demand for improvement of quality of therapists has increased with the recent advancement 
 in medical technologies and the growing understanding of society toward rehabilitation 
 medicine1 . however , the basic scholastic 
 ability of students enrolled in training schools is not increasing .
the minimum attainment level for pre - graduation education was changed from 
  becoming able to perform basic physical therapy  to  becoming able to perform basic 
 physical therapy with some advice and supervision  by the physical therapy education 
 guidelines3 .
a previous study4 reported that most novice physical 
 therapists ( pts ) need supervisors advice and can not accomplish their duties independently . 

other previous studies5,6,7,8,9 suggest that novice pts do 
 not have sufficient clinical skill and thus require postgraduate education . in the current japanese situation
first , postgraduate education is performed in individual facilities , which have 
 their own characteristics and are thus not homogenized10 .
in other facilities , 
 novice pts rotate among different departments based on the type or stage of disease12 . regarding the relation between the number 
 of therapists and the education system , postgraduate education systems are better 
 established in a facility with a large number of therapists13 .
second , many members of the japanese physical therapy association 
 are young , with ages ranging from 2030 years3 , 4.thus , lack of supervising therapists is also 
 a crucial problem . under these circumstances ,
the postgraduate education systems are not 
 likely to ensure a certain level of quality . to maintain a level of educational quality , setting an explicit goal
, goal setting has a second - order effect that promotes self - directed learning based 
 on adult learning theories14 . in line 
 with these perspectives , the medical education system has compulsory post graduation 
 clinical training for 2  years that has an explicit goal15 . in the nursing education system , postgraduate training goals and 
 guidelines on supervision have been established as well16 .
however , in the therapist education system , goals for post 
 graduation therapists have not been determined yet .
to achieve a certain level of quality in novice pts , the first goal is for them to be able 
 to implement their duties independently .
the aim of this study was to clarify the essential abilities of 
 novice physical and occupational therapists for independent execution of their duties and to 
 develop an assessment tool .
first , semi structured interviews were conducted on 15 experienced 
 therapists to create a comprehensive list of essential abilities that novice therapists 
 need17 .
second , 30 experienced 
 therapists participated in a two - round delphi study to select items for the assessment tool 
 being developed for novice therapists .
therapists working in hospitals , training schools , or 
 geriatric health services facilities ; those with experience in supervising other therapists ; 
 and those with management experience were included in the study .
all experienced therapists 
 were provided with oral explanations regarding the details of this study as ethical 
 considerations .
the 
 study was conducted with the approval of the ethics committee of fujita health university 
 ( 13 - 254 ) . before the interview , the definition of  therapist who is able to implement their duties 
 independently 
( table 1table 1.definition of terms and the interview guidedefinition of terms :  therapists who are able to 
 independently implement their duties1 ) having basic clinical skills that all therapists 
 should develop regardless of individual domain expertise 2 ) not requiring supervisors active guide3 ) being able to behave appropriately in workplaces 
 ( as members of society)the details of an interviews guide used in this study:please answer the following questions , envisioning what you supervise novice 
 therapists:1 ) when do you feel that therapists under your 
 supervision reach the level enough to routine clinical practice 
 independently?2 ) what actions do you expect such novice therapists 
 to achieve under your supervision?3 ) when you have been brought up as a therapist , what 
 type of experience did you need to become able to independently implement your 
 duties ? ) , which was defined based on the definition of doctors basic clinical 
 ability18 , was presented to 
 participants to ensure that the term has the same meaning to the subjects .
all participants 
 were simultaneously interviewed using with focus group semi structured interview 
 methods19 based on an interview guide 
 ( table 1 ) .
the participants were asked to 
 imagine supervising other therapists and answer questions such as , 
what novice pt behaviors 
 affect your appreciation that therapists under your supervision have the ability to fulfill 
 their professional duties independently ?  the researchers encouraged the participants to 
 verbalize their thought and listened with close attention .
all interview contents were 
 recorded using an ic recorder and were converted into character data to create narrative 
 records .
therapists who are able to fulfill 
 their professional duties independently  and classified the contents into categories based 
 on similarity of content .
we used 5-point rating method ( 1=unnecessary ; 
 2=relatively necessary ; 3=necessary ; 4=absolutely necessary but may not be achieved within 6 
 months ; 5=absolutely necessary and should be achieved within 6 months ) focusing on 
  therapists who are able to fulfill their professional duties independently .  in the second round , the ratings of each rater and the frequency distribution , median , and 
 interquartile range of all participants ratings were presented .
subsequently , all raters 
 were again asked to rate the items extracted from the first round . using the results of the 
 second round , the items where more than 80% of the total number of experienced therapists 
 scored a rating of 4 or 5 were adopted as evaluation items .
then , these items were 
 classified based on semantic similarity , and each category was named by the abstraction of 
 their semantic contents . to confirm the reliability of the results ,
the items must also be 
 classified into such categories by other experienced therapists serving as third party . 
 based on the classifications set by the researchers and third - party therapists ,
one hundred fifty - six items were extracted from data obtained through interview with 15 
 experienced participants in relation to abilities necessary for therapists to fulfill their 
 professional duties independently . by unifying similar or overlapping items ,
these items 
 were aggregated to 86 items . after a considerable discussion using two - round delphi 
 technique ,
these items were classified into three 
 categories : basic attitudes , 19 items ; therapeutic skills , 20 items ; clinical 
 practice - related thoughts , 16 items ( table 
 2table 2.outcomes of the development of a clinical ability evaluation table for 
 therapistsevaluation items : basic attitudeusing appropriate language as a member of societyadhering to appointed times and deadlinescomplying with rules in the workplaceunderstanding the role and duties of the therapist as 
 a team memberadopting appropriate actions in consideration of the 
 role of the therapist as a team membercontributing to the improvement of coordination as a 
 team memberefficiently implementing duties so as to be completed 
 within working hoursappropriately understanding and considering 
 confidentiality and personal information managementperforming appropriate infection control measures 
 ( including hand wash)performing appropriate equipment management ( before 
 and after use)performing treatment , with a sense of 
 responsibilityappropriately managing the therapist s own physical 
 condition and schedule and avoiding interfering with his / her dutiesappropriately implementing reporting , communication , 
 and consultation procedures ( developing and expressing the therapist s own 
 thoughts ) in all timesidentifying problems which are difficult to 
 independently addressconsulting problems which are difficult to 
 independently address with appropriate persons in appropriate situationsseriously accepting and addressing issues noted by the 
 supervisor or the therapist s own failuresdeveloping positive attitudes and making efforts to 
 achieve knowledge and skillsperforming treatment and implement duties based on 
 learning outcomes and experiencetherapeutic skillsadopting appropriate measures , such as life - saving 
 techniques , to manage sudden changes in patients conditionsappropriately dealing with individual patients in 
 consideration of their symptomsusing appropriate verbal or non - verbal communication 
 methods for individual patientsshowing empathy when communicating with patients in 
 consideration of their psychological conditionsappropriately listening to patients and their families 
 to clarify their needshaving medical knowledge necessary for a 
 therapistselecting appropriate evaluation items for individual 
 patientsperforming vital ( blood pressure and heart rate ) 
 measurement , according to each situationappropriately ( and also accurately , efficiently ) 
 conducting medical interviews with patientsappropriately ( and also accurately , efficiently ) 
 examining reflexesappropriately ( and also accurately , efficiently ) 
 conducting orthopedic examinationappropriately ( and also accurately , efficiently ) 
 evaluating painappropriately ( and also accurately , efficiently ) 
 evaluating coordinationappropriately ( and also accurately , efficiently ) 
 evaluating muscle toneappropriately ( and also accurately , efficiently ) 
 measuring the range of motionappropriately ( and also accurately , efficiently ) 
 evaluating the muscle strengthappropriately ( and also accurately , efficiently ) 
 conducting sensory examinationappropriately ( and also accurately , efficiently ) 
 performing morphometryappropriately ( and also accurately , efficiently ) 
 evaluating the motor function of patients with paralysis ( using the sias and 
 brunnstrom stage test)appropriately ( and also accurately , efficiently ) 
 evaluating adl ( using instruments , such as the fim and barthel index)clinical practice - related thoughtsclarifying individual patients general 
 characteristicsidentifying individual patients possible risks based 
 on the results of examinationlogically examining the causes of problems in 
 movements or activities of daily livingdeveloping treatment programs to achieve goals ( also 
 referring to literature)safely implementing treatment programssafely handling treatment devicesappropriately managing risks related to medical 
 accidents , such as tube removal and bleedingappropriately managing risks related to fallsproviding appropriate range - of - motion trainingproviding appropriate muscle - strengthening 
 trainingproviding appropriate assistance and guidance for the 
 maintenance of sitting positionsproviding appropriate assistance and guidance for the 
 maintenance of standing positionsproviding appropriate assistance and guidance for 
 standing from a seatproviding appropriate assistance and guidance for 
 transferproviding appropriate assistance and guidance for gait 
 trainingcontinuously evaluating ( and observing ) patients in 
 the progress of treatmentcriteria : ratings .
4=being able to accurately understand and adopt appropriate actions without 
 supervision . 3=being able to accurately understand and adopt appropriate actions under monitoring 
 and supervision .
2=being able to understand and adopt appropriate actions to a certain extent under 
 monitoring and supervision . 1=being unable to understand or adopt appropriate actions even under monitoring or 
 supervision . 0=being inappropriate for implementation . ) . the  coefficient , representing the agreement rate between the researcher 
 and third - party experienced therapist , was 0.86 .
criteria : ratings . 4=being able to accurately understand and adopt appropriate actions without 
 supervision . 3=being able to accurately understand and adopt appropriate actions under monitoring 
 and supervision . 2=being able to understand and adopt appropriate actions to a certain extent under 
 monitoring and supervision .
1=being unable to understand or adopt appropriate actions even under monitoring or 
 supervision . 0=being inappropriate for implementation
this study adopted the sequential exploratory strategy performed from a qualitative 
 approach to a quantitative approach in a phased manner21 , 22 . in other words ,
the 
 data were collected qualitatively and examined quantitatively using the delphi technique , 
 which is a questionnaire method with repetitive feedback23,24,25 . as a result ,
the focus group interview used in the present study might be effective in facilitating the 
 collection of a broad range of opinions from experienced therapists because similar 
 experiences about supervision assists in causing a sense of empathy and stimulates the 
 discussion .
the items were classified into three categories : basic attitudes , therapeutic 
 skills , and clinical practice - related thoughts .
the high  coefficient between 
 classifications by the researcher and a third - party therapist suggest high reliability of 
 the classification .
the basic attitudes category consisted of items associated with the ability for continuing 
 self - education , as mentioned in the japanese physical therapy association s code of 
 ethics26 .
in addition , an attitude of 
 humility toward each patient and a cooperative attitude toward other professionals were 
 included in this category .
thus , the results suggest that knowledge of these social skills is also important in 
 the postgraduate education of novice therapists .
the therapeutic skills category consisted 
 of abilities associated with collection of medical information such as communication with 
 patients and assessment technique .
these items suggest that novice therapists should have a 
 certain amount of communication skill in addition to medical knowledge .
thus , optimal 
 communicational education methods have to be developed for the postgraduate education of 
 novice therapists .
the clinical practice - related thoughts category included items associated 
 with integration of patient information obtained from medical assessment , determination of 
 disabilities ( impairment , activity limitation , participation restriction ) , planning of 
 therapeutic program , re - evaluation , and corresponding plan revision .
these items are 
 substantially coincident with the clinical reasoning model proposed by edwards , which 
 includes a set of processes such as the recognition and interpretation of medical 
 information , development and revision of hypothesis , determination of intent , and 
 re - evaluation after intervention27 . in the present study ,
experienced therapists were encouraged to consider not only knowledge 
 of implementing therapy - related duties , clinical practice - related thoughts , or therapeutic 
 skills , but also appropriate social skills and attitudes , self - management , and 
 self - education , for continuous self - improvement .
the 55 evaluation items may cover all 
 domains defined in the taxonomy ( cognitive , emotional , and psychomotor ) , which is a concept 
 often used in medical education and services28 .
therefore , the preset items might accurately represent the 
 abilities needed by therapists to implement their duties independently and should be the 
 appropriate goals of novice therapists .
 [ purpose ] the aim of this study was to clarify essential abilities of novice physical and 
 occupational therapists for independent execution of their duties and to develop a 
 clinical competence assessment tool . [ subjects ] forty - five experienced therapists 
 participated in this study . 
 [ methods ] a two - phase mixed - methods design was used . 
 first , 
 semi structured interviews were conducted on 15 experienced therapists to create a 
 comprehensive list of essential abilities that novice therapists need . 
 second , 30 
 experienced therapists participated in a two - round delphi study to select items for the 
 assessment tool being developed . 
 [ results ] fifty - five items were extracted and classified 
 into three categories : basic attitudes , therapeutic skills , and clinical practice - related 
 thoughts . 
 [ conclusion ] present results suggest that not only knowledge of execution of 
 therapy - related duties and therapeutic skills is essential in novice therapist , but also 
 appropriate abilities in social adjustment , self - management , and self - education . 
 the newly 
 developed tool might be useful for postgraduate education in clinical practice . 