance and included 10 items with factor load- clinical education. Educators must be committed to using
ings ≥0.5. valid assessment tools that measure their students’ per-
Based on 60 evaluations, 20 items of the MTCCP formance in their clinical areas objectively, accurately, and
achieved internal congruence, with a Cronbach’s alpha consistently in terms of the prioritization of core clinical
coefficient of 0.982. The inter-evaluator reproducibility duties on a day-to-day basis [35].
for clinical reasoning, professional behavior, and the The reliability level obtained by the MTCCP is greater
total MTCCP score was almost perfect; the ICCs were than that reported for Blue MACS (0.78 and 0.83) [22] or
0.984, 0.930, and 0.983, respectively. for the CIET, which had an overall ICC value of 0.84 [37].
These values may be associated with the clarity of the
Discussion evidence proposed for each item, which allows the
Assessing clinical competencies is important when pre- evaluator to easily establish whether an evaluated stu-
paring PT students for clinical practice [35–37]. A range dent meets the criteria. Another reason for the reprodu-
of tools has been used to evaluate clinical competencies cibility of the present results could be related to the
[38–41]. The literature on the assessment of the clinical discrete measurement scale of 1–5 used in this study.
Torres-Narváez et al. BMC Medical Education (2018) 18:280 Page 5 of 8

Table 1 Content validity index of the measurement tool for clinical competencies in physiotherapy
Relevance Sufficiency Pertinence Coherence Clarity
CVI CVI CVI CVI CVI
Professional behavior 1.00 0.90 1.00 1.00 0.74
1
Professional behavior 1.00 0.85 1.00 0.95 1.00
2
Professional behavior 0.90 0.90 0.84 0.90 0.85
3
Professional behavior 1.00 0.85 1.00 0.90 0.79
4
Professional behavior 1.00 0.95 1.00 0.95 0.90
5
Professional behavior 1.00 0.90 1.00 0.95 0.95
6
Professional behavior 1.00 1.00 1.00 1.00 1.00
7
Professional behavior 1.00 0.95 1.00 1.00 1.00
8
Professional behavior 0.95 0.85 0.95 0.95 0.69
9
Professional behavior 1.00 0.89 1.00 1.00 0.95
10
Clinical reasoning 1.00 1.00 1.00 1.00 1.00
1
Clinical reasoning 0.95 0.89 0.95 0.84 0.73
2
Clinical reasoning 0.94 0.83 0.94 0.89 0.94
3
Clinical reasoning 1.00 0.94 1.00 1.00 1.00
4
Clinical reasoning 0.95 0.95 0.95 0.95 1.00
5
Clinical reasoning 1.00 0.84 1.00 1.00 1.00
6
Clinical reasoning 1.00 1.00 1.00 0.95 0.95
7
Clinical reasoning 0.94 0.94 0.94 0.94 0.89
8
Clinical reasoning 0.94 0.94 0.94 1.00 0.88
9
Clinical reasoning 1.00 0.94 1.00 0.94 0.78
10
CVI Content validity index

This scale allows a precise description of both the re- undergraduate physiotherapy students’ performance in
quired level of supervision and the expected under- clinical placement when using a standardized assessment
graduate achievement level. By contrast, the CPI [20] form with explicit guidelines.
uses a visual analogue scale, and the Blue MACS [22] This study is not without limitations. First, all of the
employs a Likert-type scale, which may be more subject- students were selected from a single educational institu-
ive as it is based on the evaluator’s perception of agree- tion (Universidad del Rosario), and they volunteered to
ment or disagreement. participate. This might have resulted in selection bias. In
The implication of these findings is that in clinical this study, we did not assess intra-evaluator reproduci-
competence assessment in PT education, there is a high bility; to do so would have necessitated ensuring that the
level of reliability in the assessment and scoring of measurements were made in similar conditions in order
Torres-Narváez et al. BMC Medical Education (2018) 18:280 Page 6 of 8

Table 2 Factor pattern coefficients for principal component analysis with Varimax rotation and corrected item-total correlations on
the 20 items of the MTCCP (n = 60)
Item F1 F2
Professional Behavior 1 Minimizes the actual risk of damage in itself and the population it serves. 0,67 0,57
Professional Behavior 2 Meets the ethical and bioethical principles of the professional practice. 0,58 0,68
Professional Behavior 3 Uses efficiently and adequately the physical and technological resources available in the 0,59 0,63
practice setting.
Professional Behavior 4 Has assertive verbal, nonverbal, and written communication. 0,64 0,52
Professional Behavior 5 Establishes interdisciplinary academic relations for the benefit of his/her training process 0,53 0,63
and of the user’s assistance.
Professional Behavior 6 Shows initiative and leadership in managing knowledge and organizing activities within 0,44 0,78
the practice.
Professional Behavior 7 Shows continuous commitment to improvement for his/her personal and professional 0,35 0,88
development.
Professional Behavior 8 Bases his/her professional undertaking on the best available scientific evidence. 0,50 0,73
Professional Behavior 9 Fully assumes the undertaken commitments typical of the professional performance and 0,50 0,80
his/her role as a student.
Professional Behavior 10 Takes part meeting efficiency and quality in the administrative activities of his/her practice. 0,30 0,85
Clinical reasoning 1 Produces an initial hypothesis of the user’s clinical condition based on the available 0,81 0,3
information: clinical records, observations, and interviews.
Clinical reasoning 2 Selects the tests and measures consistent with the user’s priorities and the best 0,79 0,47
available scientific evidence.
Clinical reasoning 3 Applies the selected tests and measures skillfully. 0,73 0,43
Clinical reasoning 4 Analyzes the obtained information to produce a diagnosis of the user’s functional 0,78 0,42
condition.
Clinical reasoning 5 Determines the physiotherapeutic prognosis that allows him/her to project goals and 0,74 0,49
treatment plan.
Clinical reasoning 6 Establishes the general objective of the treatment plan according to the user’s 0,83 0,40
diagnosis and prognosis.
Clinical reasoning 7 Structures the treatment plan taking the available resources and evidence into account. 0,76 0,51
Clinical reasoning 8 Applies the therapeutic strategies established in the treatment plan skillfully. 0,76 0,45
Clinical reasoning 9 Carries out educational strategies for body and movement in order to fulfill the 0,85 0,32
set objectives.
Clinical reasoning 10 Evaluates the impact of his/her interventions and makes the required adjustments to 0,76 0,546
the treatment based on the behavior of the relevant clinical variables.
Eigenvalues 15,10 1,03
% of variance 44,76 35,92
F1, Factor 1 (clinical reasoning) and F2, Factor 2 (professional behavior) and include the next sentence: Boldface numbers identify the relation between each item
and its factor taking into account the factor loadings (F1 ≥ 0.70) (F2 - ≥0.5)

to confirm their independence. However, it was not In future research, the MTCCP instrument could be
possible to carry out this assessment due to changes used both to help improve learning processes in individ-
in the patients and in the students’ learning pro- ual PT students and to evaluate the effects of education
cesses in the clinical setting. Nevertheless, future on clinical performance. In the academic context, the
studies should make an effort to assess intra-evalu- MTCCP could help educators and students to identify
ator reproducibility. which areas of learning students feel insecure with and
To further improve the validity and reliability of the therefore need further practice in. The MTCCP can be
instrument, we recommend investigating the scale in used in summative and formative evaluation processes:
other institutional settings in order to ascertain whether the summative evaluation would give an account of the
its validity and integrity remain intact in different clin- student’s performance level based on the score obtained,
ical settings. Based on these applications, a confirmatory whereas in the formative evaluation, without the pres-
factor analysis should be conducted to confirm that the sure of a formal qualification, both the CI and the stu-
items on the adjusted scales accurately reflect the under- dent identify the strengths and weakness of the student
lying constructs. and make decisions that promote learning. The CI can
Torres-Narváez et al. BMC Medical Education (2018) 18:280 Page 7 of 8

establish the pedagogical strategies according to the stu- and students); we used these codes in the subsequent evaluation tools and
dent’s needs, and students appropriate these strategies in data analysis.

order to achieve significant learning in clinical compe- Consent for publication

tence training [42]. Not applicable.

Competing interests
Conclusions The authors declare that they have no competing interests.
The MTCCP is a valid and reliable instrument for asses-
sing the performance of entry-level PT students in clin- Publisher’s Note
ical areas in hospital settings. As such, it could be an Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
important tool in PT education and research. In educa-
tion, the MTCCP could be used to determine what skills Author details
1
the student feels less confident using and what add- Universidad del Rosario, Bogotá, Colombia. 2Escuela de Medicina y Ciencias
de la Salud, GI Ciencias de la Rehabilitación, Bogotá, Colombia. 3Programa de
itional training/learning opportunities could be provided.
Fisioterapia, Bogotá, Colombia.
In research, it could be used to assess the impact of the
curriculum and pedagogical strategies on students’ clin- Received: 6 June 2017 Accepted: 1 November 2018
ical performance. Further research is needed to deter-
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