Curriculum regulation and its oversight are indispensable and vital components of professional development. Regulatory bodies along with professional organisations have an essential role in curriculum regulation. The Pakistan Speech and Language Pathology Association, a body duly registered under the laws of Pakistan and whose governing body exclusively comprises pathologists with master's in Speech Language Pathology, has taken up the matter of standardisation and uniformity of curriculum with universities and with the Higher Education Commission. The commission regulates the undergraduate curricula, but there remains lack of uniformity in curriculum and its monitoring in Pakistan. The current narrative review was planned to highlight the indiscipline in rehabilitation curriculum development and implementation and its causes.
Keywords: Curriculum, Inhibitors, Physical therapy, Regulatory body, Speech language pathology.
Curricula regulation is indispensable for any profession as it is essential to connect professionals of a health specialty globally. Professional governing bodies and relevant ministries are responsible for this regulation. In Pakistan, the representative body of medical profession is the Pakistan Medical Association (PMA), while the Pakistan Medical Commission (PMC) is the governmental regulatory body.1 Regulatory bodies have an essential role in improving quality of education by playing their role as facilitators2 along with professional organisations. If involved in the development of curricula, they can guarantee a standard so much so that without accreditation with a regulatory body, universities in some countries do not offer degree programmes in subjects involving health and engineering.3
In the field of physical therapy and speech language pathology programmes, the American Physical Therapy Association (APTA) and the American Speech and Hearing Association (ASHA) have provided standard protocols, guidelines, job regulations and standards. These are applicable to physical therapists (PTs) and Speech language pathologists/therapists (SLPs/Ts), PT and SLP/T assistants, and PT and SLP/T students as well as institutions.4 The basic aim of these is to improve the health and quality of life (QoL) of individuals by advancing rehabilitation by physical and speech language and cognitive therapy practice, education, research, funding and healthcare workforce adequacy. This will also increase the awareness and understanding of Rehabilitation professionals' role in the nation's healthcare system as well as lobbying for healthcare reforms.4
In Pakistan the Rehabilitation profession is a comparatively new field with just two decades of progression in the academia and it is, therefore, not involved in university accreditation / implementation of the curricula, rules and regulations related to students and institutions, nor involved in providing any strategic plans, healthcare system community and institutions. Thus, a gap exists which needs to be filled by a body to safeguard, regulate and control Rehabilitation curricula.5 This is essentially required due to the fact that Rehabilitation residency training programmes lack uniformity in the level of training as well as mentorship for students' scholarly activities partly due to the fact that even standardised curricula's utilisation remains variable.6
In Pakistan, the National Curriculum Overview Committee (NCRC) was formulated by the Higher Education Commission (HEC)7 to deal with the process of curriculum development and implementation just for the entry-level undergraduate programmes, while the postgraduate curriculum development and implementation is left to the stakeholders and syndicate bodies of institutions.8 Curriculum regulation is important as application of well-planned and essentially revised curricula offer transmuting opportunities.9
With so many areas and domains in it, curricula cannot be defined in a nutshell. Hence, researchers use different definitions, like curriculum is a means of obtaining certain goals and objectives related to education; as a course and content of study; a plan to implement certain educational activities in a systematic manner; a document or outline of a programme put up on paper; and as a programme to achieve experiences in a holistic manner. Planning and instructions intrinsically are part and parcel of a curriculum and its perceived outcomes.10 Curriculum is the cornerstone of an academic institution and diligent designing of curriculum guarantees its realisation. Changiz T et al. in a systematic review asserted that medical institutions may adopt varied approaches to manage medical education programmes. This incorporates curriculum committees to maintain teamwork and to coordinate among the participating medical professionals and other stakeholders, like faculty and students, as well as technological capacities to guarantee efficient and effective curriculum control and oversight to conform to the desired accreditation requirements.11 This can be attained by ascertaining and setting objectives, designing routes to achieve, make executive strategies for operationalisation backed by evaluation and monitoring to confirm that goals and targets are attained and to identify zones entailing consideration or upgrading.11
In spite of the fact that science which supports study of curriculum education is not mature enough, drawbacks in curriculum may be isolated with the objective to resolve significant curriculum concerns. A number of disorders12 can affect curriculum viability including:
i. Curriculo-sclerosis: extreme departmentalisation due to extreme ownership of the subject and fighting for the hours of the discipline;
ii. Curriculum carcinoma: imbalance due to excess of some curriculum segment;
iii. Curriculo-arthritis: miscommunication between disciplines due to lack of interaction; and
iv. Iatrogenic curriculitis: excess tampering of curriculum due to sudden, unplanned response to adjust to meet societal demands and expectations.
Hence, the curriculum, despite being of a high standard, may be confronted with inhibitors, which, if efforts are not made to isolate them, may go undetected. Anxiety marks curricula of higher education because of its responsibility towards socioeconomic augmentation of society, with the burden being on the educators.13 In Pakistan, the Rehabilitation curricula is also challenged by rapid changes as a result of globalisation, changing disease patterns, like coronavirus disease-2019 (COVID-19), emergence of the discipline of speech language pathology, addition of new modalities in physical therapy curricula, economic hardships, and critical lack of adequately trained personnel. To retain value SLPs, SLTs and PTs need to respond to the varying needs of the healthcare system.14
For the execution of educational process in a systematic manner, it needs to be fundamentally centred on the curriculum.15 Standards and inhibitors of a curriculum need to be correlated to its content, including education, strategies used, learners, teachers, evaluation, environment associated with education and work, technologies used, communication and leadership.16
Standards of curriculum: Quality at institutions of higher educational include mission and vision development to satisfy both internal as well as external goals and standards, including resource acquisition, redressal of learner complaints, instructor competence, and interaction of students with staff, faculty and administration.17 According to a study,18 students' involvement and feedback in appraisal of an educational programme and student-faculty interaction are important. Hence, the objective of curriculum development and operation should be that students attain wide range of generic capabilities related to the profession with sufficient essential comprehension as well as skills development honing in on practice of Rehabilitation medicine, developing generic aptitudes and skills equated with other specialties.19
A number of factors/standards are mandatory for curriculum implementation, including the learners/students, resources both in terms of material as well as facilities, instructors, the institutional milieu, interest of academic clusters, instructional guidance as well as evaluation and culture.20 Curriculum development is not only contingent upon the experts, but practitioners (clinicians) with sufficient exposure of teaching techniques have a role to play to make learning significant,15 with students being the focus in terms of curriculum realisation.20
Curriculum quality Inhibitors: These impact the viability of the curriculum and include lack of student-staff participation in decision-making; responsiveness to rising authentic requests of student; wanting procedures, policies, systems and obligations; lack of resources; stringent cultures discouraging openness regarding quality implementation of top-to-bottom approach; less focus on inculcating culture of research; discouraging pooling of beat practices; and weak communication mechanisms.21
1) Lack of stakeholders participation: Participation of all stakeholders, including teachers, in curriculum development is indispensable.15 Discourse and practices as regards development of curricula vary significantly both within and across institutions, with academia playing a crucial and enabling role to make available strategic requirements for higher education.13 According to a study, though Pakistan government's efforts were seen to bring reforms in the education sector, including curricula, but the anticipated outcomes are not realized.15 This might also be due to different inhibitors or difficulties, like not enough importance being attached to teacher development.15 Teacher training and development should invariably be oriented to produce reflective and research-based practitioners who could address academic as well as professional matters, and are sufficiently proficient to update the curricula in line with students' learning requirements.15
2) Lack of regulatory body: A framework for development of curricula includes three-level approach including institutional level, developmental level, and discourse guiding practice.13 A regulatory body is fundamentally obligated to institute curriculum control as well as development.5 In Pakistan, there is a high prevalence of disability (2.65%) with no regulatory body to govern the Rehabilitation profession except some bodies working for professional growth, such as the Pakistan Physiotherapy Society (PPS), the Chartered Society of Physiotherapy (CSP) of Pakistan, the Pakistan Speech Language Pathologists Association (PSLPA), and the Pakistan Physical Therapy Association (PPTA) which was established in 2008 and joined the World Confederation of Physical Therapy (WCPT) in 2011.5
The HEC is presently regulating the physical therapy education in Pakistan and its members, along with the NCRC, approved the first curriculum for physical therapy education in the country, culminating in an entry-level degree, thus giving physical therapy an autonomous profession status.5 With time, the institutions that offer courses have mushroomed, with 69 offering Doctor of Physical Therapy (DPT) courses alone. In Pakistan, three chartered universities are offering Masters of Science (MS) degree in SLP, and some have Bachelors of Science (BS) SLP degree programmes. It has been observed that due to the non-existence of a regulatory body, the growth has gone un-regulated and unmonitored, resulting in mushrooming of institutions with poor-quality curriculum implementation.5
The HEC and the WCPT have the mandate and can propose guidelines regarding curriculum and practice, but implementation still remains unchecked due to the unfortunate absence of a regulatory body. Hence, a regulatory authority is the need of the hour to develop, regulate and protect Rehabilitation curriculum,5 accompanied by legislation, and the Ministry of National Health Services and Regulations has proposed a council framework with representation from all fields of Rehabilitation, including SLP.22
The PSLPA, a body duly registered under the laws of Pakistan, has taken up the matter of standardisation and uniformity of curriculum with the accredited universities and the HEC. It has approached the Federal Public Service Commission (FPSC) and the provincial public service commissions, which recruit for public-sector health facilities, to restrict recruitment of SLP and SPT graduates from the chartered universities that offer relevant MS and BS degree programmes because such programmes involve training and residency in hospital and clinical settings. The PSLPA has advocated for categorisation of degree and other programmes, and has consistently been approaching the HEC and all relevant bodies at federal and provincial levels to ensure uniformity and standardisation of the Rehabilitation curricula and clinical assessment. Also on the agenda are elements like elimination of quackery, promotion of research, development of national/international online portals for research and linkages amongst the national and international SLP and Rehabilitation communities. This will enable the sharing of updated clinical, training techniques and international best practices with the ultimate aim being to provide the most appropriate care and rehabilitation for patients.
3) Privation of community-based learning and problem-based learning: Curricular implementation is affected on account of privation of community-based learning (CBL) and problem-based learning (PBL), absence of assessment criteria, lack of resources for implementation and stringent oversight by a regulatory authority. According to a study done in Saudi Arabia, developing countries with scarce resources are not adept at designing fresh curricula and invariably adhere to curricula being subject-based. Availability of adequate resources, like financial support, manpower and logistics, in developing countries23 may go a long way towards implementing PBL curricula.
4) Miscellaneous barriers: A local study identified three categories of barriers to implementing; institutional, programme-based, and curriculum-associated. Key barriers were recognised as faculty transfer, policy inconsistencies, absence of stakeholder interaction and ineffective leadership.24 The inadequacy of infrastructure is evident in the implementation of curriculum with compromised synchronisation between faculty and administration, which apparently offers financial and legislative facilitation.24 The barriers perceived by PT and SLP/T denote that there remain deficient mindfulness of the scope of PT and SLP practice in Pakistan.25
A scoping review revealed barriers of leadership role as the prime challenge, followed by curriculum issues, like development, involvement of students in the planning of curriculum, management of curriculum, infrastructural issues, resistance of faculty to change, financial issues, deficient information technology and lack of research as barriers to World Federation of Medical Education (WFME) standards accreditation.26 Language as a barrier was identified in a Chinese study encompassing international medical students in the perspective of curricular implementation,27 which also deemed PBL essential for enhancing the experience.
Only with a legally empowered, developed and vibrant regulatory body can the Rehabilitation curricula be professionally managed. As the number of educational institutions and number of SLPs, SLTs and PTs rapidly increase, there is a dire need for the establishment of a regulatory body for proper monitoring, implementation, evolution and progression consistent with international/national trends and recognised evaluation criteria for improvement in speech language pathology and physical therapy curricula to promote the science of Rehabilitation in Pakistan.
The field of Rehabilitation requires a legally and operationally empowered regulatory authority to maintain consistency, uniformity and standardisation of educational curriculum and development, with adequate representation from diverse Rehabilitation fields to ensure best possible services for the patients.
Conflict of Interest: None.
Source of Funding: None.
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