Physiotherapy 104 (2018) 46–53

Systematic review

Clinical performance assessment tools in physiotherapy

practice education: a systematic review
A. O’Connor a,∗ , O. McGarr b , P. Cantillon c , A. McCurtin a , A. Clifford a
aDepartment of Clinical Therapies, Health Sciences Building, University of Limerick, Limerick, Ireland
b School of Education, University of Limerick, University of Limerick, Limerick, Ireland
c Discipline of General Practice, Clinical Science Institute, National University of Ireland, Galway, Ireland

Abstract
Background Clinical performance assessment tools (CPATs) used in physiotherapy practice education need to be psychometrically sound
and appropriate for use in all clinical settings in order to provide an accurate reflection of a student’s readiness for clinical practice. Current
evidence to support the use of existing assessment tools is inconsistent.
Objectives To conduct a systematic review synthesising evidence relating to the psychometric and edumetric properties of CPATS used in
physiotherapy practice education.
Data sources An electronic search of Web of Science, SCOPUS, Academic Search Complete, AMED, Biomedical Reference Collection,
British Education Index, CINAHL plus, Education Full Text, ERIC, General Science Full Text, Google Scholar, MEDLINE, UK and Ireland
Reference Centre databases was conducted identifying English language papers published in this subject area from 1985 to 2015.
Study selection 20 papers were identified representing 14 assessment tools.
Data extraction and synthesis Two reviewers evaluated selected papers using a validated framework (Swing et al., 2009).
Results Evidence of psychometric testing was inconsistent and varied in quality. Reporting of edumetric properties was unpredictable in spite
of its importance in busy clinical environments. No Class 1 recommendation was made for any of the CPATs, and no CPAT scored higher
than Level C evidence.
Conclusions Findings demonstrate poor reporting of psychometric and edumetric properties of CPATs reviewed. A more robust approach is
required when designing CPATs. Collaborative endeavour within the physiotherapy profession and interprofessionally may be key to further
developments in this area and may help strengthen the rigour of such assessment processes.
© 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Clinical performance assessment; Physical therapy; Physiotherapy; Student; Assessment tool

Introduction provided with formative and summative feedback during each

The World Confederation of Physical Therapy (WCPT)
stipulates that practice education must account for approx-
imately one third of the overall content of physiotherapy
academic programmes [1,2] emphasising its importance in
physiotherapy education. Physiotherapy students must “meet
the competencies established by the physical therapist pro-
fessional entry level education programme” [1] and must be
∗ Corresponding author. Fax: +353 61 234251.
E-mail address: Anne.OConnor@ul.ie (A. O’Connor).
practice education module [2]. This is achieved through an
assessment process, where clinical performance is assessed
based on observation by a supervising clinician, known as a
practice educator.
Clinical performance assessment has long challenged edu-
cation providers for reasons related to evidence supporting
assessment methods and factors related to the subjective
nature of observation-based assessment [3–9]. No litera-
ture review to date has synthesised the evidence related to
psychometric testing (validity and reliability) and edumetric
properties (feasibility, usefulness and educational impact) of

https://doi.org/10.1016/j.physio.2017.01.005
0031-9406/© 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
 A. O’Connor et al. / Physiotherapy 104 (2018) 46–53
CPATs used in physiotherapy practice education. Current evi-
dence suggests that psychometric evidence for many of these
is inconsistent [10–12] with little or no attention paid to their
edumetric properties.
A recent systematic review in medical education also
acknowledged poor reporting of edumetric properties in
CPATs [13]. This is despite their importance in determining
a tool’s practicality and feasibility in the workplace. Lengthy
or ambiguously worded assessment tools can frustrate busy
clinicians which in turn can impact on rigorous comple-
tion of student assessments [14]. Psychometric properties
are more commonly reported although not always compre-
hensively [12,13]. Such properties include content validity
which captures how accurately learning outcomes described
in a CPAT measure various aspects of clinical performance.
This is determined by matching selected assessment criteria
with published guidelines required for physiotherapy entry
level practice [15,16]. Criterion validity assesses the extent
to which the measure is related to the outcomes. Evidence of
construct validity demonstrates that a tool is sensitive enough
to detect changes in student performance over time which
confirms progression of student learning [16–18]. Additional
psychometric properties include inter-rater and intra-rater
reliability which when present ensure consistency of grading
across a variety of practice educators and practice educa-
tion sites. Test–retest reliability is also necessary in CPATs
to ensure consistent ranking of students on repeated assess-
ment, particularly relevant in practice education when regular
observation forms the basis for awarding final grades. There-
fore, CPATs with less than acceptable psychometric and
edumetric testing may cast doubt on their inherent ability
to identify both the excelling student and the incompetent
or unsafe student. This can result in an assessment process
that is potentially unreliable and precarious with implications
for educational programmes, client safety and professional
bodies [3,6].
Physiotherapy undergraduate students, like nursing stu-
dents, are expected to work unsupervised from the time of
graduation unlike medical students who must complete fur-
ther postgraduate study, known as an internship, in order
to practice independently. Only one qualitative evaluation
framework has been developed to evaluate and synthe-
sise evidence pertaining to the psychometric and edumetric
properties of clinical performance assessment tools used
in the clinical learning environment. This was developed
by the Accreditation Council for Graduate Medical Edu-
cation (ACGME) in the United States of America [19].
This framework defined guidelines for grading psychome-
tric and edumetric properties of assessment instruments
as well as outlining a system for assigning an overall
evidence grade for each tool. While developed for grad-
uate medical students, it was considered appropriate for
use in this study as it lends itself easily to use by other
health professions [13] especially given the similarities in
expectations of the physiotherapy graduate and the medical
intern.
47
In the absence of other reviews of this kind, the need to
evaluate and synthesise the evidence related to the edumetric
and psychometric properties of CPATs used in physiotherapy
education was deemed essential.
The specific aims of this systematic review were to:
1. Identify and synthesise available evidence pertaining to
the psychometric and edumetric properties of clinical per-
formance assessment tools used in physiotherapy practice
education using the ACGME framework.
2. Discuss the findings within the broader context of health
professional clinical performance assessment.
Methods
Search strategy
A systematic review of the literature was undertaken
using combinations of search terms (Table S1) to iden-
tify English language peer-reviewed papers published from
January 1985 to December 2015 relating to CPATs used
in physiotherapy. Prior to 1985 few clinical performance
assessment tools had been reported in physiotherapy litera-
ture [20,21]. Databases included Web of Science, Academic
Search Complete, AMED, Biomedical Reference Collec-
tion, British Education Index, CINAHL plus, Education Full
Text, ERIC, General Science Full Text, MEDLINE, UK and
Ireland Reference Centre, Google Scholar and SCOPUS.
Reference lists were examined by hand for further citations
and checked for eligibility using the same inclusion and
exclusion criteria.
Inclusion criteria
• Any peer-reviewed paper describing a CPAT used in phys-
iotherapy practice education employing observation-based
assessment methods, which included reference to psycho-
metric or edumetric testing.
• Experimental and observational studies, randomised and
non-randomised designs, and prospective or retrospective
cohort studies.
• Full text papers written in the English language.
• Publication date from January 1985 to December 2015.
Exclusion criteria
• Any peer-reviewed paper describing assessment tools
where standardised patients, simulated settings, Objective
Structured Clinical Examinations or learning portfolios
were used to assess clinical performance.
• Assessment tools exclusively from disciplines other than
physiotherapy.
• Research studies where the full-text paper was not avail-
able.
• Assessment tools involving student self-assessment only.
48 A. O’Connor et al. / Physiotherapy 104 (2018) 46–53

Table 1
Details of assessment tools.
Name of tool Associated citations Region of origin No. of items Response type
Examination of Clinical Competence Loomis 1985 [21] Canada 40 Rating scale (3 point)
(ECC)
Blue MACS Hrachovy et al. 2000 USA 50 Rating scale of achievement
(8 point)
Clinical Internship Evaluation Tool Fitzgerald et al. 2007 USA 42 Rating scale
(CIET)
PT CPI (1997 version) Roach et al. 2002 [15]; USA 24 100 mm Visual analog scale
Adams et al. 2008 [18];
Proctor et al. 2010 [20]
Royal College of Surgeons Ireland Meldrum et al. 2008 [29] Ireland 36 % grading
tool (RCSI tool)
Common Clinical Assessment Form Coote et al. 2007 Ireland 40 % grading
(CAF)
PT MACS Stickley et al. 2005; Luedtke USA 53 Rating scale and 10 cm Visual
Hoffman et al. 2012 [22] analog scale
Univ. Birmingham tool (UoB) Cross et al. 2001 United Kingdom 10 Rating scale
Clinical Competence Scale (CCS) Yoshino et al. 2013 Japan 53 items in 7 Rating scale (4 point)
domains
Clinical Performance Assessment Joseph et al. 2011 [25]; South Africa 8 Weighted scoring; max score
Form (CPAF) Joseph et al. 2012 [26] achievable 100
PT CPI (2006 version) Roach et al. 2012 [16] USA 18 Ordered categorical scale (6
points)
Assessment of Physiotherapy Dalton et al. 2011 [23]; Australia 20 Ordered categorical scale (5
Practice (APP) Dalton et al. 2012 [24]; points)
Murphy et al. 2014 [14]
Canadian Physical Therapy Mori et al. 2015 [27] Canada 16 Rating scale
Assessment of Clinical Performance
(ACP)
Clinical Competence Evaluation Muhamad et al. 2015 [12] Malaysia 35 5 point Likert scale
Instrument (CCEVI)

• Audits based on the use of an assessment tool but without
reference to psychometric testing or edumetric properties.
• The development of a tool but no evidence of testing or
validation.
• Assessment tools used solely for physiotherapy post-
graduate education where specialisation in an area of
physiotherapy practice was the subject of assessment.
Study selection & data extraction
An electronic search was completed by reviewer (AOC).
Titles and abstracts of studies retrieved were independently
screened to identify studies meeting the inclusion criteria. A
system was used to label these studies. Those labelled ‘yes’
and ‘unsure’ were checked independently by reviewer (AC)
for decision regarding inclusion. If a decision was unclear
from the abstract, the full-text article was obtained for assess-
ment. Any disagreements were resolved through discussion
between the reviewers (AOC and AC). A further reviewer
(PC) was available for disagreements but was not required.
Data extraction involved reviewer (AOC) identifying all
empirical evidence related to psychometric and edumetric
properties in line with the ACGME framework. The grading
for overall recommendation and criteria for determining the
level of evidence are outlined in Table S2.
Reviewer (AOC) independently evaluated all included
studies. Reviewer (AC) blind reviewed 25% of these papers.
Minor disagreements between the two reviewers were due to
ambiguity in the wording of standards for validity and reli-
ability. The descriptors for each standard were discussed by
the two reviewers and consensus was reached. Once agreed,
the two reviewers independently rechecked all papers and
reached final consensus. After this Reviewer (AOC) reviewed
the remaining papers holding regular meetings with Reviewer
(AC) to discuss any queries. Reviewer (PC) was not required
during the process.
Results
Search results and article overview
The initial search identified 4436 articles. PRISMA guide-
lines were followed in relation to protocol design and data
extraction (Fig. S1). 62 articles met the initial study criteria
after title and abstract review. Following full text review, 20
papers remained describing 14 CPATs. The characteristics of
these tools are summarised in Table 1.
14 of the studies were prospective cohort studies and
six were retrospective in design. Seven CPATs, the Physical
Therapy Clinical Performance Instrument (PT CPI 1997 and
 A. O’Connor et al. / Physiotherapy 104 (2018) 46–53
2002 versions) [15,16,18,20], Physical Therapy Manual for
the Assessment of Clinical Skills (PT MACS) [11,22], APP
[14,23,24], Clinical Performance Assessment Form (CPAF)
[25,26], Assessment of Clinical Performance (ACP) [27] and
Common Clinical Assessment Form (CAF) [28] had multiple
institution involvement during testing. Four CPATs had sin-
gular institution involvement [17,21,29,30]. Three CPATS,
the University of Birmingham tool (UoB) [10], the Clinical
Competency Evaluation Instrument (CCEVI) [12] and the
Clinical Competence Evaluation Scale (CCS) [31] did not
provide enough information to determine institution involve-
ment.
All CPATs identified were similar in layout. Performance
criteria (ranging from 8 to 53 items) were outlined for all
tools. All but two used visual analogue scales, categorical
rating scales or Likert scales for grading students. Two CPATs
were graded by assigning a percentage for each performance
criteria within the form [28] or per section of the form [29].
Validity evidence
Content validity was described for 12 CPATs and construct
validity outlined for seven (see Table 2). Criterion valid-
ity was demonstrated for one assessment tool (ECC). Two
CPATs, APP and UoB, scored highest for validity evidence,
both scoring Level A evidence. Both versions of the PT CPI
were awarded an overall B grade for validity evidence. The
remaining ten CPATs provided insufficient information relat-
ing to validity evidence for an overall grade to be assigned.
Reliability evidence
Evidence of Internal Consistency was available for eight
tools (Table 2). One paper described test–retest reliability
[13]. Eight tools demonstrated evidence of inter-rater relia-
bility (Table 2). The highest overall grading for evidence of
reliability was awarded to the APP and the UoB tool (Level
B) while the CAF, CPAF and CCEVI were awarded a Level
C grade. There was insufficient information to grade any of
the other tools.
Edumetric evidence
All CPATs scored a Level B grade regarding their ease of
use apart from one tool (ACP) which provided insufficient
information to judge. The time taken to complete a student
assessment using any of the reviewed CPATs was either not
reported or took longer than 20 minutes; hence no CPAT was
awarded an A grade for this edumetric property. Informa-
tion regarding resources required to implement CPATs was
inconsistent, with no tool scoring higher than a B grade (see
Table 2). Nine of the 14 CPATs were awarded a C grade for
evidence of ease of interpretation. No tool provided sufficient
information to warrant a grade for educational impact.
49
Overall ACGME grade and summary of evidence
No CPAT was awarded an overall Class 1 recommendation
or Level A evidence. The highest grading for overall recom-
mendation (Table 2) was Class 2 awarded to PT CPI (1997
version), APP, and UoB. No tool was awarded higher than
Level C evidence. The award of a B grade or above required
a CPAT to demonstrate published evidence in a minimum of
two settings of all components required by the framework
(validity, reliability, ease of use, resources required, ease of
interpretation, educational impact).
Discussion
This systematic review identified and synthesised avail-
able evidence related to psychometric and edumetric testing
of 14 CPATs used in physiotherapy practice education from
20 peer-reviewed papers. Five CPATs were developed in the
USA, two in Canada, two in Ireland, and one each in United
Kingdom, Australia, Japan, Malaysia and South Africa. With
hundreds of recognised entry level physical therapy education
programmes in existence [32], this indicates a low level of
publications meeting the inclusion criteria, thus highlighting
the paucity of research in this area. No Class 1 recommen-
dation was made, and no CPAT scored higher than Level
C evidence based on the framework criteria. These findings
suggest limitations in the robustness of these tools. Evidence
from medical education and nursing has emphasised the need
for rigorous testing of CPATs highlighting that inconsisten-
cies in these areas may affect judgments made by assessors
and have implications on graduates’ readiness for practice
and patient safety [3,6].
Psychometric evidence
Eight CPATs demonstrated internal consistency and inter-
rater reliability. No reasons were provided to explain why
these tests had not been carried out on the other CPATs,
apart from one [16] which reported that because inter-rater
reliability had been established for an earlier version of the
tool, it was not necessary to repeat it although the tool had
been significantly modified. Evidence of test–retest reliabil-
ity was provided for one CPAT [12]. Test–retest reliability is
an essential property of any CPAT to ensure robust grading
and ranking of students when regular observation of clinical
performance is the cornerstone to deciding the final grade
awarded.
Evidence of validity testing was also inconsistent; some
CPATs demonstrated significant testing (APP and UoB), oth-
ers provided little or no evidence (Blue MACS and RCSI
tool). In several papers, information regarding the devel-
opment and validity testing of the tool was only briefly
described. This, together with some ambiguity in the wording
of framework standards led to early discussion between the
two reviewers to agree on what was acceptable.
 50
Table 2
ACGME grading for the overall recommendation & level of evidence.
Name of tool Validity evidence Overall Reliability evidence Overall Edumetric properties Overall Overall
validity reliability evidence recommend.
grade grade grade class
Content Construct Internal Inter-rater Test–retest Ease of Ease of Resources Educational
validity validity consistency reliab. reliab. use interpreta- required impact
tion
1 Evaluation of Clinical Competence Yes Yes NI No Yes No NI B C B NI C Class 3
(ECC)
2 Blue MACS No No NI No No No NI B C B NI C Class 3

A. O’Connor et al. / Physiotherapy 104 (2018) 46–53

3 Physical Therapist Manual for the Yes NI NI Yes No No NI B C B NI C Class 3
Assessment of Clinical Skills (PT
MACS)
4 Physical Therapist Clinical Yes Yes B Yes Yes No NI B C B NI C Class 2
Performance Instrument (PT CPI,
1997 version)
5 Physical Therapist Clinical Yes Yes B Yes No No NI B C B NI C Class 3
Performance Instrument (PT CPI,
2006 version)
6 Royal College Surgeons Ireland NI No NI No Yes No NI B NI C NI C Class 3
(RCSI) tool
7 Common Clinical Assessment Form Yes Yes NI No Yes No C B NI B NI C Class 3
(CAF)
8 University of Birmingham tool Yes Yes A No Yes No B B C B NI C Class 2
(UoB)
9 Assessment of Physiotherapy Yes Yes A Yes Yes No B B C B NI C Class 2
Practice (APP)
10Clinical Performance Assessment Yes No NI Yes Yes No C B C B NI C Class 3
Form (CPAF)
11Clinical Competence Scale (CCS) Yes No NI Yes NI No NI B NI C NI C Class 3
12Clinical Internship Evaluation Tool Yes No NI Yes No No NI B C B NI C Class 3
(CIET)
13Canadian PT Assessment of Clinical Yes No NI No No No NI NI NI NI NI NI NI
Performance (ACP)
14Clinical Competence Evaluation Yes Yes NI Yes Yes Yes C B NI C NI C Class 3
Instrument (CCEVI)
NI: Not enough Information in paper to judge.
 A. O’Connor et al. / Physiotherapy 104 (2018) 46–53
11 CPATs used Likert scales, rating scales or visual ana-
logue scales to assess student performance despite recent
research identifying difficulties with these scales [33]. Such
scales employ ordinal data which infers that while response
categories have a ranking, the intervals between the val-
ues offered may not be assumed as equal. The problem is
exacerbated when attempts are made to convert these scores
to numerical grades as means and standard deviations are
inappropriate for such data. Modes or medians should be
employed, however this is rarely acknowledged. Experts have
described this practice as providing meaningless information,
encouraging competition, stress and anxiety among health
professional students rather than promoting continuous pro-
gression of learning in the clinical learning environment
[33,34].
A further growing body of evidence suggests that psycho-
metric tests alone are insufficient to assess the complexity
of clinical performance, and can lead to over-emphasis on
standardisation of tests, providing meaningless conversion
of behaviours such as communication and team working
skills to numbers [33–35]. It has been suggested that a mul-
tifaceted approach to clinical performance assessment may
be more robust, and may help strengthen the validity and
reliability of the assessment process [5,36]. The Mini CEX
and Global Rating Scales are examples of tools used in
medicine and nursing which have demonstrated high levels of
validity and reliability [13,37,38]. Other clinical performance
assessment adjuncts used in physiotherapy education include
professional portfolios, student self-assessment and reflective
essays. These have been criticised due to lack of psycho-
metric evidence to support their sustained use in a singular
context. However, medical education research has recently
begun re-examining the benefits of subjective data gathered
in the clinical learning environment using sensible multiple
sampling. This, employed in conjunction with psychomet-
ric tests, may provide a more holistic picture of a student’s
readiness to practice [9,33,34,37]. The physiotherapy pro-
fession could benefit from examining clinical performance
assessment methods employed by other health professions.
Consideration of existing assessment methods in physiother-
apy may be worth re-exploring as potential components of a
clinical performance assessment toolbox rather than as sole
assessment methods.
Edumetric evidence
Reporting of edumetric properties was inconsistent across
all CPATs. While improvements were often demonstrated
in student grades from midway to the end of placement, it
was impossible to attribute this to the educational impact
of the CPAT used. Evidence for ease of interpretation and
ease of use was variable, perhaps explained by the fact that
it was not a specific aim of any of the studies. A discrep-
ancy is apparent between the priority placed on edumetric
properties by Higher Education Institutions (HEIs) during
CPAT development and the importance of these properties to
51
practice educators in the workplace. HEIs rely heavily on
their clinical colleagues to facilitate and assess student learn-
ing. The practicality and feasibility of an assessment tool
used in a time-constrained environment must be considered
as paramount when developing an assessment tool. Findings
from this review are similar to a recent review in medical
education [13] which also criticised the lack of evidence for
educational impact and evaluation of educational outcomes.
These findings reiterate the need for greater emphasis on
edumetric testing in the early stages of CPAT development.
Collaboration
The APP and PT CPI (1997 version) each had three
associated research studies involving large numbers of par-
ticipants. Recent work [38] has highlighted the significance
of multiple institution involvement in psychometric testing
demonstrating how validity evidence can accrue for indi-
vidual assessment tools when multiple studies are involved
e.g. Mini Clinical Evaluation Exercise [38], Global Rating
Scale [13]. Rigorous testing is necessary and achievable in
physiotherapy if greater emphasis were placed on develop-
ing and validating existing tools rather than creating new
ones, and focussing efforts on larger studies. The surfeit
of assessment tools that have developed across physiother-
apy education has compounded this problem largely due
to the development of individual tools unique to single
institutions. Ongoing development and testing of existing
assessment instruments has been advocated [39,40] and
should be considered by the physiotherapy profession in
order to ensure more rigorous testing of assessment tools.
This is especially important in the context of this study find-
ings and the poor levels of evidence demonstrated for most
CPATs.
Nationally agreed assessment tools are relatively new in
physiotherapy education. Investigation of the feasibility and
acceptability of the APP (originating from Australia) was
explored by a physiotherapy programme in Canada [14] but
not implemented there as the ACP [14,23,24] was devel-
oped and introduced around the same time. This suggests
that assessment tools may have an inherently localised con-
text which may make internationally acceptable and agreed
assessment tools problematic. Factors complicating this may
be the variation across countries in entry requirements to
physiotherapy programmes, programme delivery and the
final qualification obtained [32]. Whether there is potential
for international collaboration in this regard is unclear but
WCPT may provide the impetus for initiating discussion in
this area.
Limitations of the study
The ACGME framework had been employed pre-
viously in medical education [13]. Those authors
also reported ambiguity in the wording of standards
within the framework. It is possible that the current
52 A. O’Connor et al. / Physiotherapy 104 (2018) 46–53
reviewers’ interpretation may have varied slightly from
the original framework, but they remained consistent
throughout the review process for this paper. The reviewers
were both physiotherapists who had been working in
the area of physiotherapy education for over 10 years;
this may have facilitated consensus during the review
process.
Conclusion
Findings from this review highlight that further discussion
regarding development of CPATs within physiotherapy prac-
tice education is necessary to ensure rigour of this assessment
process. A demand for objectivity, accuracy and consistency
of student grading by practice educators in the midst of priori-
tisation of core clinical duties on a day-to-day basis is critical
in order to achieve readiness for practice and patient safety
assurance. Further discussion should occur in the context of
evaluating other adjuncts to the clinical performance assess-
ment process. Engagement with medicine and other allied
health education providers may provide the physiotherapy
profession with new perspectives on clinical performance
assessment that may assist with reinforcing current processes.
The WCPT may be the keystone towards enabling this dis-
cussion to occur, in particular looking towards international
collaboration during CPAT development.
Key messages
• This systematic review identifies and synthesises the
evidence relating to the psychometric and edumetric
properties of clinical performance assessment tools
used in physiotherapy practice education.
• Findings highlight that psychometric and edumetric
evidence of these assessment tools is reported incon-
sistently, and these properties require more systematic
and rigorous testing procedures in the early stages of
assessment tool development.
• Collaborative research effort inclusive of physiother-
apy and other health professions may help provide
a greater bank of knowledge in clinical performance
assessment.
Conflict of interest: None.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.physio.2017.01.005.
References
[1] World Confederation for Physical Therapy. WCPT guideline for a
standard evaluation process for accreditation/recognition of physical
therapist professional entry level education programmes. London, UK:
WCPT; 2011. www.wcpt.org/guidelines/accreditation (Access date
12th February, 2017).
[2] World Confederation for Physical Therapy. WCPT guideline for
physical therapist professional entry level education. London, UK:
WCPT; 2011. www.wcpt.org/guidelines/entry-level-education (Access
date 13th February, 2017).
[3] Fahy A, Tuohy D, McNamara M, Butler M, Cassidy I, Brad-
shaw C. Evaluating clinical competence assessment. Nurs Stand
2011;25(50):42–8.
[4] Govaerts MJB, Schuwirth LWT, Van der Vleuten CPM, Muijtjens
AMM. Workplace-based assessment: effects of rater expertise. Adv
Health Sci Educ 2011;16(2):151–65.
[5] Kogan JR, Conforti L, Bernabeo E, Iobst W, Holmboe E. Opening the
black box of clinical skills assessment via observation: a conceptual
model. Med Educ 2011;45(10):1048–60.
[6] Govaerts M, van der Vleuten CP. Validity in work-based assessment:
expanding our horizons. Med Educ 2013;47(12):1164–74.
[7] Wu XV, Enskar K, Lee CCS, Wang WR. A systematic review of clini-
cal assessment for undergraduate nursing students. Nurse Educ Today
2015;35(2):347–59.
[8] Franklin N, Melville P. An exploration of the pedagogical issues facing
competency issues for nurses in the clinical environment. Collegian
2015;22(1):25–31.
[9] Whitehead C, Kuper A, Hodges B, Ellaway R. Conceptual and practical
challenges in the assessment of physician competencies. Med Teach
2015;37(3):245–51.
[10] Cross V, Hicks C, Barwell F. Exploring the gap between evidence
and judgement: using video vignettes for practice-based assess-
ment of physiotherapy undergraduates. Assess Eval High Educ
2001;26(3):189–212.
[11] Stickley LA. Content validity of a clinical education performance tool:
the Physical Therapist Manual for the assessment of clinical skills. J
Allied Health 2005;34(1):24–30.
[12] Muhamad Z, Ramli A, Amat S. Validity and reliability of the clin-
ical competency evaluation instrument for use among physiotherapy
students. Pilot study. Sultan Qaboos Univ Med J 2015;15(2):e266–74.
[13] Jelovsek JE, Kow N, Diwadkar GB. Tools for the direct observation
and assessment of psychomotor skills in medical trainees: a systematic
review. Med Educ 2013;47(7):650–73.
[14] Murphy S, Dalton M, Dawes D. Assessing physical therapy
students performance during clinical practice. Physiother Can
2014;66(2):169–76.
[15] Roach K, Gandy J, Deusinger S, Clark S, Gramet P. Task force for the
development of student clinical performance instruments: the develop-
ment and testing of APTA clinical performance instruments. Phys Ther
2002;82(4):329–53.
[16] Roach KE, Frost JS, Francis NJ, Giles S, Nordrum JT, Delitto A. Valida-
tion of the Revised Physical Therapist Clinical Performance Instrument
(PT CPI): version 2006. Phys Ther 2012;92(3):416–28.
[17] Fitzgerald LM, Delitto A, Irrgang JJ. Validation of the clinical intern-
ship evaluation tool. Phys Ther 2007;87(7):844–60.
[18] Adams CL, Glavin K, Hutchins K, Lee T, Zimmerman C. An evaluation
of the internal reliability, construct validity, and predictive validity of
the Physical Therapist Clinical Performance Instrument (PT CPI). J
Phys Ther Educ 2008;22(2):42–50.
[19] Swing S, Clyman S, Holmboe E, Williams R. Advancing resi-
dent assessment in graduate medical education. J Grad Med Educ
2009;1:278–86.
[20] Proctor PL, Dal Bello-Haas VP, McQuarrie AM, Sheppard MS,
Scudds RJ. Scoring of the Physical Therapist Clinical Performance
 A. O’Connor et al. / Physiotherapy 104 (2018) 46–53
Instrument (PT-CPI): analysis of 7 years of use. Physiother Can
2010;62(2):147–54.
[21] Loomis J. Evaluating clinical competence of physical therapy students.
Part 2: assessing the reliability, validity, and usability of a new instru-
ment. Physiother Can 1985;37(2):91–8.
[22] Luedtke-Hoffmann K, Dillon L, Utsey C. Is there a relationship between
performance during physical therapist clinical education and scores
on the National Physical Therapy Examination. J Phys Ther Educ
2012;26(2):41–9.
[23] Dalton M, Davidson M, Keating J. The Assessment of Physiother-
apy Practice (APP) is a valid measure of professional competence of
physiotherapy students: a cross-sectional study with Rasch analysis. J
Physiother 2011;57(4):239–46.
[24] Dalton M, Davidson M, Keating JL. The Assessment of Phys-
iotherapy Practice (APP) is a reliable measure of professional
competence of physiotherapy students: a reliability study. J Physiother
2012;58(1):49–56.
[25] Joseph C, Hendricks C, Frantz J. Exploring the key performance areas
and assessment criteria for the evaluation of students’ clinical perfor-
mance: a Delphi study. S Afr J Physiother 2011;67(2):9–15.
[26] Joseph C, Frantz J, Hendricks C, Smith M. Evaluation of a new clinical
performance assessment tool: a reliability study. S Afr J Physiother
2012;68(3):15–9.
[27] Mori B, Brooks D, Norman KE, Herold J, Beaton DE. Development
of the Canadian physiotherapy assessment of clinical performance:
a new tool to assess physiotherapy students’ performance in clinical
education. Physiother Can 2015;67(3):281–9.
[28] Coote S, Alpine L, Cassidy C, Loughnane M, McMahon S, Meldrum
D, et al. The development and evaluation of a common assessment
form for physiotherapy practice education in Ireland. Physiother Irel
2007;28(2):6–10.
[29] Meldrum D, Lydon A, Loughnane M, Geary F, Shanley L, Sayers
K, et al. Assessment of undergraduate physiotherapist clinical perfor-
Available online at www.sciencedirect.com
ScienceDirect
53
mance: investigation of educator inter-rater reliability. Physiotherapy
2008;94:212–9.
[30] Hrachovy J, Clopton N, Baggett K, Garber T, Cantwell J, Schreiber
J. Use of the Blue MACS: acceptance by clinical instructors and self-
reports of adherence. Phys Ther 2000;80(7):652–61.
[31] Yoshino J, Usuda S. The reliability and validity of the Clinical
Competence Evaluation Scale in physical therapy. J Phys Ther Sci
2013;25(12):1621.
[32] World Confederation for Physical Therapy. Entry level physical therapy
qualification programmes. London, UK: WCPT; 2015. Available from:
http://www.wcpt.org/node/33154. [Updated 22 December 2015; Cited
20 March 2016].
[33] Hanson J, Rosenbergand A, Lindsey Lane J. Narrative descriptions
should replace grades and numerical ratings for clinical perfor-
mance in medical education in the United States. Front Psychol
2013;4(668):1–10.
[34] Hodges B. Assessment in the post-psychometric era: learning to love
the subjective and collective. Med Teach 2013;35:564–8.
[35] Regehr G, Ginsburg S, Herold J, Hatala R, Eva K, Oulanova O. Using
standardized narratives to explore new ways to represent faculty opin-
ions of resident performance. Acad Med 2012;87(4):419–27.
[36] Hauer KE, Holmboe ES, Kogan JR. Twelve tips for implementing tools
for direct observation of medical trainees’ clinical skills during patient
encounters. Med Teach 2011;33(1):27–33.
[37] Eva K, Hodges B. Scylla or Charybdis? Can we navigate between objec-
tification and judgement in assessment? Med Educ 2012;46:914–9.
[38] Kogan JR, Holmboe ES, Hauer KE. Tools for direct observation and
assessment of clinical skills of medical trainees: a systematic review. J
Am Med Assoc 2009;302(12):1316–26.
[39] Yanhua C, Watson R. A review of clinical competence assessment in
nursing. Nurse Educ Today 2011;31(8):832–6.
[40] Lofmark A, Thorell-Ekstrand I. Nursing students’ and preceptors’
perceptions of using a revised assessment form in clinical nursing
education. Nurse Educ Pract 2014;14:275–80.