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Alternative research assignment, Part II

Instructions

Alternative Research Assignment: Writing Assignment on Peer Reviewed Article.

Guidelines for paper. This assignment is submitted in two parts. Both parts are submitted directly to your instructor. Each part is equivalent to two hours of research credit (25 points for each part, in order to achieve a total of 50 points towards your final grade).

Part 1/Appendix C: You will upload two
 peer-reviewed empirical journal articles from an APA or ACA journal (see list) that has been published within the past five years. These two peer-reviewed empirical articles must be topically related to one another. In addition, you will write a review of each article, as if you were reviewing for the journal editor. To do this, please complete the worksheet, Appendix C. You just present a brief summary of the purpose of the study, the research question(s) posed or hypotheses, the sample collected, the measures, and the major findings from the study. Afterwards, you will then provide a numbered list of limitations of the article. You should be able to find all of this information in the text of the article.

Part 2:
 
You will write a critical review that synthesizes your reactions to the two articles. Your paper must be APA style (e.g., title page, no abstract, double-spaced, reference page). The paper should be 800-1000 words. Please use the following organization. The first section should include a general summary of the studies conducted (between 200-400 words).

The second section should involve your critical analysis of the articles (less than 600-800 words). Identify and defend the article that makes the strongest argument and will have the more significant impact on the topic/population it is written about. Integrate information from your course into the critique of the article. You might discuss the practical significance of the research.

The third section will involve your suggestions for future research in this area, based on what you have learned in your course. This should not be a summary of what the authors suggested as recommendations for future research, but rather, your own personal suggestions for future research based on the reported findings.

Please use headings in alignment with APA style (i.e., Summary, Analysis, Suggestions for Future Research). The paper will be graded based on the quality of content and alignment with APA style. Each article may earn up to four credits toward your research requirement. You must turn in both your summary/analysis of the article and a PDF of the article (or link to the article if a PDF is not available) when you submit your work for this alternative. Be sure to write your paper in your own words! Using actual phrases from the article without quotes is plagiarism. Paraphrasing sentences (e.g., substituting words here and there) is also plagiarism. Using the authors’ ideas without providing credit is also plagiarism. You also may not plagiarize your own work from another course. 
Any plagiarism will result in zero credit for the assignment.

Due Date

Nov 20, 2020 5:00 PM

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Appendix C: Information Sheet for Part 1 of Research Writing Assignment/Alternative 2

Name: ___Myranda Chaney__________________

Instructor: Professor Kim-Chang______________

Please complete the chart below. If you cannot answer every question, then you might need to find a different article. An empirical article should have an experiment conducted (including research questions/hypotheses, a study sample, and measures used). You can access journals through your GSU account at https://library.gsu.edu/ The GSU librarians are also happy to help you find articles that fit the requirements.

Article one

Article two

Article Title

(1 point each)

Traumatology

Psychological Trauma: Theory, Research, Practice, and Policy

Author(s)

(1 point each)

Traumatology Forum Research Group.

Interpsych Traumatology Forum (Organization)

Academy of Traumatology.

Talya Greene, Michael A. P. Bloomfield, and Jo Billings

Year Published

(1 point each)

Quarterly, beginning in March

Online First Publication, June 15, 2020

Journal Name

(1 point each)

Traumatology

Psychological Trauma and Moral Injury in Religious Leaders During COVID-19

APA Citation

(1 point each)

Traumatology Forum Research Group, et al. Traumatology. Traumatology Forum Research Group, 1995.

Greene, T., Bloomfield, M. A. P., & Billings, J. (2020, June 15). Psychological Trauma and Moral Injury in Religious Leaders During COVID-19. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000641

Research Questions/Hypotheses (if more than one, use bullet points)

(1 point each)

Refereed/Peer-reviewed

Being part of a faith-based community can be a protective factor for mental health following disasters and crises.

Description of Sample/Participants

(1 point each)

· Psychic trauma — Treatment – Periodicals

· Post-traumatic stress disorder — Treatment – Periodicals

· Stress (Psychology) — Treatment – Periodicals

Psychotherapy — Periodicals

· Frontline workers—those who are key to the treatment of individuals with COVID-19

· Another group of frontline workers at high risk of psychological distress, but who have largely been overlooked are religious leaders of faith-based communities.

Measures (e.g. tests, surveys, interview forms, etc.; if more than one, use bullet points)

(1 point each)

· Title from contents screen (viewed Mar. 11, 2005).

Vols. for 2002- published: Abingdon, U.K. : Extensa.

· Two issues per v.

Chronological designation dropped with v. 1, issue 2 and resumed with v. 6, issue 1 (Apr. 2000).

· It is important for religious leaders to attend to self-care.

· This means taking regular breaks and trying to schedule time away from professional tasks.

· Try to eat, drink, and sleep properly.

Limitations of Experiment (use bullet points)

(1 point each)

Mode of access: World Wide Web.

One area that has not yet been addressed in the academic literature but may be particularly relevant in the COVID-19 pandemic, is that of moral injury in religious leaders.

How do these two articles relate to one another?

(7 points total)

Studies of challenges experienced by day-to-day trauma and mental health issues.

Total: 25 points

7

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/342189058

Psychological Trauma and Moral Injury in Religious Leaders During COVID-19

Article  in  Psychological Trauma Theory Research Practice and Policy · June 2020

DOI: 10.1037/tra0000641

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University College London

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Psychological Trauma: Theory,
Research, Practice, and Policy
Psychological Trauma and Moral Injury in Religious
Leaders During COVID-19
Talya Greene, Michael A. P. Bloomfield, and Jo Billings
Online First Publication, June 15, 2020. http://dx.doi.org/10.1037/tra0000641

CITATION
Greene, T., Bloomfield, M. A. P., & Billings, J. (2020, June 15). Psychological Trauma and Moral Injury
in Religious Leaders During COVID-19. Psychological Trauma: Theory, Research, Practice, and
Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000641

Psychological Trauma and Moral Injury in Religious Leaders During
COVID-19

Talya Greene
University of Haifa and University College London

Michael A. P. Bloomfield
University College London and Camden and Islington NHS

Foundation Trust, London, United Kingdom

Jo Billings
University College London

Religious leaders are at risk of psychological trauma and moral injury during the COVID-19 pandemic.
This article highlights potentially traumatic or morally injurious experiences for religious leaders and
provides evidence-based recommendations for mitigating their impact.

Keywords: PTSD, coronavirus, stress, burnout, mental health

Since the outbreak of the COVID-19 pandemic, considerable
media and academic attention has been directed toward the mental
health impact on various high-risk groups, particularly “frontline”
workers—those who are key to the treatment of individuals with
COVID-19 (Chen et al., 2020; Lai et al., 2020). Another group of
frontline workers at high risk of psychological distress, but who
have largely been overlooked are religious leaders of faith-based
communities. Although they are not involved in the medical care
of people, they play a key role in supporting individuals, families,
and communities in coping with the pandemic and especially so
for those who are ill or bereaved by COVID-19. Due to the
implementation of quarantine and other social distancing mea-
sures, there has been a huge shift in the daily work practices of
religious leaders, some of which increase the risk of negative
mental health outcomes (Lewis, Turton, & Francis, 2007), and in
particular for moral injury.

Being part of a faith-based community can be a protective factor
for mental health following disasters and crises (Milstein, 2019).
This is partly due to the sense of belonging and the emotional and

material support derived from being part of a community. It is
clear, however, that religious leaders are key, because community
members may turn to them for comfort and advice in getting
through difficult times. Although this role can be deeply reward-
ing, it also comes with risks.

Previous studies have highlighted the risk of burnout in religious
leaders, noting that they tend to not prioritize self-care and often
experience work overload, emotional isolation, and the feeling
they are permanently on call (Jackson-Jordan, 2013, Lewis et al.,
2007). Furthermore, religious leaders can suffer distress as result
of their exposure to other people’s traumatic experiences, often
referred to as secondary or vicarious trauma (Hendron, Irving, &
Taylor, 2014). These negative mental health outcomes are likely to
occur more frequently during the COVID-19 pandemic and may
be compounded by the fact that religious leaders and their com-
munity have a shared experience of the trauma stressor. In some
respects this may be helpful, but it also poses risks because
religious leaders have to actively cope with their own experiences
while also helping others (Baum, 2014).

One area that has not yet been addressed in the academic
literature, but may be particularly relevant in the COVID-19 pan-
demic, is that of moral injury in religious leaders. Moral injury has
been defined as the psychological distress caused by actions, or
their omission, that violate an individual’s moral code (Litz et al.,
2009). Although moral injury is not in itself a mental disorder, it
has been associated with a range of mental health problems,
including posttraumatic stress disorder (PTSD), depression, anxi-
ety, and suicidality (Griffin et al., 2019; Williamson, Stevelink, &
Greenberg, 2018). Moral injury has generally been studied in the
context of military experiences. Although there are studies of
moral injury in other occupational groups, such as teachers, jour-
nalists, and health care workers (Griffin et al., 2019; Williamson,
Murphy, & Greenberg, 2020; Williamson et al., 2018), there has
not yet been any focus on religious leaders.

Potentially morally injurious events (PMIEs) refer to acts that an
individual has done or failed to do (transgressions of self; Nash et

Editor’s Note. This commentary received rapid review due to the time-
sensitive nature of the content. It was reviewed by the journal editor.—
KKT

X Talya Greene, Department of Community Mental Health, University of
Haifa, and Division of Psychiatry, University College London; X Michael
A. P. Bloomfield, Division of Psychiatry, University College London, and the
Traumatic Stress Clinic, St Pancras Hospital, Camden and Islington NHS
Foundation Trust, London, United Kingdom; X Jo Billings, Division of
Psychiatry, University College London.

Correspondence concerning this article should be addressed to Talya
Greene, Department of Community Mental Health, University of Haifa,
199 Aba Houshy Avenue, Haifa 3498838, Israel. E-mail: [email protected]
univ.haifa.ac.il

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Psychological Trauma:
Theory, Research, Practice, and Policy

© 2020 American Psychological Association 2020, Vol. 2, No. 999, 000
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000641

1

al., 2013) or has observed other people do or fail to do (transgres-
sions of others). Additionally, people may feel that they have been
betrayed by those in positions of authority or even a sense of
theological challenge (Fontana & Rosenheck, 2004; Koenig,
Youssef, & Pearce, 2019). In the following text we highlight some
PMIEs for religious leaders that may arise during the COVID-19
pandemic.

Due to restrictions implemented in many countries, religious
leaders are not able to conduct in-person meetings or make hos-
pital or home visits and are prohibited from gathering their com-
munities together. In addition, religious leaders are not able to
conduct weddings, christenings, and many other joyful lifecycle
events, which may feel like a loss and give a sense of “imbalance”
in the work they are doing. Although the public health reasons for
doing so are clear, religious leaders may find themselves strug-
gling with not being able to provide support and comfort to their
congregation in the ways that they are accustomed to and feel
distressed by this act of omission. In other words, failing to do
what they feel morally obliged to do, which may feel like a
transgression of self.

Another area that is likely to be particularly problematic con-
cerns death and mourning. The normal rituals that religious leaders
perform are being interfered with. Religious leaders are prohibited
from visiting those dying from COVID-19 and providing direct
in-person comfort and end-of-life religious rituals. In many coun-
tries, mourners at funerals are limited to immediate family (re-
gardless of the cause of death), and sometimes not even that; if any
of the mourners have symptoms of COVID-19, they will not be
allowed to attend. Open-coffin funerals are not allowed for those
who died from COVID-19, nor is ritual cleaning of the body of the
deceased, as undertaken by some religions. Religious leaders may
find themselves conflicted because they have no choice but to
follow these instructions, which are potentially devastating to both
the mourners and indeed the religious leaders themselves and may
cause a sense of betrayal; leaders may even believe that they
themselves have committed a religious transgression.

Recommendations

Given the risks relating to moral injury, and more broadly to
burnout, and secondary trauma, what does the literature suggest
regarding protective factors? Below is a list of recommendations
based on existing knowledge regarding psychological stressors for
religious leaders, as well as drawing from evidence based on other
occupational groups (Billings et al., 2020; Greenberg, Docherty,
Gnanapragasam, & Wessely, 2020; Ludick & Figley, 2017; Wil-
liamson et al., 2020, 2018).

Self-Care

It is important for religious leaders to attend to self-care. This
means taking regular breaks and trying to schedule time away from
professional tasks. Try to eat, drink, and sleep properly.

Spirituality

Self-care for religious leaders includes not only physical and
mental but also spiritual aspects. This is an unprecedented situation
that may be theologically challenging for some. Setting aside time
to focus on spirituality can help with processing this.

Acknowledge Moral Conflicts

It is important to acknowledge the moral conflicts that will
likely emerge. Discussing them with colleagues and being pre-
pared for some of the possible responses may facilitate coping and
acceptance of distress.

Purpose

Religious leaders should try to maintain a strong sense of
purpose. Although it is difficult to do work in conditions that are
far from ideal, it plays a critical role in comforting people in
difficult times.

Supervision and Peer Support

Try to implement supervision, mentoring, and peer-to-peer sup-
port. Religious leaders can often find themselves isolated and
depleted by their role. If such structures already exist, it is not
sufficient just to have them but vital to actively make use of them.

Social Support

Staying in touch with family and friends is a key buffer of
distress and can be a great source of strength.

Professional Support

Religious leaders should be aware of the professional support
that is available. This can include general psychological support.
For some denominational groups, there are bespoke counseling
services for their leaders. Religious leaders should know how to
access this support and be prepared to do so if needed.

Conclusion

It is important that religious leaders keep in mind that they are
doing important work but are also living through difficult times
along with everyone else. Furthermore, they will experience some
stressors unique to their role. Attending to self-care, sharing dif-
ficult experiences with colleagues, accepting the likelihood of
moral conflict, and getting professional help when needed can all
facilitate coping with the unique challenges brought by the
COVID-19 pandemic.

References

Baum, N. (2014). Professionals’ double exposure in the shared traumatic
reality of wartime: Contributions to professional growth and stress.
British Journal of Social Work, 44, 2113–2134. http://dx.doi.org/10
.1093/bjsw/bct085

Billings, J., Greene, T., Kember, T., Grey, N., El Leithy, S., Lee, D., . . .
Bloomfield, M. (2020). Supporting Hospital Staff During COVID-19:
Early Interventions, Occupational Medicine. Occupational Medicine.
Advance online publication. http://dx.doi.org/10.1093/occmed/kqaa098

Chen, Q., Liang, M., Li, Y., Guo, J., Fei, D., Wang, L., . . . Zhang, Z.
(2020). Mental health care for medical staff in China during the
COVID-19 outbreak. Lancet Psychiatry, 7(4), e15– e16. http://dx.doi
.org/10.1016/S2215-0366(20)30078-X

Fontana, A., & Rosenheck, R. (2004). Trauma, change in strength of
religious faith, and mental health service use among veterans treated for

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2 GREENE, BLOOMFIELD, AND BILLINGS

PTSD. Journal of Nervous and Mental Disease, 192, 579 –584. http://
dx.doi.org/10.1097/01.nmd.0000138224.17375.55

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wessely, S. (2020).
Managing mental health challenges faced by healthcare workers during
covid-19 pandemic. British Medical Journal, 368, m1211. http://dx.doi
.org/10.1136/bmj.m1211

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz,
M., . . . Maguen, S. (2019). Moral injury: An integrative review. Journal
of Traumatic Stress, 32, 350 –362. http://dx.doi.org/10.1002/jts.22362

Hendron, J. A., Irving, P., & Taylor, B. J. (2014). Clergy stress through
working with trauma: A qualitative study of secondary impact. Journal
of Pastoral Care & Counseling, 68, 1–14. http://dx.doi.org/10.1177/
154230501406800404

Jackson-Jordan, E. A. (2013). Clergy burnout and resilience: A review of
the literature. Journal of Pastoral Care & Counseling, 67, 1–5. http://
dx.doi.org/10.1177/154230501306700103

Koenig, H. G., Youssef, N. A., & Pearce, M. (2019). Assessment of moral
injury in veterans and active duty military personnel with PTSD: A
review. Frontiers in Psychiatry, 10, 443. http://dx.doi.org/10.3389/fpsyt
.2019.00443

Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., . . . Hu, S. (2020).
Factors associated with mental health outcomes among health care
workers exposed to coronavirus disease 2019. Journal of the American
Medical Association Network Open, 3, e203976 – e203976. http://dx.doi
.org/10.1001/jamanetworkopen.2020.3976

Lewis, C. A., Turton, D. W., & Francis, L. J. (2007). Clergy work-related
psychological health, stress, and burnout: An introduction to this special

issue of Mental Health, Religion and Culture. Mental Health, Religion
& Culture, 10, 1– 8. http://dx.doi.org/10.1080/13674670601070541

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., &
Maguen, S. (2009). Moral injury and moral repair in war veterans: A
preliminary model and intervention strategy. Clinical Psychology Re-
view, 29, 695–706. http://dx.doi.org/10.1016/j.cpr.2009.07.003

Ludick, M., & Figley, C. R. (2017). Toward a mechanism for secondary
trauma induction and reduction: Reimagining a theory of secondary
traumatic stress. Traumatology, 23, 112–123. http://dx.doi.org/10.1037/
trm0000096

Milstein, G. (2019). Disasters, psychological traumas, and religions: Re-
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Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., &
Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events
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MILMED-D-13-00017

Williamson, V., Murphy, D., & Greenberg, N. (2020). COVID-19 and
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Williamson, V., Stevelink, S. A. M., & Greenberg, N. (2018). Occupational
moral injury and mental health: Systematic review and meta-analysis.
British Journal of Psychiatry, 212, 339 –346. http://dx.doi.org/10.1192/
bjp.2018.55

Received April 16, 2020
Revision received May 14, 2020

Accepted May 18, 2020 �

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3TRAUMA, MORAL INJURY, RELIGIOUS LEADERS AND COVID-19

View publication statsView publication stats

  • Psychological Trauma and Moral Injury in Religious Leaders During COVID-19
    • Recommendations
      • Self-Care
      • Spirituality
      • Acknowledge Moral Conflicts
      • Purpose
      • Supervision and Peer Support
      • Social Support
      • Professional Support
    • Conclusion
    • References

RESEARCH Open Access

Rubric for the evaluation of competencies
in traumatology in the Degree of
Physiotherapy: Delphi approach
Esther Díaz-Mohedo1 , Rita Romero-Galisteo1* , Carmen Suárez-Serrano2 , Esther Medrano-Sánchez2 and
Rocío Martín-Valero1

Abstract

Background: In health professions, the curriculum that must be met in order to obtain the academic certificate is
based on the development of the so-called competencies. The broad content of the Practicum of the Degree of
Physiotherapy has led to the creation of multiple types of evaluation, which makes it difficult for faculty members
to reach a consensus on competencies. The aim of this study was to develop and validate content of a rubric for
the evaluation of acquired competencies related to physiotherapeutic performance and intervention in
traumatology within the Practicum of the Degree of Physiotherapy.

Methods: Following the Delphi methodology, a group of experts from all over the Spanish territory participated in
the study. Through on-line questionnaires, several sequential rounds were established, alternated by controlled
feedback until obtaining a consensus in the opinion of the experts, which allowed elaborating the final rubric.

Results: Initially, 16 experts were contacted, of whom 10 worked and completed the final content of the rubric. For
the 3 rounds that were conducted, the initial 142 interventions of the initial proposition, which correspond to
specific competencies, were reduced to the final 29 items that compose the specific evaluation rubric presented in
this study.

Conclusions: This rubric is an evaluation instrument with valid content for the assessment of specific competencies
of Traumatology in the Practicum of the Degree of Physiotherapy.

Keywords: Evaluation, Higher education, Physiotherapy, Rubric, Delphi

Background
In health professions, the curriculum that must be met
in order to obtain the academic certificate is based on
the development of the so-called competencies. These
are defined not only as the understanding of the content,
problem solving, clinical abilities and attitudes; they also
include the know-how (or procedural knowledge) in the
professional context, which requires the student to

implement the acquired knowledge in a creative, flexible
and responsible manner [1]. In Europe, higher education
is usually standardised though the Bologna Process [2,
3]. This challenge of homogenising the teaching-learning
procedures involves the use of a common language,
which has resulted in the proposition of contents and
tools from different disciplines to respond to such a goal
[4, 5].
At the same time, the evaluation of the abilities ac-

quired by the undergraduate students of the Degree of
Physiotherapy during their university education has gen-
erated multiple publications in the last years, which have

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected]
1Faculty of Health Sciences, Department of Physiotherapy, University of
Málaga, C/ Arquitecto Francisco Peñalosa, 3, 29071 Málaga, Spain
Full list of author information is available at the end of the article

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474
https://doi.org/10.1186/s12909-021-02904-4

provided different tools designed to assess the compe-
tencies acquired in different areas, such as patient edu-
cation [5], clinical performance [6] and interprofessional
collaboration [7].
Despite the existence of other, widely studied evalu-

ation tools [8, 9], the convenience of having consensual
guidelines to score and evaluate the learning of the stu-
dents has popularised the use of rubrics. These are use-
ful to examiners, instructors and students [10]. In
Physiotherapy, the evaluation of the clinical practices
within the Practicum subject is varied, since their con-
tent in the different fields is heterogeneous, which gen-
erates a lack of consensus in the scientific literature
about the contents that must be evaluated in the differ-
ent areas [11]. In addition to this, a large number of the
evaluation tools that are currently used do not comply
with the adequate psychometric properties [12, 13]. In
the evaluation of the Practicum of the Degree of Physio-
therapy (an eminently practical subject, developed in the
different health centres), such lack of consensus is evi-
dent in the specific assessment of the competencies in
Traumatology [14].
Consensus methods, such as Delphi, allow synthesising

information about a specific problem. Sequential rounds,
alternated by controlled feedback, are used with the aim
of reaching a consensus in the opinion of a group of
identified experts [15]. Therefore, this is a useful ap-
proach in situations where individual judgements must
be considered to address an incomplete state of
knowledge.
The aim of this study was to develop and validate the

content of a rubric for the evaluation of acquired com-
petencies related to physiotherapeutic performance in
Traumatology within the Practicum of the Degree of
Physiotherapy.

Methods
The Delphi methodology was followed, which is useful
and widely employed to identify and clarify roles, to
reach consensus and to synthesise information, both in
medical field and education, allowing the participation
of an identified group of experts within the Spanish ter-
ritory [5].

Participants
Using a purposive sampling approach [16], 16 potential-
participant experts were identified by members of the re-
search team and were subsequently contacted and in-
vited to participate in the Delphi questionnaire via e-
mail. For these clinical consensus studies, Jones and
Hunter recommend the participation of specialists in the
specific area [17].
In this study, an expert was defined as a physiotherap-

ist with over 5 years of experience as either a faculty

member in the Practicum subject of the Degree of
Physiotherapy, as a clinical tutor participating in the
Practicum, or as a healthcare professional specialised in
the field of Physiotherapy and specifically in Traumatol-
ogy. The expert was also required to be working within
the Spanish territory.

All participants signed informed consent documents.
The study was approved by the Ethics Committee of the
University of Málaga (CEUMA: 34-2020-H).

Procedure
This study incorporated three rounds of on-line ques-
tionnaires, described in the next section, which proved
to the sufficient to generate an adequate feedback and
establish a broad consensus on different opinions. New
rounds were planned to accommodate additional inter-
ventions or other problems that could justify this re-
search. Each round of questionnaires was open for two
weeks and a reminder e-mail was sent to all participants
who had not replied two days before the submission
deadline.

First round
The questions of the first round were formatted in the
on-line software LimeSurvey and were sent through a
link via e-mail to each participant. The first Delphi
round consisted of two sections.
In the first section, socio-demographic information of

the experts was requested, including gender, age, profes-
sional area, professional experience in years and geo-
graphic location. This information was used to obtain
feedback about the structure of the expert panel and
guarantee the heterogeneous flow of contributions with
regard to the analysis of the data.
In the second section, the experts were asked the

open-ended Delphi question, developed by the authors
of the study with the specific aim of generating enough
themes integrated in the answers of the panel members,
in line with a Delphi approach [5].
The initial question was designed to direct the experts

toward the consideration of multiple competencies and
the consideration of competencies that physiotherapists
may or may not have regarding physiotherapy applied in
the field of Traumatology: “ What practical interventions
do you think that undergraduate Physiotherapy students
should carry out during their clinical practice in order to
respond to the specific competencies related to the con-
tents of Physiotherapy in Traumatology within the Prac-
ticum subject?”.
Based on the answers obtained, a search was con-

ducted in different databases to identify possible profes-
sional interventions in this field. The terms used were
“physiotherapy”, “traumatology”, “competencies”, “as-
sessment”, “evaluation”, “skills”, “knowledge” and

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474 Page 2 of 10

“methods”. This literature review allowed completing the
identification of different categories/areas of competen-
cies that had to be addressed to improve the validity of
the content of this tool.
The editing of the obtained feedback was slightly

modified to make it clearer. The 44 interventions into
which the initial 142 interventions were summarised are
the following:

Specific

1. – Systematically elaborate and complete the
physiotherapeutic medical record.

2. – Correctly record and write down the most
relevant aspects of the evaluation of the patient:
anamnesis, inspection, observation, examination,
extraction and interpretation of data from medical
reports and complementary diagnostic tests.

3. – Know the generalities of the most common
medical-surgical interventions in the scope of trau-
matology, as well as the cicatrization time of the
different tissues.

4. – Identify as many symptoms and signs reported by
the patient, as well as the psychosocial risk factors
that may influence his/her recovery.

5. – Identify yellow and red flags or alarm signals that
could require referral to a specialist during the
patient’s evaluation/treatment process.

6. – Perform a complete evaluation of the patient’s
movement and its possible alterations, making use
of the pertinent measurement instruments
(goniometer, measuring tape, stabilizer, etc.),
recording such results adequately.

7. – Carry out a complete evaluation of the patient’s
gait and its possible alterations.

8. – Assess and record pain through validated
instruments and identify the type of pain presented
by the patient (nociceptive, visceral, neuropathic or
chronic/dysfunctional).

9. – Conduct a diagnostic palpation that allows you to
obtain information of local suffering points, tissue
normality and alterations of the palpated area,
tissue asymmetries, etc., with anatomical precision
and pressure adapted to the depth of the evaluated
Sec.

10. – Carry out a neurological assessment of the patient
through a test of superficial and deep sensitivity and
reflexes, recording such information with specific
terminology and interpreting the results adequately.

11. – Correctly select and perform orthopedic and/or
functional tests, and interpret the results
adequately.

12. – Write down the report of the patient’s
physiotherapeutic evolution and/or discharge.

13. – Be capable of clinical reasoning, formulating
coherent hypotheses and proposing differential
diagnosis strategies that allow you to correctly
identify the dysfunction presented by the patient
and establish the physiotherapeutic diagnosis
according to the internationally accepted rules.

14. – Correctly propose coherent physiotherapeutic
objectives for the short, medium and long term,
considering the pathology and the individuality of
the user and his/her expectations and preferences.

15. – Plan the treatment in coherence with the
objectives set, attending to the adequacy, validity
and efficiency criteria, considering risks and
contraindications, and efficiently managing the
treatment time.

16. – Explain to the patient the purpose of the
therapeutic interventions ensuring the adherence to
the treatment.

17. – Reevaluate results periodically and adapt the
intervention plan.

18. – Correctly execute a functional (preventive and/or
therapeutic) and neuromuscular bandaging,
knowing how to choose among the different
materials and techniques to achieve the best result
based on the objective set.

19. – Correctly execute a compressive bandaging to
treat the edema.

20. – Correctly execute the procedure to calculate the
TI curve in a certain muscular group and correctly
interpret the result to subsequently proceed with
electrostimulation.

21. – Know the effects of an electrotherapeutic
application (motor electrostimulation, TENS,
galvanic current, magnetotherapy, laser, shockwave
therapy), know how to apply it correctly, selecting
among the different parameters, establishing
dosimetries and application times, etc., to achieve
the best result based on the objective set.

22. – Know the effects of the different types of active
exercise (isometric, concentric and eccentric
isotonic, functional, motor control, etc.), adequately
choosing among them and prescribing and
controlling their correct execution to achieve the
best result according to the objective set in a
musculoskeletal dysfunction.

23. – Know the principles of proprioceptive reeducation
in its different phases, adequately selecting the
techniques depending on the evolution phase of the
patient, and perform, prescribe and control its
execution to achieve the best result according to
the objective set.

24. – Know the effects of an application of
thermotherapy (paraffin baths, microwaves, short
wave, ultrasound, tecar therapy, etc.), know how to

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474 Page 3 of 10

apply it correctly, selecting among the different
parameters, establishing dosimetries and application
times, etc., to achieve the best result according to
the objective set.

25. – Know the effects of support and loading in lower
limb injuries, and know how to carry out the
procedure of progressive loading and gait
reeducation for the patient.

– Know the effects of the following manual therapy
techniques, adequately selecting among them and
executing them correctly to achieve the best result
according to the objective set:

26. – Masotherapy,
27. – Neuromuscular techniques,
28. – Myofascial techniques,
29. – Articulatory techniques,
30. – Manipulative techniques,
31. – Neurodynamic techniques,
32. – Dry needling techniques,
33. – Mulligan techniques,
34. – Sohier techniques.
35. – Know and apply cortical reorganisation

techniques (motor imagery, mirror therapy, gradual
exposure to movement).

36. – Know the indications and contraindications of all
the above described therapeutic interventions.

37. – Know, design and implement Patient Health
Education programmes in different situations
(chronic diseases, pain, risk groups, etc.)

38. – Take into account safety measures, such as hand
washing, use of gloves and protecting injured areas
(depending on the patient’s evolution phase).

39. – Know and use relaxation techniques.

Transversal

40. – Show verbal and non-verbal communication skills,
as well as an active listening attitude.

41. – Show empathy for the patient and face conflict
situations adequately.

42. – Use an appropriate vocabulary in all contexts:
patient, family and interdisciplinary team.

43. – Be active and proactive in the workplace, and
interact correctly with the rest of the team
members.

44. – Be responsible (punctual, correctly identified and
uniformed, comply with the internal functioning
rules of the centre, the data protection law, rotation
dates and timetable/schedule, take care of the
material, etc.), reflect on the risks and consequences

of your interventions, and communicate with the
manager in the face of any event.

Second round
The open questions of the first round were subjected to
a frame analysis, as recommended by the Delphi ap-
proach [18]. The principal investigator, who was quali-
fied for the use of qualitative research methods, read all
the data several times to familiarise with the meanings
that were attributed to the practical competencies and
the corresponding practical interventions. Each potential
theme was discussed by the research team. An initial list
of 142 interventions was synthesised and reduced to 39
items by the research team, based on a tentative list
from different sources: competencies defined by the
Ministry of Education for the Degree of Physiotherapy,
statements about competencies from the White Paper
about the Physiotherapy degree in Spain [19]. In compli-
ance with Order CIN/2135/2008, the requirements for
the verification of official university titles that enable a
person to work as a physiotherapist were established and
grouped into three dimensions: clinical history in
Physiotherapy, physiotherapeutic diagnoses and clinical
reasoning in traumatology. The final 39 items were writ-
ten in the present tense, according to the design of the
intervention, and they were presented in a format that
allowed being verified by the expert panel [5]. Each
member of the panel of the first round received an e-
mail directly from the principal investigator with a link
to the second questionnaire with the 29 items that cor-
responded to the different competencies. The experts
were asked to express, independently, their degree of
conformity with the statements of each of the item pro-
posed by all of them. The answers were established in a
5-point Likert scale, from 1 (totally disagree) to 5 (totally
agree). A final space was included, in which the experts
could leave a comment that could help to identify add-
itional competencies-interventions which they believed
were not included or to point out any problems they de-
tected among the 39 items provided.
The analysis of the Delphi panels was performed using

descriptive statistics that included measures of central
tendency (median) and dispersion (interquartile range).
Consensus was defined as the 75th percentile or higher
values in the score of each item obtained by the panelists
and an interquartile range below 3.
The interventions that did not reach a consensus or

needed to be reformulated with respect to the items in
this round were the following:

– Understanding the generalities of the medical-
surgical interventions that are most commonly
attended to in the field of Traumatology, as well as
the wound healing times of the different tissues.

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474 Page 4 of 10

– Identifying most of the symptoms and signs
reported by the patient, as well as the psychosocial
risk factors that may influence his/her recovery.

– Conducting a complete evaluation of the gait of the
patient and its possible alterations.

– Conducting a diagnostic palpation that allows
obtaining information of local pain points, tissue
normality and alterations of the examined area,
tissue asymmetries, different sensations, etc., with
anatomic precision and pressure adapted to the
depth of the assessed plane.

– Knowing the effects of the following techniques of
Manual Therapy, selecting adequately among them
and executing the correctly in order to obtain the
best result based on the objective set: Myofascial
Techniques, Manipulation Techniques, Dry
Needling Techniques, Mulligan Techniques and
Sohier Techniques.

– Knowing and applying different cortical
reorganization techniques (motor imagery, mirror
therapy and graded exposure to movement).

Third round
Each member of the panel received a new e-mail with a
link to the second questionnaire with the resulting 30
items that corresponded to the different competencies.
They were asked to proceed in the same manner, i.e., ex-
pressing their degree of conformity with the statements
of the items-interventions on which they all agreed,
using the same 5-point Likert scale, again with an add-
itional open space to leave any comments and/or
suggestions.
The answers of the third round were analysed based

on the same stabilization criteria, resulting in a final ru-
bric with 29 items.

Table 1 Demographic characteristics of the expert panel

Gendern
(%)

Workplace n
(%)

Years of teaching experiencen
(%)

Years of clinical experiencen
(%)

Age (years)n
(%)

Female 3 (30 %)

Male 7 (70 %)

U. of Castilla la
Mancha

2 (20 %)

U. of Jaén 1 (10 %)

U. of Sevilla 1 (10 %)

U. of Valencia 2 (20 %)

U. of Ponferrada 1 (10 %)

U. of Granada 1 (10 %)

U. of La Coruña 1 (10 %)

U. of Málaga 1 (10 %)

0 to 10 3 (30 %)

11 to 20 4 (40 %)

21 to 30 2 (20 %)

31 to 40 1 (10 %)

0 to 10 4 (40 %)

11 to 20 4 (40 %)

21 to 30 1 (10 %)

31 to 40 0 (0 %)

41 to 50 1 (10 %)

20–30 1 (10 %)

31–40 2 (20 %)

41–50 4 (40 %)

51–60 1 (10 %)

61–70 2 (20 %)

U. University

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474 Page 5 of 10

Results
Expert panel
Of the 16 experts that were invited to participate, 10 ac-
cepted the invitation and signed an informed consent
form. These 10 responded to all three rounds (10/10,
100 %). The demographic characteristics of the expert
panel are presented in Table 1.

Summary of the Delphi process
The Delphi phase required 3 rounds to reach consensus
(Fig. 1). This method produced a list of 39 interventions
that were associated with each of the 13 competencies
(Table 2).
Of the 39 interventions provided in the second round,

30 were agreed on and presented in the third round, in
which the experts agreed upon 29 interventions that
they finally considered important to include in the rubric
of the Practicum of Physiotherapy to respond to the spe-
cific competencies related to Physiotherapy in Trauma-
tology (Fig. 1).

The final interventions and their corresponding spe-
cific competencies are shown in Table 2.

The intervention that did not reach the consensus of
the expert panel was the following:

– Correctly executing the procedure to calculate the
time-intensity curve (TIC) in a specific muscular
group and correctly interpreting the result for the
subsequent electrostimulation procedure.

Discussion
In this study, we developed and validated the content of
a rubric for the evaluation of specific competencies re-
lated to physiotherapeutic performance and intervention
in the field of traumatology for use by undergraduate
Physiotherapy students in the corresponding Practicum.
After the analysis of the initial 142 interventions, a final
evaluation rubric with 29 interventions, corresponding
to 13 specific competencies, was agreed upon by 10
experts.
The current certification state of university titles gen-

erates the need to create competency-based evaluation
tools that guarantee the quality of the evaluation pro-
cesses based on the direct observation of the different
interventions of the students with real patients in the

Fig. 1 Summary of the procedure by rounds

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474 Page 6 of 10

Table 2 Competencies and their association with the interventions

Specific competencies of the White Paper about
the Degree of Physiotherapy

Interventions of the rubric

1. Elaborate and complete the clinical physiotherapy
history.

Elaborate and complete the clinical physiotherapy history in a systematic manner

Correctly record and write the most relevant aspects of the valuation of the patient:
anamnesis, inspection, observation, exploration, extraction of data of medical reports and
diagnostic tests

2. Examine and assess the functional state of the
patient/user.

Identify alarm signs that may influence the evolution of the treatment and/or may require
referral to the specialist during the evaluation/treatment of the patient

Perform, in patients who require so, an evaluation (visual and/or instrumental) of the
movement of the patient (range, quality, strength,…) and its possible alterations, recording
such results adequately

Assess and record pain, in patients who require so, through validated instruments, and
identify the type of pain observed (nociceptive, visceral, neuropathic or chronic-dysfunctional)

When appropriate, conduct a neurological assessment of the patient through a superficial and
deep sensitivity test and a reflex test, recording such information with proper terminology
and interpreting the results adequately

3. Determine the physiotherapy diagnosis. Identify most of the symptoms and signs reported by the patient

Correctly select and conduct orthopedic and/or functional tests and adequately interpret the
results

Be able to perform clinical reasoning, proposing coherent hypotheses and strategies of
differential diagnosis

4. Design the physiotherapy intervention or
treatment plan.

Correctly prescribe and control physical exercise in its different modalities (isometric,
concentric and eccentric isotonic, functional, motor control, conscious movement, etc.),
adequately selecting among them to achieve the best result according to the objective set in
a musculoskeletal dysfunction

Prescribe, perform and/or control the Proprioceptive and Neuromuscular Re-education Tech-
niques in their different phases, adequately selecting the techniques according to the evolu-
tionary phase of the patient to achieve the best result based on the objective set

5. Execute, direct and coordinate the physiotherapy
intervention plan.

Correctly propose coherent physiotherapeutic objectives in the short, medium and long term,
considering the pathology and the individuality of the user and his/her expectations and
preferences

Plan the treatment based on the objectives set, attending to the criteria of adequacy, validity
and efficiency, considering risks and contraindications and efficiently managing the treatment
time

Correctly perform a bandaging (functional, neuromuscular, compressive), knowing the best
choice among the different materials and techniques to achieve the best result according to
the objective set

Correctly carry out an application of electrotherapy (motor electrostimulation, TENS, galvanic
current, magnetotherapy, laser, shock waves), selecting among the different parameters, and
establishing dosimetries and application times, etc., to achieve the best result according to
the objective set

Know the effects of the different techniques of Manual Therapy: massage therapy
(decontraction, bowel evacuation, cicatrization massage, Cyriax), adequately selecting among
them and correctly executing them to achieve the best result according to the objective set

Correctly carry out an application of thermotherapy (paraffin baths, MW, PSWT,
radiofrequency, etc.), selecting among the different parameters, and establishing dosages and
application times, etc., to achieve the best result according to the objective set

Carry out the procedure of progressive loading and gait reeducation in patients who require
so due to the lower limbs injuries

Correctly carry out the following techniques of Manual Therapy: neuromuscular techniques,
adequately selecting among them to achieve the best result according to the objective set

Correctly carry out the following techniques of Manual Therapy: articulatory techniques,
adequately selecting among them to achieve the best result according to the objective set

Correctly carry out the following techniques of Manual Therapy: neurodynamic techniques,
adequately selecting among them to achieve the best result according to the objective set

6. Motivate others. Explain to the patient the purpose of the therapeutic interventions to achieve their adherence
to the treatment

Díaz-Mohedo et al. BMC Medical Education (2021) 21:474 Page 7 of 10

clinical context. The evaluable criteria must consider
those tasks from the cognitive, procedural, affective and
interpersonal perspectives, including the evaluation of
the different interventions conducted. These range from
the integral approach applied in the first contact with
the patients/users of the health system to the diagnoses
and the different therapeutic and preventive interven-
tions carried out [20].
The evaluation performed during the university prac-

tical training helps students to develop abilities that will
allow them to establish an adequate relationship with
their patients [21]. Previous studies claim that rubric-
based evaluations are equivalent to and possibly more
accurate than the traditional evaluation methods (clinical
evaluation of health professionals) in the improvement
of the knowledge and abilities acquired through educa-
tion by the students of health professionals [22].
There is a …