Is there an agreement among the items of the Korean physical therapist licensing examination, learning objectives of class subjects, and physical therapists’ job descriptions?

Purpose: To determine the agreement among the items of the Korean physical therapist licensing examination, learning objectives of class subjects, and physical therapists’ job descriptions. Methods: The main tasks of physical therapists were classified, and university courses related to the main tasks were also classified. Frequency analysis was used to determine the proportions of credits for the classified courses out of the total credits of major subjects, exam items related to the classified courses out of the total number of exam items, and universities that offer courses related to the Korean physical therapist licensing examination among the surveyed universities. Results: The proportions of credits for clinical decision making and physical therapy diagnosis-related courses out of the total number credits for major subjects at universities were relatively low (2.06% and 2.58%, respectively). Although the main tasks of physical therapists are related to diagnosis and evaluation, the proportion of physiotherapy intervention-related items (35%) was higher than that of examination and evaluation-related items (25%) on the Korean physical therapist licensing examination. The percentages of universities that offer physical therapy diagnosis and clinical decision making-related courses were 58.62% and 68.97%, respectively. Conclusion: Both the proportion of physiotherapy diagnosis and evaluation-related items on the Korean physical therapist licensing examination, and the number of subjects related to clinical decision making and physical therapy diagnosis in the physical therapy curriculum, should be increased to ensure that the examination items and physical therapy curriculum reflect the practical tasks of physical therapists.


Introduction
National health personnel licensing examinations assess whe ther graduates are equipped with the basic abilities required to perform healthrelated tasks as specialists. So far, the items on the Korean physical therapist licensing examination have fol lowed the learning objectives of each major course, but the is sue of whether current trends in examination items appropri ately address current clinical practices has been raised frequent ly. To address this issue and suggest solutions, the National Health Personnel Licensing Examination Board in Korea con ducted its first physical therapist job analysis in 2000 [1]. Then, given the advancements in the physical therapy field and the http://jeehp.org consequent formation of a greater number of subdivisions within the field, a second physical therapist job analysis was conducted in 2012 [2]. This is in line with job analysis studies in various healthcare sectors for similar reasons [36]. Althou gh the second physical therapist job analysis addressed the question of whether specialized and detailed task analysis can be achieved, whether the national licensing examination as sesses the qualities and abilities required of a physical therapist remains unknown.
According to the World Confederation for Physical Thera py, the qualities required of a physical therapist are measuring and evaluating patient functions, setting up therapy planning, and enhancing her/his own ability to predict therapy outcomes. Hence, the need for a new type of national physical therapist licensing examination arose, and the national physical thera pist licensing examination was revised in 2014 to address this need. The newly revised national physical therapist licensing examination includes strengthened diagnosis, examination, and evaluation items, as well as clinical decision making items; it now assesses practical physical therapist task performance realistically. However, to assess practical physical therapist task performance effectively, it is necessary to identify whether the practical tasks of physical therapists are reflected in the exami nation and physical therapy curriculum. Therefore, the aim of the present study is to identify an agreement among the items of the Korean physical therapist licensing examination, learn ing objectives of class subjects, and physical therapists' job de scriptions.

Job analysis
To determine the tasks perceived as important by physical therapists and tasks that are frequently conducted simultane ously, the materials used in the second physical therapist job analysis were studied [2]. First, based on the results of a survey of 392 physical therapists, elements corresponding to the tasks whose 'satisfaction of job description' and 'task frequency' scores were four points ('important' and 'frequently do') or higher were isolated. Second, elements corresponding to the tasks whose scores on both items were above the average were se lected by calculating the mean score of two items, 'importance' and 'task frequency, ' for each of the first selected elements. Thr ough the above selection process, we isolated the following el ements corresponding to tasks for which both importance and performance frequency were high: elements related to di agnosis and evaluation (patient information gathering, identi fication of history, system review, examination of the muscu loskeletal system, special tests of the musculoskeletal system, examination of the neurologic system, special tests of the neu rologic system, goal setting, care plan, documentation of the care plan, explanation of the care plan, reevaluation, compar ison of the initial and final evaluations, modification of the goal, and modification of the care plan) and elements related to intervention (therapeutic exercise, manual therapy, and participation in preventive activities).

Korean physical therapist licensing examination
The subjects of the Korean physical therapist licensing ex amination were classified, and the proportion of items per taining to each subject out of the total number of items was determined. Apart from the practical examination, the sub jects of the Korean physical therapist licensing examination consist of 'foundations of physical therapy, ' 'physical therapy diagnosis, examination, and evaluation, ' 'physical therapy in tervention, ' and 'medical regulation' (Table 1), and they ac count for 60 items (30%), 50 items (25%), 70 items (35%), and 20 items (10%), respectively. One point is allotted to each item in the Korean physical licensing examination. To pass the ex amination, examinees should score at least 120 on the written examination without failing any of the subjects.

Learning objective
Twentynine colleges and universities in Korea were ran domly sampled among the colleges and universities with a physical therapy department, and the physical therapy curri cula of the selected institutes were analyzed. Since physical therapyrelated curricula were revised in accordance with the changes to the physical therapist licensing examination sys tem in 2014, we investigated majorrelated subjects for fresh men at the selected universities in 2014. Among the 29 select ed colleges and universities, there were 18 fouryear universi ties and 11 threeyear colleges. Based on the collected data, major subjects in physical therapy at the colleges and universi ties were classified along the lines of the topics in the subjects of the national physical therapist licensing examination.

Data and statistical analysis
To determine an agreement between job descriptions and learning objectives and that between job descriptions and the national licensing examination, the subjects that included the learning objectives of tasks with high frequency and impor tance were classified. Proportions of the classified subjects in all major subjects in physical therapy at the selected colleges and universities were analyzed to verify an agreement between job descriptions and learning objectives. Furthermore, the proportions of items related to the classified subjects out of the total number of items on the Korean physical therapist li censing examination were analyzed to verify an agreement between job descriptions and the national licensing examina http://jeehp.org tion. Finally, the proportion of universities that offer subjects related to the Korean physical therapist licensing examination at the selected colleges and universities was analyzed to inves tigate an agreement between learning objectives and the na tional licensing examination.
The agreement among job descriptions, learning objectives, and the national licensing system were analyzed using frequen cy analysis, and PASW SPSS ver. 18.0 (SPSS Inc., Chicago, IL, USA) was employed for statistical processing.

Results
The subjects that were related to jobs with high importance and performance frequency as identified in the job analysis were those pertaining to the following: physical therapy diag nosis, measurement and evaluation, clinical decision making, physical therapy of the musculoskeletal system, physical ther apy of the neurologic system, and orthopedic physical therapy.
The two lowest average proportions of subject credit out of the total credits of major subjects were identified in the clini cal decision makingrelated subjects (2.06%) and physical ther apy diagnosisrelated subjects (2.58%), as listed in Table 2. The number of items that included the learning objectives of sub jects related to the elements corresponding to tasks with high importance and performance frequency accounted for 60% of the total items on the Korean physical therapist licensing ex amination. Among them, the learning objectives of physical therapy diagnosisrelated subjects, measurement and evalua tionrelated subjects, and clinical decision makingrelated sub jects were included in the 'physical therapy diagnosis, exami nation, and evaluation' part of the examination, and they ac counted for 25% of the total items. In contrast, the learning objectives of subjects pertaining to physical therapy of the mus culoskeletal system, physical therapy of the neurologic system, and orthopedic physical therapy were included in the 'physical therapy intervention' part of the Korean physical therapist li censing examination, and they accounted for 35% of the total items.
The proportions of colleges and universities that offer physi cal therapy diagnosisrelated subjects (58.62%) and clinical decision makingrelated subjects (68.97%) were relatively low compared to the figures for other subjects (Table 3).

Discussion
The results of the present study show that despite the im portance of physical therapy diagnosis and evaluation in phys ical therapists' perception and the high performance frequen cies of associated tasks, the proportion of physical therapy di agnosis and evaluationrelated items on the national licensing examination and the proportion of courses on the related sub jects in the surveyed colleges and universities were relatively low.
Clinical decision making starts from clinical inference to determine the required examination and moves to evaluation and intervention for patients, which require physical thera pists to apply knowledge and techniques, selfreflection, expe rience, and ability to change evaluations or interventions intu itively based on patients' characteristics [7]. In current clinical practice, the importance and performance frequencies of tasks related to clinical decision making that require complex think ing abilities have been increasing. Thus, it is very important to offer clinical decision makingrelated subjects in the physical therapy curriculum to foster and produce wellequipped phys ical therapists. Although content similar to clinical decision making is partially included in various subjects, it is necessary to offer subjects directly related to clinical decision making to enhance integrated and complex thinking abilities.
The above result indicates that physical therapy diagnosis related tasks are essential for determining patient conditions to judge whether physical therapists can treat them, thus al lowing physical therapists to provide effective intervention based on patients' symptoms and conditions. Physical therapy curricula at universities in the USA, which is one of the ad vanced nations in terms of healthcare, had higher proportions of credits for evaluation, differential diagnosis, and progno sis basicsrelated subjects than credits for physical therapy in terventionrelated subjects [810]. This finding means that the U.S. emphasizes the importance of physical therapy diagnosis related subjects and reflects the importance of these subjects in university curricula. Considering that one of the most im portant goals of university education is to produce wellequip ped physiotherapy graduates, it is necessary to increase the number of physical therapy diagnosisrelated subjects.
The results verified that the number of tasks related to diag nosis and evaluation was greater than the number of tasks re lated to physical therapy intervention after an analysis of the tasks characterized by high importance and high performance frequency. However, in the Korean physical therapist licensing examination, the number of physical therapy interventionre lated items (70 items, 35%) is higher than the number of physi cal therapy diagnosis and evaluationrelated items (50 items, 25%). In comparison, in the USA's national licensing exami nation for physical therapists, the proportion of foundation for evaluation, differential diagnosis, and prognosisrelated items is 32.5%, which is higher than the proportion of physi cal therapy interventionrelated items (28.5%) [11]. In addi tion, the importance of practicerelated items has been em phasized, not only in the physical therapist licensing examina tion, but also in the other healthcare profession licensing ex aminations such as the medical licensing examination [12]. Considering that the proportion of items on the physical ther apist licensing examination in the U.S. and the requirement that items on the national licensing examination should reflect practical jobrelated contents, it is necessary to increase the proportion of items related to physical therapy diagnosis and evaluation.
Only 68.97% of the surveyed colleges and universities offer courses related to clinical decision makingrelated subjects. However, in the USA, at least two semesters of six or seven credits of clinical decision makingrelated subjects are offered to students [8,9]. Furthermore, all surveyed universities in the USA offer foundation courses on evaluation, differential diag nosis, and prognosis, and integrate the subjects of examina tion, evaluation, diagnosis, and intervention to cover various topics and diseases in the aforementioned foundation courses [810]. Given the trends in physical therapy education in ad vanced nations, where the abilities of physical therapists are emphasized, it is essential to include clinical decision making and physical therapy diagnosisrelated items on the national licensing examination. The present study has several limitations. First, the sample size of 29 universities is too small. Second, because the main tasks of physical therapists were determined based on the sur vey results from a job analysis conducted in a previous study, it is necessary to conduct job analysis based on the majors of physical therapists and type of hospital in the future to deter mine the main tasks of physical therapists.
In conclusion, the proportion of physiotherapy diagnosis and evaluationrelated items, subjects corresponding to tasks with high importance and performance frequency, should be increased in the Korean physical therapist licensing examina tion to ensure that examination items reflect practical tasks performed by physical therapists. Finally, with consideration given to the tasks performed by physical therapists practically and the national licensing examination items, it is necessary to increase the number of clinical decision making and phys ical therapy diagnosisrelated subjects in the physical therapy curriculum.