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Clinical Competency in Clinical Learning

Original Editor - Stacy Schiurring based on the course by Angela Patterson

Top Contributors - Stacy Schiurring and Jess Bell  

Clinical Competency in Rehabilitation Education and Professional Development

Clinical education for rehabilitation professionals is a dynamic process in which students advance through various stages of learning at different rates, depending on individual factors, such as prior knowledge, experience, and personal growth. Throughout their education, students are progressively exposed to more complex clinical situations, with the ultimate expectation that they will be prepared for entry-level practice by graduation. This individualised progression is crucial in shaping how students develop and apply clinical reasoning, as they move from basic tasks and knowledge acquisition to making informed, independent decisions in real-world settings. As students progress, they refine their ability to assess, analyse, and respond to patient needs, ensuring they are well-equipped to enter the professional workforce with the competence and confidence required for effective practice.

"Understanding where a student falls on a learning continuum helps clinical instructors select appropriate teaching strategies to foster clinical reasoning development." - Dr. Angela Patterson OTD, OTR/L

There are various tools available to clinical instructors and mentors to assess and guide students and newly graduated rehabilitation professionals to be more independent and capable in patient care. This article explores two assessment tools: the American Physical Therapy Association Clinical Performance Instrument and Benner's Stages of Clinical Competence. It is the responsibility of each clinical instructor to utilise the framework or assessment tool best suited for their student's and institution's needs.

American Physical Therapy Association Clinical Performance Instrument

The American Physical Therapy Association (APTA) Clinical Performance Instrument (CPI) is a tool used in the United States to assess and document the clinical performance of physiotherapy students during their internships or clinical education experiences. It is a comprehensive evaluation system that allows clinical instructors (CIs) to track a student’s progress in developing the knowledge, skills, and professional behaviours necessary to become a competent physiotherapist. The CPI is structured around specific performance criteria and is used to provide constructive feedback and guide the student’s learning and development. The CPI is designed to track student progression over time, ensuring that they develop the skills needed to perform at an entry level by the end of their clinical education training. This tool helps to identify whether students are progressing at the expected pace and whether they meet the criteria needed for successful completion of their clinical education.[1][2]

There are five performance dimensions in the APTA CPI to help evaluate a physical therapy student's clinical performance and development in a structured and comprehensive way. Each dimension focuses on key aspects of professional practice, which are essential for preparing students to transition to entry-level practice. The five dimensions include supervision, quality, complexity, consistency and efficiency.

Supervision: this dimension evaluates how much oversight a student requires to perform tasks effectively. At entry level, a student should demonstrate the ability to work with minimal supervision, indicating readiness for independent practice.

Quality: this dimension assesses the depth of the student's clinical knowledge and the proficiency of their skills. The goal is for the student to perform at a high level, demonstrating accuracy, problem-solving, and clinical reasoning consistent with entry-level expectations.

Complexity: this dimension measures how many variables the student must consider during a clinical task. As students progress, they are expected to handle more complex cases and make decisions that involve numerous factors such as patient history, diagnosis, and treatment plans.

Consistency: this dimension looks at how reliably the student demonstrates expected behaviours. The goal is for the student to consistently apply their skills and knowledge across different situations and settings, showing professional development and competency.

Efficiency: this dimension assesses how well the student manages time and resources while delivering care. A student is expected to complete tasks in a timely manner while maintaining quality, which becomes more refined as they grow toward entry-level practice.


For each performance dimension, clinical instructors rate a student’s performance on a scale from 1 to 5:

  • 1 (Needs Improvement): the student requires significant development in this area.
  • 2 (Beginning): the student is beginning to demonstrate competency, but improvement is needed.
  • 3 (Intermediate): the student demonstrates adequate competency in this area, but there is room for improvement.
  • 4 (Advanced Intermediate): the student performs at a high level in this area and is nearly fully competent.
  • 5 (Entry-Level): the student meets the expected level of competence for an entry-level physical therapist, demonstrating proficiency in this area.

Written Feedback: in addition to numerical ratings, CIs provide detailed written feedback for each performance criterion. This feedback offers specific examples of what the student did well, areas for improvement, and strategies for further development. This qualitative feedback helps students understand their strengths and weaknesses and provides actionable guidance for their growth.

Goal Setting and Action Plans: the CPI encourages goal-setting and action plans for further improvement. Based on the feedback, students are encouraged to set specific learning goals and discuss strategies with their clinical instructors to continue developing their clinical skills.

Self-Assessment: in addition to evaluations from the clinical instructor, students are often asked to complete a self-assessment, where they reflect on their performance, strengths, and areas for growth. This process promotes self-reflection and helps students take responsibility for their learning.

The APTA CPI is a valuable tool for assessing and guiding the development of physical therapy students during their clinical education. By evaluating key components like professional behaviour, clinical reasoning, patient management, and interpersonal skills, it ensures that students are prepared for the demands of their future roles as healthcare professionals. The combination of ratings, feedback, and goal-setting provides students with clear, constructive guidance to improve their clinical performance and ultimately succeed in their careers.

Benner's Stages of Clinical Competence

Benner's Stages of Clinical Competence is a model that describes the development of clinical expertise in healthcare professionals. The model outlines five stages through which healthcare professionals progress as they gain experience, knowledge, and skills in their practice. These stages are based on the idea that clinical competence evolves over time and through stages of increased experience, from relying on rules and guidelines (novice) to making intuitive, expert decisions (expert). As practitioners progress, they move from learning basic tasks and rules to developing holistic, intuitive understanding and flexible decision-making skills. Their approach to clinical practice becomes more fluid and context-aware, allowing for better prioritisation, anticipation of patient needs, and adaptation to complex or changing circumstances.[3][4]

The five stages of clinical competence in this model are novice, advanced beginner, competent, proficient and expert.[3][4]

Novice: novices are beginners who have little to no experience in a particular area of practice. They rely heavily on rules and guidelines to make decisions and approach tasks. At this stage, the focus is on understanding basic facts, rules, and principles. Novices often lack a deep understanding of the context or the ability to prioritise tasks. Novices are typically very task-oriented and may struggle with clinical judgment because they lack the experience to make decisions based on situational context.

Advanced Beginner: advanced beginners have gained some clinical experience and can recognise recurring patterns in practice. However, they still require guidance and are not yet able to make complex decisions independently. Advanced beginners will start to understand and apply rules more flexibly but still need support when dealing with complex or unfamiliar situations. At this stage, individuals can perform some tasks competently but still lack the ability to prioritise or make clinical decisions based on experience.

Competent: competent practitioners have developed a deeper understanding of their role and can handle more complex situations with a greater degree of independence. They can prioritise tasks and make decisions based on the situation. Competent practitioners have developed a sense of organisational ability and can anticipate potential issues. They rely more on experience rather than strict rules. While competent healthcare professionals have a solid grasp of patient care and can manage tasks efficiently, they may still lack flexibility and may not have the intuitive, holistic approach of more advanced professionals.

Proficient: proficient practitioners have a more holistic understanding of patient care and can see the bigger picture. They can anticipate patient needs and make decisions based on a deep understanding of the situation, not just rules or past experiences. Proficient practitioners are able to understand patient problems more intuitively and can prioritise actions based on a deeper, context-aware understanding of the situation. They approach patient care with flexibility and are capable of adjusting their actions and decisions according to the changing needs of the patient. They also provide mentorship to less experienced colleagues.

Expert: experts are highly skilled and intuitive, with an extensive background of experience. They are capable of making complex decisions rapidly, with a deep understanding of the clinical situation, often without needing to consciously apply rules. Expert practitioners have an in-depth understanding of both theory and practice. Their knowledge is vast, and they rely on intuition developed through years of experience. Experts are masters of their practice, and they can handle complex, ambiguous, or novel situations with ease. They make decisions fluidly and efficiently, often mentoring others with insight and advanced knowledge.

Benner's model highlights the importance of hands-on experience in developing clinical expertise and suggests that professionals grow through a process of reflection, increased knowledge, and skill-building over time. It offers a useful framework for understanding how healthcare professionals evolve and how their learning and development can be supported at different stages.

Additional Resources

Clinical Assessment Tools

Below are links to explore and learn more about the clinical tools discussed in this article.

Other clinical education/competency tools:

Additional Optional Reading

The following journal articles explore the validity of clinical assessment tools or explore the effectiveness of rehabilitation clinical education.

References

  1. ↑ Task Force for the Development of Student Clinical Performance Instruments, American Physical Therapy Association's Task Force for the Development of Student Clinical Performance Instruments, Roach K, Gandy J, Deusinger SS, Clark S, Gramet P, Gresham B, Hagler P, Lewthwaite R, May BJ. The development and testing of APTA clinical performance instruments. Physical Therapy. 2002 Apr 1;82(4):329-53.
  2. ↑ Crawford BF, Sinclair AL. Physical Therapist and Physical Therapist Assistant Clinical Performance Instruments: Validation Study. [Internet] 2023. (cited 12 February 2025). Available from: https://www.apta.org/contentassets/b38cea3dbf7049a8b44d4cda452fbfc0/apta-clinical-performance-instrument---technical-brief.pdf.
  3. ↑ 3.0 3.1 Ozdemir NG. The development of nurses’ individualized care perceptions and practices: Benner’s novice to expert model perspective. International Journal of Caring Sciences. 2019 May 1;12(2):1279-85.
  4. ↑ 4.0 4.1 Boyer S, Chickering M. Perspective Chapter: Clinical Competency Framework–Standardized Nurse Competence Development. 2024.
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