practice analysis study of clinicians and registered ... · the multiple-choice examinations for...

PRACTICE ANALYSIS STUDY OF CERTIFIED CLINICIANS AND REGISTERED TECHNICIANS

Prepared for Orthotics Prosthetics Canada

202 - 300 March Road Ottawa, Ontario K2K 2E2

Prepared by

Professional Examination Service Department of Research and Advisory Services

475 Riverside Drive New York, NY 10115

September 2014

i

Acknowledgements

On behalf of Professional Examination Service (ProExam), we are pleased to have conducted this important study for Orthotics Prosthetics Canada (OPC). This report describes the contemporary practice of orthotic and prosthetic credentialed Clinicians and Technicians in Canada, and presents recommendations regarding OPC examination construction initiatives. ProExam endorses OPC’s efforts in developing exemplary examination programs as reflected in the multiple-choice examinations for Certified Clinicians and Registered Technicians. This report represents the culmination of nearly one year of planning, execution, data analyses, and writing in support of this goal. A project of the magnitude depends on the hard work and commitment of many professionals, and we are pleased to acknowledge their contributions to the final product. We are indebted to the Practice Analysis Task Force (PATF) for the wisdom and direction it provided. Its members—Hannah Abel C.O., Kieran Bliss C.P.(c), Scott Hedlund C.P.(c), John Kooy C.O.(c), and Heather Miklovich C.O.(c)––along with OPC executives Carla Reimer C.O.(c), President, and Jennifer Russell-Smyth C.P.(c), Secretary/Treasurer—worked tirelessly throughout the project. Additional support and guidance were provided by Armand Huneault, C.P.O(c), OPC President-elect. We thank them all for their dedication and hard work. Finally, we are grateful to Linda Laakso, C.O.(c) OPC Vice President and Practice Analysis Task Force Chair. She provided thoughtful and consistent support during the conduct of the study. We conclude by stating that the views expressed in this report are those of ProExam and do not necessarily reflect the view of OPC or of those experts who provided advice on the conduct of this practice analysis. Sandra Greenberg, PhD, Vice President for Research and Development, ProExam Carla M. Caro, MA, Research Director, ProExam New York, New York November, 2014

ii

Contents

List of Tables ................................................................................................................................... iv

List of Exhibits ................................................................................................................................. vi

List of Appendices .......................................................................................................................... vii

Executive Summary ........................................................................................................................ 1

Objectives of the Practice Analysis Study ..................................................................................... 9

Methods ........................................................................................................................................ 10

Task Force Selection .................................................................................................................. 10 Task Force Meeting 1 (Virtual) .................................................................................................. 10 Task Force Meeting 2 (In-person) ............................................................................................. 10 Independent Review ................................................................................................................. 11 Survey of the Profession ........................................................................................................... 12

Screening Questions ........................................................................................................................... 13 Rating Scales ...................................................................................................................................... 13

Pilot Test of the Survey ............................................................................................................. 14 Translation of the Survey .......................................................................................................... 15 Survey Dissemination ................................................................................................................ 15

Supplementary Data Collection .......................................................................................................... 15

Quantitative and Qualitative Survey Results .............................................................................. 17

Survey Response Rate ............................................................................................................... 17 Professional and Demographic Characteristics of Survey Respondents .................................. 17 Domain Ratings ......................................................................................................................... 27 Results Related to Tasks ........................................................................................................... 30

Tasks Missing from the Survey ........................................................................................................... 41

Work and Practice Characteristics ............................................................................................ 41 Practice Areas ........................................................................................................................... 45 Prosthetic Practice Areas .......................................................................................................... 45 Orthotic Practice Areas ............................................................................................................. 51 Results Related to Knowledge and Skills .................................................................................. 59 Qualitative Responses ............................................................................................................... 64

Guidance for Test Specifications.................................................................................................. 68

Rationale and Discussion .................................................................................................................... 69

Suggested Follow-up Activities in Regard to Dissemination of Information ............................ 72 Suggested Follow-up Activities in Regard to Maintaining the Currency of the Examination .. 73

References .................................................................................................................................... 74

iv

List of Tables

Table 1 Domains and tasks in the practice analysis survey of the disciplines of orthotics and prosthetics ..................................................................................................................... 11

Table 2 Survey response rate ........................................................................................................ 17 Table 3 Discipline from which survey completed ......................................................................... 17 Table 4 Perspective from which survey completed ...................................................................... 18 Table 5 Credentials held ............................................................................................................... 18 Table 6 Year Clinicians credentialed ............................................................................................. 19 Table 7 Year Technicians credentialed ......................................................................................... 19 Table 8 Current employment status ............................................................................................. 20 Table 9 Primary work setting ........................................................................................................ 20 Table 10 Number of prosthetics/orthotics employees located at primary work setting ............. 21 Table 11 Where prosthetic and/or orthotic education obtained ................................................. 21 Table 12 Highest educational degree/certificate/diploma earned .............................................. 23 Table 13 Type of 4-year university degree earned ....................................................................... 23 Table 14 Type of Master's degree earned .................................................................................... 23 Table 15 Additional healthcare professional licenses and/or certifications held ........................ 24 Table 16 Province or territory ....................................................................................................... 24 Table 17 Gender ............................................................................................................................ 26 Table 18 Age .................................................................................................................................. 26 Table 19 Percentage of Time in each domain, total sample......................................................... 27 Table 20 Percentage of time in domains by cohort and total ...................................................... 28 Table 21 Domain Criticality by cohort and total ........................................................................... 28 Table 22 Task Frequency ratings, mean values by cohort ............................................................ 30 Table 23 Task Criticality ratings, mean values by cohort.............................................................. 35 Table 24 Percentage of time performing activity by cohort ........................................................ 41 Table 25 Where prostheses and orthoses manufactured by cohort ............................................ 43 Table 26 Primary practice setting by cohort ................................................................................. 43 Table 27 Percentage of patients in each age category by cohort ................................................ 44 Table 28 Percentage of patients in each category by cohort ....................................................... 44 Table 29 Percentage of orthoses and prostheses provided for patients incorporating the use of

computer-aided design and manufacturing (CAD/CAM) .............................................. 44 Table 30 Percentage of time in prosthetic practice areas by level of credential and total ......... 45 Table 31 Percentage of lower extremity prosthetics by level of credential and total ................ 46 Table 32 Percentage of upper extremity prosthetics by level of credential and total ................ 46 Table 33 Percentage of new and mature transtibial amputees being fit with each type of

suspension ..................................................................................................................... 47 Table 34 Percentage of new and mature transfemoral amputees being fit with each type of

suspension ..................................................................................................................... 47 Table 35 Percentage of new and mature transtibial amputees being fit with each type of

interface ........................................................................................................................ 48 Table 36 Percentage of new and mature transfemoral amputees being fit with each type of

interface ........................................................................................................................ 48

v

Table 37. Percentage of CP respondents performing each activity for each prosthetic practice area ................................................................................................................................ 49

Table 38. Percentage of RTP respondents performing each activity for each prosthetic practice area ................................................................................................................................ 50

Table 39 Percentage of work time in orthotic practice areas by level of credential and total ... 51 Table 40 Percentage of orthotic work time in practice areas and orthoses by level of credential

and total ........................................................................................................................ 53 Table 41 Percentage of lower extremity orthoses by level of credential and total .................... 54 Table 42 Percentage of KAFOs by level of credential and total................................................... 54 Table 43 Percentage of CO respondents performing each activity for each type of orthosis ..... 55 Table 44 Percentage of RTO respondents performing each activity for each type of orthosis ... 57 Table 45 Empirically-derived hypothetical domain-level test specifications by credential ......... 68 Table 46 Final recommended test specifications for the OPC Certified Clinician and Registered

Technician examinations ............................................................................................... 69

vi

List of Exhibits

Exhibit 1. Clinician knowledge and skills ....................................................................................... 59 Exhibit 2. Technician knowledge and skills ................................................................................... 62

vii

List of Appendices

Appendix 1. Practice Analysis Task Force and OPC Stakeholders ................................................ 75 Appendix 2. Independent Reviewers and Instructions ................................................................. 77 Appendix 3. Results of the Survey Pilot Test ................................................................................ 81 Appendix 4. Screen Captures of Survey Instrument ................................................................... 103 Appendix 5. Survey Invitations and Follow-ups .......................................................................... 120 Appendix 6. Write-in Responses ................................................................................................. 129 Appendix 7. Task Ratings, Total Sample: Frequency Distributions and Summary Statistics ...... 138 Appendix 8. Instructions for Subject-Matter Expert Review of the Knowledge and Skills ........ 154 Appendix 9. Qualitative Responses ............................................................................................ 158 Appendix 10. Final Delineation of Domains and Tasks ............................................................... 208

OPC Practice Analysis of the Profession Page 1

Executive Summary

Orthotics Prosthetics Canada (OPC) contracted with Professional Examination Service (ProExam) to develop and implement a practice analysis and study for Certified Clinicians and Registered Technicians in the disciplines of orthotics and prosthetics. Practice analysis is an important basis by which a credentialing agency establishes, maintains, and defends the content validity of its examination programs. The specific objectives of the study were to:

conduct a practice analysis of the orthotic and prosthetic disciplines by delineating and validating the domains of practice, the specific tasks performed, and the associated knowledge and skills required to perform each task;

leverage the work of the Compendium of Prosthetic and Orthotic Treatment (CPOT) projects in the development of the delineation of practice;

identify differences in the disciplines of orthotics and prosthetics with regard to practice areas;

identify differences in the practice patterns with regard to performance of tasks, and the knowledge and skills used, by Certified Clinicians and Registered Technicians;

quantify time spent and tasks performed with regard to various orthotic and prosthetic devices;

describe—in terms of age and etiology—the patients to whom orthotic and prosthetic credentialed Clinicians provide direct patient care; and

develop defensible test specifications for the disciplines of orthotics and prosthetics in connection with the multiple-choice examinations for Certified Prosthetists, Certified Orthotists, Registered Prosthetic Technicians and Registered Orthotic Technicians.

Public protection is considered as central to the organizing framework of the study. This practice analysis and validation study used a process-based approach (tasks within domains) as the primary organizing framework, and supplemented that approach with the delineation of knowledge and skills. The goal of the practice analysis aspect of the study was to develop a description of the profession; that is, to provide profiles of what contemporary professionals do and the knowledge and skills they need. The goal of the validation aspect of the study was to provide priorities, e.g., the highly critical tasks that are performed by all practitioners and/or technicians, the subset of knowledge and skills essential at the time of initial credentialing, and the practice areas and devices with which practitioners most frequently work. The results will be used to update the test specifications for Certified Prosthetists, Certified Orthotists, Registered Prosthetic Technicians and Registered Orthotic Technicians. The results may also be


used to identify targets for in-service and/or continuing education, and to provide guidance for education programs in regard to curriculum review and/or programmatic self-assessment. ProExam completed the following steps in collaboration with the Practice Analysis Task Force (PATF):

Conducted one face-to-face and four virtual meetings with the PATF

Developed the delineation of practice. A layout of the final structure of the delineation of domains and tasks is shown below.

Domains and tasks in the practice analysis survey of the disciplines of orthotics and prosthetics

Domain Tasks

Patient Evaluation 11

Treatment Planning 10

Treatment Implementation and Evaluation 23

Ongoing Treatment and Re-evaluation 15

Professional Practice 14

Total 73

ProExam developed an online survey of practice, the Practice Analysis Survey of the Disciplines of Orthotics and Prosthetics. The survey included the following components:

Introduction: Including a description of the purpose of the survey and instructions for completing the survey. Screening Questions: To determine if respondents had been practicing in the past 12 months; and to enable respondents to select the perspective from which to respond to the survey (Certified Prosthetist (C.P.(c)), Certified Orthotist (C.O.(c)), Registered Technician Prosthetics (R.T.P.(c)) or Registered Technician Orthotics (R.T.O.(c)). Note: For ease of reference in the remainder of this report, the initials CP will serve to designate C.P.(c); CO will serve to designate C.O,(c); RTP will serve to designate R.T.P.(c); and RTO will serve to designate R.T.O(c). Section 1: Tasks, including 73 tasks delineated in association with five domains of practice. Section 2: Domains, including five domains of practice.


Section 3: Orthotics and Prosthetics Practice Area and Device Lists, including activities performed in connection with orthotic and prosthetic devices. Respondents were routed to either the Orthotics or the Prosthetics version of the practice areas depending on their answer to the screening question. Clinicians and Technicians in each discipline answered the same questions about practice areas and devices. Section 4: Patient and Practice Characteristics, including questions regarding patient population and health care practice patterns. Section 5: Background Information, including questions about the respondent’s educational and professional background, work setting, and demographic characteristics.

Section 6: Qualitative Comments, including open-ended questions regarding the comprehensiveness of the draft delineation, and expected changes in practice.

The Results of the Practice Analysis Survey of the Disciplines of Orthotics and Prosthetics The overall return rate was 47%. The return rate was derived by taking the number of completed surveys and dividing it by the number of surveys that were eligible to be completed. Five hundred seventy-four valid invitations were sent, representing the entire population of OPC-Certified Clinicians and Registered Technicians, and 270 individuals completed the survey, for an overall response rate of 47%. This is a very strong rate of response when compared with studies of other professions wherein potential respondents were required to respond to a detailed and comprehensive survey such as that used in the present study. Highlights Related to Background Information

Of the 270 respondents, 116 (43%) were from the prosthetics discipline and 154 (57%) were from the orthotics discipline.

Of the Clinicians who completed the survey, 90 did so from the perspective of a CP, and 122 completed from the perspective of a CO. Of the Technicians who completed the survey, 26 did so from the perspective of an RTP, and 32 did so from the perspective of an RTO. In total, 212 respondents were Clinicians (CP, CO, and CPO) and 58 were Technicians (RTP, RTO, and RTPO).

CPs had almost 20 years of experience, on average, in prosthetic practice, while COs had 21 years of experience in orthotic practice. RTPs and RTOs both averaged slightly more than 16 years of experience in their respectively disciplines.

More than 90% of respondents were employed full time; the majority of respondents (57%) primarily worked in a private practice setting, and 38% primarily worked in a hospital or rehabilitation centre.


More than 50% of respondents worked in settings with six or fewer prosthetics/orthotics employees (including residents and interns), and 19% worked in settings with 16 or more such employees.

Eighty-four percent of respondents obtained their prosthetic and/or orthotic education in a college diploma program. With regard to the highest level of education earned in any discipline, about 43% had earned a 4-year university degree whereas 35% had earned a college diploma. Roughly equivalent percentages of respondents (just under 7%) had earned either a high school or equivalent degree or a master’s degree.

Respondents in general did not hold many other healthcare licenses or certification, with only 8% holding any other certification.

All provinces were represented among the respondent pool, with the largest number 97, (37%) coming from Ontario, followed by Alberta, with 49 (18%) and British Columbia with 36 (about 14%). No responses were received from respondents in any of the territories.

Respondents were primarily male (72%) and the largest proportion (36%) were from 45 to 54 years of age.

Highlights Related to Domains, Tasks, Knowledge and Skills

The total sample of respondents spend the most time in Domain 3: Treatment Implementation and Evaluation (36%), and relatively equivalent amounts of time in Domain 4: Ongoing Treatment and Re-evaluation (19%) and Domain 1: Patient Evaluation (17%). They spend less time in either of the two remaining domains, including Domain 2: Treatment Planning and Domain 5: Professional Practice. The allocation of only 4% of time to Other, suggests that the identification of these five domains represented a comprehensive description of the major practice responsibilities of members of the sample.

In comparing CPs to COs, the rank order of the domains is similar, but not identical. Both CPs and COs spend the most time in Domain 3: Treatment Implementation and Evaluation, (33% and 29%, respectively). However, CPs rank Domain 4, Ongoing Treatment and Re-evaluation as second, spending 28% of time in that domain, while COs rank Domain 1: Patient Evaluation as second, spending 24% of time in that domain. Both groups rank Domain 2: Treatment Planning and Domain 5: Professional Practice similarly.

The pattern of domain ratings for the RTPs and the RTOs is more consistent. Both RTPs and RTOs spend more than one half of their time in Domain 3: Treatment Implementation and Evaluation, and little time in Domain 1: Patient Evaluation (5% and 2% for RTPs and RTOs, respectively. RTPs spend between 7% and 16% in each of the remaining three domains, with the most time spent in Domain 5: Professional Practice. RTOs spend relatively similar amounts of time in each of the remaining three domains; that is between 9% and 12% in each domain.


The mean domain Criticality ratings for the total sample indicate that each of the five specifically-identified domains is moderately-to-highly critical. The ratings of the CPs and COs are generally very consistent, varying by no more than 0.2 rating scale points, and the ratings of the RTPs and RTOs are virtually identical, varying by no more than 0.1 rating scale points. The RTPs and RTOs rate the domain they spend the most time in, Domain 3: Treatment Intervention and evaluation as somewhat more critical than the remaining domains.

The mean task Frequency ratings indicates that the majority of tasks were performed frequently-to-routinely by both CPs and COs. In general, the COs indicated that they performed tasks in each of the clinical domains (that is, domains 1 to 4), more frequently than did the CPs. In comparison, the Frequency ratings of the RTPs and RTOs were more varied. Tasks in Domain 1: Patient Evaluation and Domain 2: Treatment Planning were generally performed never-to-rarely by the Technicians, whereas tasks in the remaining three domains were performed never-to-routinely, depending on the specific task. The ratings of the RTPs and the RTOs were generally similar, with either cohort performing some tasks more frequently than the other cohort.

In contrast to the Frequency ratings, the task Criticality ratings of the CPs and the COs were uniformly high, indicating that these tasks are all moderately-to-highly critical to optimizing outcomes for patients. Moreover, the ratings of the two cohorts were relatively similar; with only two exceptions, the ratings did not vary by more than 0.3 rating scale points. The pattern of ratings for the RTPs and RTOs was somewhat different. Whereas the members of each cohort generally indicated that the tasks were moderately-to-highly critical in regard to optimizing outcomes, the RTPs rated the majority of tasks as more critical than did the RTOs.

With respect to knowledge and skills (KSs), PATF members and external subject-matter experts (SMEs) reviewed the KSs using an iterative process of review and critique. The final list of Clinician and Technician KSs had a great deal of common material, with slightly more KSs required for Clinician than for Technician practice. The final Clinician KS list contained 48 knowledge areas and 28 skills, whereas for Technicians, the final list contained 46 knowledge areas and 25 skills.

Highlights Related to Practice Patterns and Orthotic and Prosthetic Devices

CPs and COs spend more than one half of their time providing clinical care associated with their discipline (55% and 59%, respectively), and less time in fabrication (16% and 14%, respectively). Members of both cohorts indicate they spend similar amounts of their time performing administrative activities (15% and 14% for CPs and COs, respectively), and educational activities (6% for both). They spend no more than 4% of their time performing any other specifically-identified activities. In contrast, RTPs and RTOs spend nearly all of their time in fabrication. RTPs spend 87% of their time in either prosthetic fabrication (75%) or orthotic fabrication, and some time in administration


(5%). In contrast, RTOs spend 99% of their time in orthotic fabrication, indicating that in contrast to the RTPs, their practice is singularly focused on the one discipline.

With respect to prosthetic practice, CP and RTP respondents spend the most time with transtibial patients (49% and 36%, respectively), and somewhat less time with transfemoral patients (20% and 19%, respectively). CPs and RTPs spend 6% and 9%, respectively, of time with transradial or wrist disarticulation patients and less time in all other practice area.

With respect to orthotic practice, COs and RTOs spend more than two thirds of their time in the lower extremity practice area (70% and 76%, respectively). Spinal was the area where COs and RTOs spent the next greatest amount of time (10% and 7%, respectively) followed closely by upper extremity practice (9% for COs, 8% for RTOs).

Highlight Related to Qualitative Comments Each respondent was given an opportunity to respond to open-ended questions, regarding the nature of changes occurring in the practice of the profession, as well as with reference to how well positioned the profession is to meet changing patient needs. With reference to expected changes in technology, components, and materials, respondents most frequently noted the following topics:

Use of CAD/CAM will increase; computer aided design, manufacture, and processing will be more prevalent;

Use of 3D printing technology will increase;

Use of composite materials, electronic componentry, and microprocessors will be more common;

Materials and components will continue to become lighter, stronger, and more durable;

A small number of respondents indicated that there would be little or no change in technology.

With reference to expected changes in responsibility, respondents most frequently noted the following topics:

Administrative duties will continue to increase;

Clinical documentation/paperwork/ justification will increase for practitioners due to demands of payor agencies;

Time spent dealing with audits, reimbursement, insurance companies, government standards, credentialing and compliance issues will increase;

Time spent in direct patient care and involvement in fabrication will decrease;

Responsibilities for improving and measuring outcomes will increase;


Supporting staff (e.g., assistants, technicians, physicians) will increase in number and carry larger responsibilities.

With reference to expected changes in credentialing, respondents most frequently noted the following topics:

Educational requirements for certification will continue to increase;

Encroachment from other professions will increase, challenging funding agencies to evaluate outcomes;

The value of certification and subsequent desire for provincial licensure will decrease;

Annual fees for the credential will continue to increase;

The exam will be computer-based; available in a variety of locations and times.


With reference to whether the profession is well positioned to meet the changing needs of the patient population, respondents most frequently noted the following topics:

Lack in funding will continue to restrict options for patients and costs will increase;

School/certification systems are not prepared for future. Based on the number of graduates coming out of two OPC Accredited Prosthetics and Orthotic schools, compared with the increasing number of incoming patients, there might not be enough certified practitioners to provide qualified services.

Funders are not prepared for future. The gap between technological advancements available and funding available for patients will increase if provincial and federal funders continue to be non-communicative of funding changes and levels of funding.

The profession will be at greater risk of encroachment from other professions.

Development of Test Specifications

Preliminary test specifications for domains were developed as a function of the empirical data on domain-level practice of Certified Clinicians and Registered Technicians, using the process-based descriptions of the % of Time and Criticality ratings associated with the domains. Empirically-derived test specifications Certified Prosthetists and Certified Orthotists, and for Registered Prosthetic and Orthotic Technicians, were developed at the domain level using the survey data; there were different percentages for each discipline based on the ratings of each cohort. The largest element in the preliminary test specifications is Treatment Implementation and Evaluation for both CPs and COs (35% and 31%, respectively). In the case of CPs, the next largest element is Ongoing Treatment and Re-evaluation (28%), whereas in the case of COs, the next largest element is Patient Evaluation (26%). The final two domains, Treatment Planning and Professional Practice are similar in rank (4th and 5th) and overall percent emphasis, regardless of discipline. For Technicians in both disciplines, Treatment Implementation and Evaluation was by far the largest element (56% for RTPs, and 63% for RTOs).

After careful consideration the empirically-derived preliminary test specifications were adjusted to focus on those elements of practice most critical to safe patient care, and that focus on the key tasks performed by prosthetic and orthotic Clinicians and Technicians at entry to practice. Accordingly, the final test recommended test specifications for the four credentialing exams offered by OPC are as follows.

CP CO RTP RTO

% of exam % of exam % of exam % of exam

1. Patient Evaluation 17% 28% 7% 3%

2. Treatment Planning 15% 18% 10% 13%

3. Treatment Implementation and Evaluation

36% 33% 64% 70%

4. Ongoing Treatment and Re-evaluation 29% 18% 16% 11%


5. Professional Practice 3% 3% 3% 3%

Total 100% 100% 100% 100%

Objectives of the Practice Analysis Study

Orthotics Prosthetics Canada (OPC) contracted with Professional Examination Service (ProExam) to develop and implement a practice analysis and validation study for Certified Clinicians and Registered Technicians in the disciplines of orthotics and prosthetics. Practice analysis is a psychometrically and legally defensible strategy used to develop or update credentialing examinations. ProExam adheres to the highest credentialing industry standards, using guidelines consistent with best practices as described in the 2014 revision of the Standards for Educational and Psychological Testing (American Educational Research Association, National Council on Measurement in Education, and American Psychological Association), the PES Guidelines for the Development, Use, and Evaluation of Licensure and Certification Programs (Professional Examination Service, 1995) and the NCCA Standards (2005). These guidelines emphasize the importance of ensuring, on an ongoing basis, the relevance of a certification program’s test content and emphasize the concept of validity and the need to conduct a practice analysis to ensure that content assessed in credentialing initiatives are limited to those required for competent performance and serving a public protection function. Practice analysis, then, is an important basis by which a credentialing agency establishes, maintains, and defends the content validity of its examination program. The specific objectives of the study were to:

conduct a practice analysis of the orthotic and prosthetic disciplines by delineating and validating the domains of practice, the specific tasks performed, and the associated knowledge and skills required to perform each task;

leverage the work of the Compendium of Prosthetic and Orthotic Treatment (CPOT) projects in the development of the delineation of practice;

identify differences in the disciplines of orthotics and prosthetics with regard to practice areas;

identify differences in the practice patterns with regard to performance of tasks, and the knowledge and skills used, by Certified Clinicians and Registered Technicians;

quantify time spent and tasks performed with regard to various orthotic and prosthetic devices;

describe—in terms of age and etiology—the patients to whom orthotic and prosthetic credentialed Clinicians provide direct patient care; and

develop defensible test specifications for the disciplines of orthotics and prosthetics in connection with the multiple-choice examinations for Certified Prosthetists and Orthotists, and Registered Technicians in Prosthetics and Orthotics.


Public protection is considered as central to the organizing framework of the study. This practice analysis and validation study used a process-based approach (tasks within domains) as the primary organizing framework, and supplemented that approach with the delineation of knowledge and skills. The goal of the practice analysis aspect of the study was to develop a description of the profession; that is, to provide profiles of what contemporary professionals do and the knowledge and skills they need. The goal of the validation aspect of the study was to provide priorities, e.g., the highly critical tasks that are performed by all practitioners and/or Technicians, the subset of knowledge and skills essential at the time of initial credentialing, and the practice areas and devices with which practitioners most frequently work. The results will be used to update the test specifications for Certified Prosthetists and Orthotists, and Registered Technicians in both disciplines. The results may also be used to identify targets for in-service and/or continuing education, and to provide guidance for education programs in regard to curriculum review and/or programmatic self-assessment.

Methods

To accomplish the objectives of the study, ProExam worked with a Practice Analysis Task Force (PATF) over the course of a 9-month project in 2014.

Task Force Selection

OPC selected a Practice Analysis Task Force (PATF) to undertake the major work involved in developing the delineation of practice. The PATF was selected to represent a wide range of professional backgrounds, including: certified practitioners in orthotics and prosthetics, those closer to the point of certification and more experienced practitioners; individuals from different types of work settings and representing various geographic regions; and those having held leadership positions in OPC. (See Appendix 1 for a list of the PATF members). In order to conduct the practice analysis and validation study, ProExam completed the following steps.

Task Force Meeting 1 (Virtual)

ProExam convened a virtual meeting with the PATF, along with other stakeholders (including the OPC education and residency hairs and the examination standards committee co-chairs) in November 2013. During the meeting, ProExam discussed the goals of the study, introduced concepts and processes involved in practice analysis, developed roles and responsibilities, and began discussion of a communication plan regarding the study. Subsequent to this, PATF members engaged in an online review of the prosthetic and orthotic compendiums to identify common elements with regard to major areas of responsibility and activities performed.

Task Force Meeting 2 (In-person)


The PATF met in Toronto, ON for two day January 2014. During the meeting, the task force reviewed the results of the pre-meeting assignment, and also reviewed the delineation of practice developed by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics, Inc. (ABC) over the course of a series of practice analysis studies conducted from 1994 through 2014. These validated descriptions of practice were shared by ABC in a collaborative arrangement with OPC after discussion between the two organizations. Use of the validated practice descriptions from ABC provided a useful framework for the PATF to conceptualize the description of practice and harmonize the common elements from the CPOT materials regarding prosthetic and orthotic practice. The PATF developed a harmonized draft delineation of domains and tasks, a list of Clinician and Technician knowledge and skills (KSs), and a set of practice area and devices specific to each discipline. In addition, the PATF approved questions and rating scales for an online validation survey, a demographic and professional questionnaire to gather data on survey respondents, and developed specific practice-related questions designed to capture information about patient profiles and professional practice. The PATF also brainstormed the list of potential subject-matter experts (SMEs) who would be invited to participate in an independent review of the draft delineation. Subsequent to the meeting, the PATF engaged in an electronic review and critique of the meeting work products. Their feedback was compiled, and in a series of virtual meetings, the PATF members finalized the draft delineation in advance of its review by external SMEs.

Independent Review

The draft delineation of domains and tasks, as well as the practice areas and devices, was electronically circulated to a group of SMEs for independent review and comment. The SMEs included OPC stakeholders, and Clinicians and Technicians in prosthetics, orthotics, and dually-certified individuals. The SME panel was representative of key demographic and professional characteristics, included type of employer, geographic location, years of experience, and other variables. A total of 25 individuals completed the IR, including 21 Clinicians and 4 Technicians. The participants who completed the IR, as well as the instructions for their review, are provided in Appendix 2. The feedback from the IR was compiled in a master document, and in a series of virtual meetings, the PATF carefully considered all suggestions, and developed a final delineation of practice, including domains and tasks, and practice areas and devices, that would be included in an online validation survey. A layout of the final structure of the delineation of domains and tasks is shown in Table 1. For purposes of the survey, the term "patient" was used throughout the delineation, and was defined to be the "patient or client, or his or her representative (such as caregiver, family member, legal guardian, medically authorized person)."

Table 1 Domains and tasks in the practice analysis survey

of the disciplines of orthotics and prosthetics

Domain Tasks


Patient Evaluation 11

Treatment Planning 10

Treatment Implementation and Evaluation 23

Ongoing Treatment and Re-evaluation 15

Professional Practice 14

Total 73

Survey of the Profession

ProExam developed an online survey of practice, the Practice Analysis Survey of the Disciplines of Orthotics and Prosthetics. The survey included the following components:

Introduction: Including a description of the purpose of the survey and instructions for completing the survey. Screening Questions: To determine if respondent had been practicing in the past 12 months; and to enable respondent to select the perspective from which to respond to the survey (Certified Prosthetist (CP), Certified Orthotist (CO), Registered Technician Prosthetics (RTP) or Registered Technician Orthotics (RTO). Section 1: Tasks, including 73 tasks delineated in association with five domains of practice. Section 2: Domains, including five domains of practice. Section 3: Orthotics and Prosthetics Practice Area and Device Lists, including activities performed in connection with orthotic and prosthetic devices. Respondents were routed to either the Orthotics or the Prosthetics version of the practice areas depending on their answer to the screening question. Clinicians and Technicians in each discipline answered the same questions about practice areas and devices. Section 4: Patient and Practice Characteristics, including questions regarding patient population and health care practice patterns. Section 5: Background Information, including questions about the respondent’s educational and professional background, work setting, and demographic characteristics.

Section 6: Qualitative Comments, including open-ended questions regarding the comprehensiveness of the draft delineation, and expected changes in practice.


Screening Questions

Active in the profession: Have you worked as a prosthetic and/or orthotic Clinician or Technician at any time during the past 24 months? Those responding "No" were routed out of the survey.

Perspective: We recognize that your work as Clinician or Technician may be primarily in either the prosthetics or orthotics discipline, or you may divide your time equally between the disciplines. As you complete the survey, please use the perspective of your primary discipline and role. If you spend equal amounts of time in both prosthetics and orthotics work, choose one discipline and complete the survey from that perspective. Indicate the perspective from which you will complete the survey

Certified Prosthetist Certified Orthotist Registered Prosthetics Technician Registered Orthotics Technician

Depending on which perspective was chosen, the respondent was routed to survey versions containing prosthetic or orthotic practice areas and devices to rate. The perspective was used to group respondents into cohorts for sub-group analyses of the data.

Rating Scales

Section 1: Tasks – Think about the last 12 months in which you worked in the prosthetics/orthotics field.

Frequency — How frequently did you perform each task during the last 12 months in which you worked? Think about your own work when rating frequency.

Never Rarely (quarterly or less) Occasionally (monthly) Frequently (weekly) Routinely (daily)

Criticality — How critical is this task to optimizing outcomes for patients? Think about the profession in general rating criticality, regardless of how frequently you personally perform the task. Not critical Minimally critical Moderately critical


Highly critical

At end of section: If tasks that you perform related to your work as a Clinician or Technician are missing from the survey, please describe them here.

Section 2: Domains

% of Time — Overall, what percentage of your work time did you spend performing the tasks related to each domain during the last 12 months in which you worked?

Criticality — How critical is this domain to optimizing outcomes for patients? Not critical Minimally critical Moderately critical Highly critical

Qualitative Questions

In the next 3 years, what changes in the profession do you think will occur with regard to:

Changes in technology, components, and materials Changes in responsibilities Credentialing (licensure, certification)

Do you think the profession is well positioned to meet the changing needs of the patient population?

Pilot Test of the Survey

ProExam implemented a pilot test of the online validation survey to ensure that the technical aspects of the survey were functioning correctly, and as a final check on the completeness of the delineation in advance of its large-scale dissemination. Invitations to participate in the pilot test of the online survey were sent to 25 Certified or Registered practitioners identified as subject-matter experts. In addition, members of the Task Force were invited to complete the pilot survey. A total of 21 pilot tests were completed, for a response rate of 84%, with 17 of the outside SMEs completing the survey and four task force members doing so. Sixteen pilot test respondents were Clinicians and five were Technicians. A number of elements of the survey were revised based on pilot tester feedback, including the addition of response options to some of the demographic questions, and some explanatory and/or clarifying language was added to assist respondents in answering some of the questions. One question in the practice area section of the survey was modified to split a response option into two separate activities. Two tasks were slightly modified to add clarifying elements. A complete report of the pilot test process and results may be found in Appendix 3.


Translation of the Survey

Once the delineation and survey questions were approved, the entire survey was sent for translation into French by paid translators. The French-language version of the survey was uploaded to the online survey platform and was reviewed by two SMEs who were practicing prosthetists or orthotists fluent in the French language. They made a number of suggestions regarding technical aspects of the translation, and these were implemented. Screen captures of the online final survey instruments are found in Appendix 4.

Survey Dissemination

The survey was sent to the entire population of Certified Clinicians and Registered Technicians holding a OPC credential. A series of communiqués were sent to all OPC-credentialed Clinicians and Technicians in advance of the survey invitation to educate certifees regarding the purpose of the practice analysis study, alerting them to the upcoming invitation, and asking them to set their email filters to accept the invitation from [email protected]. ProExam subsequently sent invitations to all CPs, COs, CPOs, RTPs, RTOs, and RTPOs. The invitation was repeated in English and French, and links to both the English-language and French-language versions of the survey were proved to every invitee, given each respondent the option to access the survey in his or her preferred language. A total of 615 email invitations were sent, each containing a unique, password-protected link to the survey. The use of password protection enabled respondents to complete the survey over time, saving their responses each time they logged in to the survey. The survey window was open for a total of 3½ weeks. A series of reminders was sent at one week intervals to non-respondents urging them to participate. One extension was given to allow more respondents to complete the survey. Copies of the initial communications from OPC, survey invitation, and reminders may be found in Appendix 5. In recognition of the self-reflection and professional contribution involved in thoughtfully completing the survey, OPC awarded five Mandatory Continuing Education (MCE) credits to all respondents who completed it. As an incentive, survey completers were also eligible to enter a drawing to win one of 10 $100 VISA gift cards that would be randomly awarded.

Supplementary Data Collection

Subsequent to the survey being closed and preliminary data analysis completed, OPC members requested that additional data be collected with reference to orthotic practice areas. While respondents had allocated their time amongst the major practice areas (lower extremity, upper extremity, spinal, scoliosis, cranial, and seating) they had not broken down their time to the device level within these overarching areas. Accordingly, ProExam implemented a supplemental data collection initiative. All CO and RTOs who had responded to the original survey were sent an invitation to participate in a brief questionnaire asking them to allocate their time across more detailed orthotic devices within each major practice area. One reminder

mailto:[email protected]


was sent over the course of the 2-week window. The screen shots of the followup questionnaire and invitation and are found in Appendices 4 and 5, respectively.


Quantitative and Qualitative Survey Results

Survey Response Rate

Table 2 provides details of the survey response rate. The return rate was derived by taking the number of completed surveys and dividing it by the number of surveys that were eligible to be completed. The number eligible was defined as the total number of survey invitations, minus those that were not deliverable due to invalid email addresses, or those wherein the invitee was routed out based on responding the screening question. Of the 615 invitations sent, 28 were returned as undeliverable and 13 individuals were screened out because they had not been in active practice during the past 24 months. Of the 574 valid invitations, 270 of those invited to participate completed the survey, for a very strong response rate of 47%. As described previously, all members of the sample were given a choice as to the language of the survey they completed. A total of 261 respondents completed the English-language survey and 9 completed the French-language survey.

Table 2 Survey response rate

Invitations sent 615

Undeliverable 1 28

Screened out 2 13

Valid Invitations 574

Surveys completed–English 261

Surveys completed–French 9

Surveys completed–Total 270

Response rate 47.0% 1 Invalid email address 2 Not practicing in last 24 months

Professional and Demographic Characteristics of Survey Respondents

The results presented in the following section document information related to the professional and demographic characteristics of the survey respondents. These results should be reviewed carefully in order to gauge the degree to which the sample of respondents faithfully represents the population of Certified Prosthetists and Certified Orthotists, and Registered Prosthetic and Registered Orthotic Technicians within Canada. Of the 270 respondents, 116 (43%) were from the prosthetics discipline and 154 (57%) were from the orthotics discipline (see Table 3).

Table 3 Discipline from which survey completed

n %


Prosthetics 116 43.0%

Orthotics 154 57.0%

Respondents were asked to select the perspective (that is, professional level) as well as the discipline from which they would complete the survey. Of the Clinicians who completed the survey, 90 did so from the perspective of a CP, and 122 completed from the perspective of a CO. Of the Technicians who completed the survey, 26 did so from the perspective of an RTP, and 32 did so from the perspective of an RTO. In total, 212 respondents were Clinicians (CP, CO, and CPO) and 58 were Technicians (RTP, RTO, and RTPO) (see Table 4).

Table 4 Perspective from which survey completed

n %

Total from Clinician perspective 212 75.5%

Certified Prosthetist 90 33.3%

Certified Orthotist 122 45.2%

Total from Technician perspective 58 21.5%

Registered Prosthetics Technician 26 9.6%

Registered Orthotics Technician 32 11.9%

Total 270 100.0%

These four perspectives were used to document the results of the practice analysis survey. Accordingly, respondents selecting a perspective were considered a cohort. Survey respondents held a range of credentials (see Table 5). Of the 270 respondents, there were 212 holding a Clinician credential and 68 held a Technician credential. Ten respondents held both a Clinician and a Technician credential. All those holding both Clinician and Technician credentials chose to respond to the survey from the Clinician perspective; there responses were included in the cohort of their respective discipline.

Table 5 Credentials held

n %

C.P.(c) 78 28.9%

C.O.(c) 108 40.0%

C.P.O.(c) 26 9.6%

R.T.P.(c) 18 6.7%

R.T.O.(c) 36 13.3%

R.T.P.O.(c) 14 5.2%


Total 280 n/a 1

1 Totals do not sum to 100%; multiple responses permitted. Ten respondents held both Clinician and Technician credentials.

Of the Clinicians, the largest percentage was credentialed prior to 1990. As shown in Table 6, a larger proportion of CPs than COs was credentialed before 1990, including those CPOs holding both credentials. In absolute numbers as well as proportionally, more CPs than COs were credentialed in the past three years.

Table 6

Year Clinicians credentialed

C.P.(c) C.O.(c)

C.P.O. (year cred. as C.P.(c)

C.P.O. (year cred. as C.O.(c)

Year credentialed n % N % N % n %

Before 1990 23 29.9% 25 23.6% 9 36.0% 7 28.0%

1990 to 1995 10 13.0% 21 19.8% 1 4.0% 2 8.0%

1996 to 2000 10 13.0% 17 16.0% 3 12.0% 4 16.0%

2001 to 2005 11 14.3% 18 17.0% 3 12.0% 5 20.0%

2006 to 2010 9 11.7% 16 15.1% 6 24.0% 3 12.0%

2011 to present 14 18.2% 9 8.5% 3 12.0% 4 16.0%

Total 77 100.0% 106 100.0% 25 100.0% 25 100.0%

Table 7 shows the distribution of year credentialed for the Technicians. The small sample size for each group makes comparison among RTPs, RTOs, and RTPSs difficult.

Table 7 Year Technicians credentialed

R.T.P.(c) R.T.O.(c) R.T.P.O. (year cred.

as R.T.P.(c) R.T.P.O. (year cred.

as R.T.O.(c)

Year credentialed n % n % n % n %

Before 1990 3 16.7% 6 17.1% 3 16.7% 6 17.1%

1990 to 1995 4 22.2% 3 8.6% 4 22.2% 3 8.6%

1996 to 2000 2 11.1% 6 17.1% 2 11.1% 6 17.1%

2001 to 2005 1 5.6% 10 28.6% 1 5.6% 10 28.6%

2006 to 2010 6 33.3% 5 14.3% 6 33.3% 5 14.3%

2011 to present 2 11.1% 5 14.3% 2 11.1% 5 14.3%

Total 18 100.0% 35 100.0% 18 100.0% 35 100.0%


Figure 1 provides information about the disciplines in which the respondents have experience, regardless of the perspective from which they answered the survey. Those who answered as CPs had almost 20 years of experience in prosthetics while those who answered as COs had a bit more experience, with 21 years. Both RTPs and RTOs had slightly more than 16 years of experience in their respective disciplines.

Figure 1 Years of experience in each discipline by members of the four cohorts

As documented in Table 8, the majority of respondents (90%) were employed full-time.

Table 8

Current employment status

n %

Full-time 239 90.2%

Part-time 21 7.9%

Not currently working in the field 5 1.9%

Total 265 100.0%

As documented in Table 9, respondents were most likely to work in private practice (57%) and somewhat less likely to work in a hospital or rehabilitation centre (38%). Few respondents were in any other setting.

Table 9 Primary work setting

C.P.(c) C.O.(c) R.T.P.(c) R.T.O.(c)

19.6

6.2

16.2

4.15.4

21.0

10.0

16.5

Years of experience in prosthetic practice

Years of experience in orthotic practice


n %

Private practice 150 57.0%

Hospital or rehabilitation centre 99 37.8%

Manufacturer, central fabrication, or

distributor

5 1.9%

Academic or educational institution 6 2.3%

Other 3 1.1%

Respondents were asked to indicate the number of employees at their primary work setting. As seen in Table 10, respondents were most likely to work in setting with between 1 and 3 other employees (30%), although 20% each worked in settings with between 4 to 6 employees or 7 to 10 employees.

Table 10

Number of prosthetics/orthotics employees located at primary work setting (Including Residents, Interns; excluding clerical employees)

n %

1 - 3 80 30.2%

4 - 6 54 20.4%

7 - 10 54 20.4%

11 - 15 28 10.6%

16 or more 49 18.5%

As documented in Table 11, respondents were overwhelmingly likely to have obtained their prosthetic and/or orthotic education in a college diploma program (84%). Whereas about 8% had obtained their education through an apprenticeship, about 7% indicate some other mechanism for obtaining their education. A review of the write-in responses indicated that respondents had attended a variety of training programs connected with colleges and various universities. (See Appendix 6 for a verbatim list of the write-in responses to all demographic questions.)

Table 11 Where prosthetic and/or orthotic education obtained

n %

College diploma program 222 83.8%

University degree program 5 1.9%

Apprenticeship 20 7.5%

Other 18 6.8%


Total 265 100.0%


Table 12 documents the highest educational degree/certificate/diploma earned in any discipline by the respondents. As can be seen, about 43% had earned a 4-year university degree whereas 35% had earned a college diploma. Roughly equivalent numbers of respondents had earned either a high school or equivalent degree or a master’s degree.

Table 12 Highest educational degree/certificate/diploma earned

n %

High school or equivalent 17 6.5%

College diploma (2-year) 93 35.4%

University (4-year) degree 112 42.6%

Master's degree 18 6.8%

Doctorate 0 0.0%

Other 23 8.7%

Table 13 provides additional detail as to the nature of the 4-year university degree earned by the respondents. More than one half of those earning such a degree (56%) had earned it in kinesiology, whereas slightly more than one fourth (26%) had earned it in the sciences.

Table 13 Type of 4-year university degree earned

n %

Sciences 35 26.3%

Kinesiology 75 56.4%

Arts 5 3.8%

Engineering 11 8.3%

Other 7 5.3%

Of those respondents earning a master’s degree, about one third had earned it in prosthetics or orthotics (22%) or rehabilitation (13%)

Table 14 Type of Master's degree earned

n %

P&O 5 21.7%

McMaster University Master’s of Science in Rehabilitation

3 13.0%


Other 15 65.2%

Respondents held a variety of healthcare professional licenses and/or certifications. As seen in Table 15, a very few respondents held either a Pedorthist/CPed©, ABC certification, or a BOC certification. No more than one respondent held any other specific professional license and/or certification. (See Appendix 6 for a list of the other write-in responses.)

Table 15

Additional healthcare professional licenses and/or certifications held

n %

Pedorthist/CPed© 4 1.5%

ABC certification 3 1.1%

BOC certification 2 0.7%

Other 13 4.8%

Respondents were located in each of the provinces in Canada, but not within the territories. As was expected, more than one third came from Ontario, and slightly less than one third came from Alberta and British Columbia together (see Table 16)

Table 16 Province or territory

n %

Ontario 97 36.5%

Alberta 49 18.4%

British Columbia 36 13.5%

Manitoba 24 9.0%

Nova Scotia 14 5.3%

Quebec 14 5.3%

Saskatchewan 13 4.9%

New Brunswick 9 3.4%

Newfoundland and Labrador 4 1.5%

Prince Edward Island 3 1.1%

Northwest Territories 0 0.0%

Nunavut 0 0.0%

Yukon 0 0.0%

Outside Canada (all USA) 3 1.1%


As documented in Table 17 and Table 18, nearly three fourths of the respondents were male, and about 60% were age 45 or older. The remaining 40% of the sample was age 25 to 44.

Table 17 Gender

n %

Female 72 28.0%

Male 185 72.0%

Table 18 Age

n %

Under 25 0 0.0%

25 – 34 37 14.2%

35 – 44 69 26.4%

45 – 54 95 36.4%

55 – 64 53 20.3%

65 or over 7 2.7%


Domain Ratings

The results presented in this section provide quantitative ratings regarding the domains, including the Percentage of Time estimates and Criticality ratings for each domain by the total sample of respondents and for respondents in each of four cohorts—CP, CO, RTP, and RTO. As seen in Table 19, regarding the five specifically-identified domains, the total sample of respondents spend the most time in Domain 3: Treatment Implementation and Evaluation (36%), and relatively equivalent amounts of time in Domain 4: Ongoing Treatment and Re-evaluation (19%) and Domain 1: Patient Evaluation (17%). They spend less time in either of the two remaining domains, including Domain 2: Treatment Planning and Domain 5: Professional Practice. The allocation of only 4% of time to Other, suggests that the identification of these five domains represented a comprehension description of the major practice responsibilities of members of the sample. A thoughtful review of the activities described by the respondents in regards to Other, indicated that no there were no material omissions in the domain structure. The verbatim comments of the respondents appear in Appendix 6.

Table 19 Percentage of Time in each domain, total sample

Domains % of time

01 Patient Evaluation: Assess and evaluate patient by collecting patient-specific characteristics that will be used to determine appropriate prosthetic/orthotic treatment.

17%

02 Treatment Planning: Analyze, evaluate and integrate information gathered in Patient Evaluation. Using this information, develop prosthetic/orthotic treatment which may include the provision of a new prosthesis/orthosis, restoration/improvement of function in current prosthesis/orthosis, or referral to other health care professionals.

14%

03 Treatment Implementation and Evaluation: Using relevant clinical and technical skills, provide the patient with the prosthetic/orthotic treatment that may include the provision of a new prosthesis/orthosis, restoration/improvement of function in current prosthesis/orthosis, or referral to other health care professionals. Provide education to patient.

36%

04 Ongoing Treatment and Re-evaluation: Review prosthetic/orthotic treatment with patient subsequent to original care. Provide additional treatment to adjust, optimize or restore function of the prosthesis/orthosis, and re-educate patient as necessary. Refer to or consult with other health care professionals, as necessary.

19%

05 Professional Practice: Practice in accordance with professional standards and legal requirements; participate in personal and professional development through continuing education, training, research, and organizational affiliations; and provide training and education to others.

10%

Other Domains 1 4%

1 Primarily administrative, management; write-in responses are found in Appendix 6. Table 20 presents the Percentage of Time ratings by each of the four perspectives. In comparing CPs to COs, it is obvious that the rank order of the domains is similar, but not


identical. Both CPs and COs spend the most time in Domain 3: Treatment Implementation and Evaluation, (33% and 29%, respectively). However, CPs rank Domain 4, Ongoing Treatment and Re-evaluation as second, spending 28% of time in that domain, while COs rank Domain 1: Patient Evaluation as second, spending 24% of time in that domain. Both groups rank Domain 2: Treatment Planning and Domain 5: Professional Practice similarly. The pattern of ratings for the RTPs and the RTOs is more consistent. Both RTPs and RTOs spend more than one half of their time in Domain 3: Treatment Implementation and Evaluation, and little time in Domain 1: Patient Evaluation (5% and 2% for RTPs and RTOs, respectively (see Table 20). RTPs spend between 7% and 16% in each of the remaining three domains, with the most time spent in Domain 5: Professional Practice. RTOs spend relatively similar amounts of time in each of the remaining three domains; that is between 9% and 12% in each domain.

Table 20 Percentage of time in domains by cohort and total

CP (n=90)

CO (n=(122)

RTP (n=26)

RTO (n=32)

Total (n=270)

% % % % %

1. Patient Evaluation 14% 24% 5% 2% 17%

2. Treatment Planning 14% 17% 7% 10% 14%

3. Treatment Implementation and Evaluation 33% 29% 54% 59% 36%

4. Ongoing Treatment and Re-evaluation 28% 17% 14% 9% 19%

5. Professional Practice 9% 10% 16% 12% 10%

Other domains 3% 3% 5% 8% 4%

The mean Criticality ratings for the total sample indicate that each of the five specifically-identified domains is moderately-to-highly critical (see Table 21). The ratings of the CPs and COs are generally very consistent, varying by no more than 0.2 rating scale points, and the ratings of the RTPs and RTOs are virtually identical, varying by no more than 0.1 rating scale points. The RTPs and RTOs rate the domain they spend the most time in, Domain 3: Treatment Intervention and evaluation as somewhat more critical than the remaining domains.

Table 21 Domain Criticality by cohort and total

Values used to calculate mean: 1=Not critical, 2=Minimally critical, 3=Moderately critical, 4=Highly critical

CP CO RTP RTO Total

M M M M M

1. Patient Evaluation 3.8 4.0 3.3 3.3 3.8

2. Treatment Planning 3.7 3.9 3.5 3.5 3.8


3. Treatment Implementation and Evaluation 3.9 3.9 3.8 3.9 3.9

4. Ongoing Treatment and Re-evaluation 3.8 3.6 3.5 3.5 3.6

5. Professional Practice 3.4 3.5 3.4 3.5 3.4

Other Domains 2.7 2.5 3.3 3.0 2.8


Results Related to Tasks

Results discussed in this section include the quantitative ratings provided by the respondents to the tasks included in the description of practice. Respondents rated each of the 73 tasks on two rating scales—Frequency and Criticality. Subsequently, respondents were provided an opportunity to identify any tasks that may have been inadvertently omitted from the survey. Table 22 documents the mean Frequency ratings of the tasks. A review of the results for the mean Frequency ratings indicates that the majority of tasks were performed frequently-to-routinely by both CPs and COs. In general, the COs indicated that they performed tasks in each of the clinical domains (that is, domains 1 to 4), more frequently than did the CPs. In comparison, the Frequency ratings of the RTPs and RTOs were more varied. Tasks in Domain 1: Patient Evaluation and Domain 2: Treatment Planning were generally performed never-to-rarely by the Technicians, whereas tasks in the remaining three domains were performed never-to-routinely, depending on the specific task. The ratings of the RTPs and the RTOs were generally similar, with either cohort performing some tasks more frequently than the other cohort.

Table 22 Task Frequency ratings, mean values by cohort

Values used to calculate mean:1=Never, 2=Rarely (quarterly or less), 3 =Occasionally (monthly), 4=Frequently (weekly), 5=Routinely (daily)

Task Frequency CP CO RTP RTO

M M M M

Domain 1: Patient Evaluation

0101. Obtain consent to treatment 4.4 4.5 1.9 1.7

0102. Conduct patient interview by taking a comprehensive patient history, including but not limited to medical history (for example, fall history and risk, previous/current treatment and surgeries, allergies to materials, current medication), diagnosis and path

4.3 4.8 1.6 1.4

0103. Review professional reports such as patient charts, documented reports, test results, treatments, referrals and ongoing treatment plans of other health care professionals

3.8 4.2 2.2 2.2

0104. Conduct physical examination by performing a diagnosis-specific functional clinical and cognitive ability examination that includes manual muscle testing, evaluation of sensory function, range of motion, joint stability, and skin integrity

4.1 4.8 1.2 1.1

0105. Perform static evaluation (for example, postural assessment, weight/non-weight bearing) with and without prosthesis/orthosis

4.4 4.8 1.4 1.3



M M M M

0106. Perform dynamic evaluation (for example, functional analysis, gait analysis) with and without prosthesis/orthosis

4.8 4.9 1.7 1.4

0107. Review patient goals and expectations 4.3 4.8 2.3 1.5

0108. Identify and administer outcome measurement tools (for example, pain scale, timed walk test, amputee mobility predictor [AMP]) to determine baseline

2.4 2.9 1.3 1.1

0109. Obtain information regarding patient from other health care professionals

3.6 3.8 2.0 1.4

0110. Obtain information regarding funding sources 4.4 4.6 1.5 1.3

0111. Document patient evaluation 4.6 4.8 1.9 1.7

Domain 2: Treatment Planning

0201. Refer patient, if appropriate, to other health care professionals for intervention beyond prosthetic/orthotic scope of practice

3.6 3.8 1.3 1.4

0202. Research treatment options, including obtaining evidence from literature to achieve treatment goals

3.2 3.3 2.1 1.7

0203. Research manufacturer’s specifications; and materials, components, design, and fabrication techniques

4.1 3.4 4.1 3.5

0204. Review treatment options with patient, including potential trial of components/prostheses/orthoses

4.3 4.4 1.7 1.7

0205. Collaborate with other health care professionals regarding treatment options

3.9 4.1 2.5 1.8

0206. Develop a treatment plan, including prosthetic/orthotic treatment, patient education, continuing and/or coordinated care, based on patient evaluation, needs, and treatment goals

4.0 4.4 1.6 1.3

0207. Communicate treatment plan to patient and ensure patient understands his or her responsibilities related to the treatment plan

4.3 4.7 1.9 1.4

0208. Ensure that patient and payors are informed of their financial responsibilities

4.4 4.8 1.4 1.5

0209. Contact funding agencies for pre-approval, and provide letters/documentation of medical necessity when required

4.3 4.3 1.2 1.1

0210. Document treatment plan 4.4 4.7 2.6 1.8

Domain 3: Treatment Implementation and Evaluation



M M M M

0301. Provide patient with preparatory care for prosthetic/orthotic treatment (for example, compression garment, serial casting)

4.1 2.9 1.2 1.1

0302. Select appropriate materials/techniques in order to perform shape capture (cast, impression, measure, trace, digitize, scan) of residual limb/body segment and/or required measurements

4.7 4.9 2.0 1.9

0303. Prepare patient for procedure required to perform shape capture and/or required measurements

4.6 4.9 1.3 1.4

0304. Perform shape capture and/or required measurements of residual limb/body segment

4.6 5.0 2.0 1.5

0305. Perform shape capture and/or required measurements from existing prosthesis/orthosis

3.5 3.0 3.2 2.7

0306. Create positive anatomical model from shape capture (for example, pour/fill cast, carve positive)

4.3 4.0 4.0 3.8

0307. Modify (rectify) anatomical model or image 4.8 4.8 2.4 2.1

0308. Fabricate/assemble a prosthesis/orthosis to prepare for initial or diagnostic evaluation (fitting)

4.0 3.5 4.7 4.9

0309. Ensure that materials, design, and components are used as specified in the treatment plan

4.7 4.9 4.7 4.8

0310. Assess prosthesis/orthosis for structural integrity prior to patient diagnostic evaluation (fitting)

4.7 4.7 4.7 4.8

0311. Ensure that manufacturers' guidelines and all instructions for use have been followed prior to patient diagnostic evaluation (fitting) (for example, torque values, patient weight limits)

4.5 4.1 4.8 4.6

0312. Assess/align prosthesis/orthosis for accuracy in sagittal, transverse, and coronal planes (bench alignment)

4.7 4.6 4.3 4.8

0313. Perform static and dynamic alignment of prosthesis/orthosis with patient

4.8 4.9 2.1 2.5

0314. Assess fit, function, control, and support of prosthesis/orthosis (for example, suspension, volume, pressure distribution, force control system)

4.9 4.9 1.8 2.2

0315. After assuring that prosthesis/orthosis is structurally sound, arrange for a trial period with prosthesis/orthosis if required

4.6 4.0 2.2 1.8

0316. Complete fabrication process after achieving optimal fit and function of prosthesis/orthosis (for example, convert test socket to definitive prosthesis/orthosis, cosmetic finishing, anatomical shaping)

3.9 3.7 4.6 4.5



M M M M

0317. Re-assess prosthesis/orthosis for structural safety and integrity prior to patient use

4.5 4.5 4.6 3.9

0318. Administer outcome measurement tools and compare to baseline

2.4 3.1 2.2 1.8

0319. Educate patient about the use and maintenance of the prosthesis/orthosis (for example, wearing schedules, donning/doffing, other instructions)

4.7 4.9 1.9 1.9

0320. Refer patient to appropriate health care professionals for necessary ancillary care

3.7 3.9 1.2 1.4

0321. Educate and work with other health care professionals with regard to patient treatment

4.0 4.0 1.9 1.6

0322. Document treatment implementation 4.6 4.9 2.4 2.2

0323. Finalize financial aspects of treatment implementation

4.2 4.3 1.2 1.2

Domain 4: Ongoing Treatment and Re-evaluation

0401. Obtain feedback from patient to evaluate outcome (for example, wear schedule/tolerance, comfort, perceived benefits and/or detriments, ability to don and doff, proper usage and function, overall satisfaction)

4.6 4.5 1.9 1.6

0402. Re-assess patient and note any changes from previous evaluation(s):

4.4 4.3 1.4 1.4

0403. Assess prosthesis/orthosis with regard to strategic contact and physical presentation (for example, multiple force systems, total contact, trimlines, static/dynamic alignment) to determine need for changes relative to treatment goals

4.5 4.5 2.0 1.9

0404. Evaluate prosthesis/orthosis for structural changes (for example, component or material failure, joint mal-alignment, change in alignment)

4.3 4.3 3.6 3.6

0405. Re-administer outcome measurement tools to assess patient’s achievement of treatment goals

2.4 2.9 1.3 1.4

0406. Formulate and discuss with the patient and payors the ongoing treatment plan to modify or replace prosthesis/orthosis

3.7 3.7 1.3 1.3

0407. Modify prosthesis/orthosis, component parts, and/or interface elements

4.4 4.2 3.6 3.9

0408. Repair, restore, and/or refurbish prosthesis/orthosis, component parts, and/or interface elements

4.2 4.0 4.2 4.6

0409. Replace prosthesis/orthosis, component parts, and/or interface elements

4.1 3.9 4.1 4.5



M M M M

0410. Assess prosthesis/orthosis for structural safety and integrity following modification, repair, or replacement

4.4 4.5 4.2 4.5

0411. Evaluate modified prosthesis/orthosis, including static and dynamic evaluation

4.6 4.5 2.7 3.2

0412. Reassess patient knowledge on use of prosthesis/orthosis

4.0 4.1 1.7 1.7

0413. Communicate ongoing treatment and outcomes with all key stakeholders

3.6 3.6 1.4 1.5

0414. Ensure that patient and payors are informed of their financial responsibilities and options regarding modification, repair or replacement of prosthesis/orthosis

3.9 4.2 1.4 1.4

0415. Document treatment 4.7 4.9 3.0 2.1

0416. Document outcomes 3.8 4.2 2.1 2.0

Domain 5: Professional Practice

0501. Abide by OPC Character and Fitness Rules and Canons of Ethical Conduct

4.9 5.0 4.5 4.7

0502. Establish procedures for patient care in compliance with provincial, territorial, and national legal requirements (for example, protection of personal health information, patient and workplace safety)

4.3 4.5 3.6 2.5

0503. Develop, implement and monitor policies and procedures with respect to human resources, physical environment, business and financial practices, and organizational management

3.3 3.6 2.5 2.1

0504. Participate in personal professional development (for example, participate in continuing education, attend/present at conferences)

3.6 3.7 3.4 3.5

0505. Contribute to the profession (for example, volunteer in professional associations, committees, and regulatory agencies)

3.3 3.3 2.5 2.4

0506. Provide education and training for prosthetic and orthotic practitioners, other health care professionals, technicians, assistants, office staff, and funding agencies

3.6 3.5 3.2 3.0

0507. Participate in education of Residents and Interns 3.2 3.2 2.9 3.5

0508. Participate in education of students (both prosthetic and orthotic, as well as others)

3.2 3.1 3.1 3.3

0509. Participate in OPC Accredited prosthetic and/or orthotic technical or clinical education programs

2.9 2.6 2.9 3.0



M M M M

0510. Conduct or participate in research, product development, clinical trials, and outcome studies

2.5 2.3 2.2 2.0

0511. Collaborate with health care professionals and other stakeholders

3.7 3.9 2.4 1.9

0512. Participate in the development, implementation, and monitoring of public policy regarding prosthetics/orthotics

2.4 2.3 1.5 1.3

0513. Serve as an expert resource (for example, lifetime cost of treatment, future cost of care, expert witness)

2.4 2.0 1.3 1.1

0514. Participate in/with consumer organizations and non-governmental organizations in order to promote competency and enhancement of prosthetic/orthotic profession

2.1 1.9 1.5 1.2

In contrast to the Frequency ratings, the Criticality ratings of the CPs and the COs were uniformly high, indicating that these tasks are all moderately-to-highly critical to optimizing outcomes for patients (see Table 23). Moreover, the ratings of the two cohorts were relatively similar; with only two exceptions, the ratings did not vary by more than 0.3 rating scale points. The pattern of ratings for the RTPs and RTOs was somewhat different. Whereas the members of each cohort generally indicated that the tasks were moderately-to-highly critical in regard to optimizing outcomes, the RTPs rated the majority of tasks as more critical than the RTOs.

Table 23 Task Criticality ratings, mean values by cohort

Values used to calculate mean:1=Not critical, 2=Minimally critical, 3=Moderately critical, 4=Highly critical

Task Criticality CP CO RTP RTO

M M M M

Domain 1: Patient Evaluation

0101. Obtain consent to treatment 3.6 3.6 3.4 2.6

0102. Conduct patient interview by taking a comprehensive patient history, including but not limited to medical history (for example, fall history and risk, previous/current treatment and surgeries, allergies to materials, current medication), diagnosis and pathology, signs and symptoms, previous/current use of a prosthesis/orthosis, work history, activities, demographic characteristics, social history and supports (for example, family/friends, workplace), cognitive capacity

3.8 3.9 3.4 3.0



M M M M

0103. Review professional reports such as patient charts, documented reports, test results, treatments, referrals and ongoing treatment plans of other health care professionals

3.3 3.5 3.3 3.0

0104. Conduct physical examination by performing a diagnosis-specific functional clinical and cognitive ability examination that includes manual muscle testing, evaluation of sensory function, range of motion, joint stability, and skin integrity

3.7 3.9 3.2 2.7

0105. Perform static evaluation (for example, postural assessment, weight/non-weight bearing) with and without prosthesis/orthosis

3.6 3.9 3.3 2.9

0106. Perform dynamic evaluation (for example, functional analysis, gait analysis) with and without prosthesis/orthosis

3.8 3.9 3.3 2.9

0107. Review patient goals and expectations 3.7 3.8 3.4 2.9

0108. Identify and administer outcome measurement tools (for example, pain scale, timed walk test, amputee mobility predictor [AMP]) to determine baseline

2.8 3.0 3.2 2.6

0109. Obtain information regarding patient from other health care professionals

3.1 3.2 3.3 2.7

0110. Obtain information regarding funding sources 3.6 3.5 3.1 2.4

0111. Document patient evaluation 3.7 3.9 3.4 2.8

Domain 2: Treatment Planning

0201. Refer patient, if appropriate, to other health care professionals for intervention beyond prosthetic/orthotic scope of practice

3.5 3.6 3.2 2.5

0202. Research treatment options, including obtaining evidence from literature to achieve treatment goals

3.1 3.3 3.1 2.7

0203. Research manufacturer’s specifications; and materials, components, design, and fabrication techniques

3.5 3.3 3.7 3.2

0204. Review treatment options with patient, including potential trial of components/prostheses/orthoses

3.6 3.6 3.1 2.8

0205. Collaborate with other health care professionals regarding treatment options

3.3 3.6 3.6 2.7



M M M M

0206. Develop a treatment plan, including prosthetic/orthotic treatment, patient education, continuing and/or coordinated care, based on patient evaluation, needs, and treatment goals

3.5 3.7 3.2 2.7

0207. Communicate treatment plan to patient and ensure patient understands his or her responsibilities related to the treatment plan

3.8 3.8 3.3 3.0

0208. Ensure that patient and payors are informed of their financial responsibilities

3.6 3.7 3.2 3.1

0209. Contact funding agencies for pre-approval, and provide letters/documentation of medical necessity when required

3.7 3.6 3.2 2.9

0210. Document treatment plan 3.7 3.8 3.4 3.0

Domain 3: Treatment Implementation and Evaluation

practice analysis study of clinicians and registered ... · the multiple-choice examinations for...

Documents