A descriptive and exploratory cross-sectional design survey was devised. The Institutional Review Boards of two collaborating universities approved exempt status for this research project to investigate DPT students from one single multi-campus university during Fall 2020 clinical experiences (IRB #: L20-211).

A web survey instrument link was sent to 725 second- and third-year DPT students’ email addresses from a large multi-campus university under investigation during Fall 2020 clinical experiences. Respondents first read the survey description and had the opportunity to provide informed consent and access the survey. Only DPT students on integrated clinical experiences (second year of didactic curriculum) or terminal clinical experiences (third year of didactic curriculum) were included. DPT students who were not on clinical experiences were excluded from participation.

We developed an electronic survey questionnaire using concepts from published studies on physical therapy self-efficacy and embedded the five-item PTSE scale to assess DPT students’ clinical reasoning self-efficacy (Appendix 1).^15,17 Three experts knowledgeable in survey methodology and publication records reviewed the survey. A graduating cohort of DPT students (n = 30) from the primary investigator’s institution pilot tested the survey for question clarity, feasibility, and reliability.

Surveys were administered after the midterm during Fall 2020 clinical experiences and completed anonymously via SurveyMonkey software (www.surveymonkey.com). Respondents received no incentives for participation. A university research assistant linked the anonymous survey data with final Fall 2020 CPI clinical reasoning (1-item) and summative (18-item) scores from the APTA PT CPI-web for all respondents.^20,21,23 Personal identifying information was removed from all data prior to being handled by the primary investigator for data analysis. The Strengthening the Reporting of Observational Studies in Epidemiology checklist (STROBE) was completed (Appendix 2).²⁴

Each participant could respond to a maximum of 28 questions. The survey began with demographic questions and inquired about comfort using telehealth technology during clinical experiences. Next, DPT students rated how confident they treated patients during initial and subsequent visits during traditional treatment without telehealth. Then, the five-item PTSE scale using a 5-point Likert scale (‘strongly disagree’ to ‘strongly agree’) asked participants to rate their clinical reasoning self-efficacy during their clinical experiences.¹⁵ If the participants responded that they had examined or treated patients using telehealth, they proceeded to the final section. If they indicated they did not examine or treat patients using telehealth, their survey ended.

The final section in the survey questioned the number of telehealth visits participated in with less than 50% direct clinical instructor supervision. Next, participants rated their confidence treating patients during initial and subsequent visits using telehealth. Finally, the five-item PTSE scale was repeated asking participants to rate their clinical reasoning self-efficacy using telehealth during their clinical experiences.

Data were analyzed using Excel version 2016 and SPSS version 26.0. Descriptive statistics summarized the distribution, central tendency, and dispersion of responses. Wilcoxon signed-rank tests evaluated the difference in DPT students’ repeat measure PTSE scores during clinical experiences with and without telehealth. Mann–Whitney U tests evaluated the difference in DPT students’ PTSE scores between integrated and terminal clinical experiences. Spearman rho correlation assessed the strength of the correlation between DPT students’ PTSE and CPI scores (clinical reasoning and summative). Significance was set at α = .05. Scores from the five-item PTSE scale questions provided a total clinical reasoning self-efficacy variable ranging from 0 if they reported ‘strongly disagree’ to 20 if they reported ‘strongly agree’ on the clinical reasoning questions. These items had a Cronbach’s alpha coefficient of .87 with, and .80 without telehealth, demonstrating good internal consistency.²⁵

A total of 211 DPT students (67% female) completed the survey (response rate = 29.1%). The largest proportion of respondents reported their primary area of clinical practice as orthopedics (82.4%) and primary clinical practice setting as outpatient clinic (85.8%).

The PTSE score ranges from 0 to 20. Respondents’ mean PTSE score for clinical experiences without telehealth was 15.1, and the mean for PTSE with telehealth 13.1 (Fig. 1). The mean student PTSE score for integrated clinical experiences was 14.1, compared to 15.5 for terminal clinical experiences. The CPI score ranges from 1 to 21, with 17 indicating entry-level and 21 beyond entry-level performance. The mean student clinical reasoning score was 16.4, and the summative mean CPI score 16.7.²³ Students participating in telehealth had a mean clinical reasoning score of 16.6 and a summative mean CPI score of 16.8 (Fig. 2). Table 1 displays respondents’ demographic characteristics.

Of the 211 DPT student respondents, 40.3% reported telehealth was available at their clinical site. Overall, 16.6% of DPT students reported they directly examined or treated patients using telehealth. At sites offering telehealth, 41.7% used it to examine or treat patients. Of those, 20% participated in 10 or more telehealth visits with less than 50% of direct clinical instructor supervision. Though, most respondents (42.9%) reported participating in one or fewer telehealth visits with less than 50% of direct clinical instructor supervision.

Overall, 39.3% of respondents either strongly agreed (7.1%) or agreed (32.2%) to be comfortable using telehealth technology during clinical experiences, 32.2% neither agreed nor disagreed, while only 22.3% disagreed, or 6.2% strongly disagreed (Fig. 3). DPT students’ confidence level in using telehealth to treat was 74% on initial and 97% on subsequent patient visits.

Wilcoxon signed-rank test revealed lower PTSE scores for DPT students who compared participation in telehealth with traditional treatment z = −4.475, n = 35, P < .001, effect size r = .53 (Table 2). The mean rank on the PTSE was less for treatment with telehealth (Mean = 13.1; Md = 14.0; SD = 3.20) than traditional treatment without telehealth (Mean = 15.1; Md = 15.0; SD = 2.34) (Table 2).

Mann–Whitney U tests revealed no significant difference in the CPI clinical reasoning score for treatment with telehealth (Md = 17.0; n = 35) and traditional treatment without telehealth (Md = 17; n = 211), U = 2,965, z = −.357, P = .721, effect size r = .07. Mann-Whitney U tests also revealed no significant difference in the CPI summative score for treatment with telehealth (Md = 17.2; n = 35) and traditional treatment without telehealth (Md = 17.0; n = 211), U = 2,878, z = −.614, P = .539, effect size r = .04 (Table 2).

Mann–Whitney U tests revealed higher DPT students’ PTSE scores during traditional treatment with terminal (Md = 15.0; IQR: 14,17; n = 142) compared with integrated clinical experiences (Md = 14.0; IQR: 13,15; n = 69), U = 2,956, z = −4.752, P < .001, effect size r = .33 (Table 2).

Spearman rho analysis found a weak positive correlation between the PTSE without telehealth, compared with the CPI clinical reasoning score, r(209) = .23, P < .001, and CPI summative score, r(209) = .22, P < .002 (Table 2).

There are several limitations of this study. The study was cross-sectional and did not intend to infer any causality from the educational process. Due to the study period during Fall 2020 of the COVID-19 pandemic, our survey had a disproportionately high number of orthopedic primary care area and outpatient clinical practice settings’ responses, which may impact the study’s overall generalizability. Finally, the external validity of the results may be in question because it remains unknown what telehealth availability will remain after the COVID-19 pandemic.²⁹ We recommend replicating the study with a larger sample size to confirm the validity of our results.

Our findings support PTSE and CPI use to assess different clinical reasoning constructs with further validation warranted. Students should demonstrate clinical reasoning competencies before entering clinical experiences.³⁰ Use of the PTSE tool may identify students with lower clinical reasoning self-efficacy and provide remediation opportunities before and during clinical experiences.

With future growth of telehealth in physical therapy expected, we recommend that academic institutions thread telehealth-specific educational strategies to promote comfort with technology and the evolution of clinical reasoning with telehealth clinical experiences throughout the curriculum. This study underscores the importance of academic and clinical educators’ appreciation of DPT student’s perceptions that contribute to clinical reasoning self-efficacy during clinical experiences with and without telehealth. Although we found students with lower clinical reasoning self-efficacy using telehealth, clinical performance, and student confidence remained strong, reflecting preparation across years of the curriculum.