A Discussion of Diversity in Physical Therapy Regulation

What do we lose without diversity? What do we gain with diversity? What elements of diversity should physical therapy boards be working on? This article is based on a 2020 Annual Meeting Webinar panel discussion with Anne Wallestad, Ruggie Canizares, Nancy Kirsch, and Adrienne Price.

According to Anne Wallestad, the CEO of BoardSource, boards tend to be overwhelmingly white. While Board Source compiles information about other marginalized identities, the disproportionately low racial and ethnicity data stands out.

It is also notable that in the more than twenty years since BoardSource has been collecting data, this has continued to be a problem with minimal incremental progress. BoardSource is looking at not only what it has been in the past and what it is now, but also what actions and initiatives need to happen to create change.

FSBPT has also been examining this for quite some time. Unfortunately, across our committees and member boards, we probably are not as well represented as we should be to reflect who we are and the communities we protect. While FSBPT has always valued diversity, the events of the last few years have made FSBPT and members hypersensitive to it and eager to find out what actions we can implement to address this need.

Data on Diversity

According to CAPTE, in 2019, the majority of graduates from PTA programs were white:

• 6% identified as African-American
• 5% identified as Asian
• 13% identified as Hispanic/Latino
• 4% identified as Other 
• 71% identified as White

When looking at the PTAs in practice from 2016-2017, it is evident that more work needs to be done to have a more inclusive profession:

• 2% identified as African-American or Black
• 1% identified as American Indian or Alaskan Native
• 3% identified as Asian
• 3% identified as Hispanic/Latino
• 1% identified as Pacific Islander or Native Hawaiian
• 88% identified as White
• 2% identified as other

While this is not where we want to be, there are some reasons for optimism. Out of about 35,000 PTA test-takers in a recent five-year span, 66% provided race and ethnicity information at registration:

• 4% identified as African-American
• 7% identified as Hispanic/Latino
• 4% identified as bi/multi-racial
• 49% identified as White

If we compare this to the data of 2019 PTA graduates, with 71% identifying as White, there is a positive trend toward diversity. Unfortunately, this is not the case with PTs. According to CAPTE, in 2019, the majority of graduates from PT programs were White, and, at 77%, it is a more significant share than the 71% for PTA graduates:

• 3% identified as African-American
• 8% identified as Asian
• 6% identified as Hispanic/Latino
• 77% identified as White
• 3% identified as other

Additionally, for PTs in practice from 2016-2017, there is still little diversity:

• 1% identified as African-American or Black
• 0% identified as American Indian or Alaskan Native
• 5% identified as Asian
• 3% identified as Hispanic/Latino
• 0% identified as Pacific Islander or Native Hawaiian
• 89% identified as White
• 2% identified as other

While the PTA workforce has seen growing diversity, the PT workforce compared to graduates actually shows a slight increase in White PTs. However, once again, there is reason for optimism when looking at the data for PT test takers:

• 2% identified as African-American
• 4% identified as Hispanic/Latino
• 5% identified as bi/multi-racial
• 48% identified as White

However, it is essential to remember that the test taker data is incomplete. Only 59% of candidates responded to this question when registering for the NPTE, similar to the PTA response level. There may be many reasons people do not want to report their ethnicity. For example, they may have concerns about exclusion and inclusion or how that information might be used. Additionally, individuals may wonder if the given labels are appropriate for them, so they may opt to just not to share that data instead.

Oregon Board of Physical Therapy

Recently, the Oregon Board of Physical Therapy sought to increase its diversity. Oregon has four statutes, one executive order, and one governing initiative that all compelled the board to examine its diversity. In December 2018 and November 2020, the board held diversity strategic planning meetings.

Instead of approaching each statutory requirement in isolation, the board decided that it made more sense to develop a holistic approach. They developed a Framework for Culturally Responsive Regulation to consider the components of diversity, equity, inclusion, racial justice, and cultural competency in the context of these four groups:

• Patients
• Licensees
• Complainants
• Board/staff

Any regulatory policy or rule will consider the role of and the impact to these groups with the end goal of achieving culturally responsive regulation.

As part of the framework, the board developed questions to help guide them:

• What is the health regulatory role in addressing culturally responsive healthcare?
• What are the needs of the various participant groups?
• What are the resulting policies, standards, and practices required to address cultural responsiveness, achieve patient outcomes, and protect the public?

The board also identified key issues:

• Holistic, systemic change will require partnerships with other organizations, especially educational institutions, to address the need for more professional candidates from under-represented groups in the educational pipeline.
• Oregon boards do not reflect the state demographic profile of Oregonians as a whole in both patient and professional licensee populations. Infusing all perspectives and representation from all groups will require intentional training and partnerships.

The board has made progress:

• Requiring a cultural competency credit in continuing education credits (as of April 2020)
• Evaluating licensing criteria for foreign-trained/immigrant populations
• Implementing diversity and inclusion training for PT board members to facilitate board awareness and create the proper lens for policymaking
• Planning to collaborate with educational communities to ensure a diversified pipeline of professionals—more specifically, the board is exploring creating outreach programs to middle and high school students
• Looking into expanding the diversity of the board via public member appointments to offset the relative lack of diversity in the profession

Board Diversity and Public Protection

Diversity, equity, and inclusion are essential to work towards actively. You do not know what you do not know. The opposite of exclusion is intentional inclusion, not the absence of something intended to exclude. It is crucial to be proactive about inclusion. This approach can take different strategies and involve different layers within an organization; in reverse, problems in one area can reverberate across the organization.

The education community should go beyond just being intentional with recruitment and also provide additional services to students with different needs. In a recent incoming class at Rutgers University, 51 percent of students identified themselves as part of an underrepresented minority. Ideally, recruitment needs to start before college or even high school. Efforts really need to begin in middle school. Programs and initiatives that encourage more students to consider becoming a PTA or PT are great opportunities for collaboration between APTA and FSBPT.

Of course, we cannot simply wait until today's middle school students become tomorrow's board members. Despite the many challenges to achieving diverse representation, board members need to address this issue now. These challenges may include organizational intent and leadership. Even if we have state-mandated initiatives, how the board adopts these initiatives can make a huge difference.

At the basic, fundamental level, we are talking about human interactions and relationships. People may want to include someone, but they may also be hesitant to ask about various potentially sensitive categories someone might belong to. For example, a group of White colleagues talking about Black Lives Matter may think it is not okay to talk about that around a black colleague. It can be a challenge for both parties to have the courage to ask uncomfortable questions and answer them. However, engaging in this dialogue is vital. When navigating differences, people can be insecure; therefore, navigating them effectively requires vulnerability, humility, and courage.

Board members should actively invite those who are not at the table. It is important to note that it does not matter that the board is diverse if the other board members do not respect and listen to the diverse voices, even if it is different than what they usually hear. Make a conscious effort to have these sometimes uncomfortable discussions and find out if people feel they are included. Collaborate with them to help proactively promote inclusion. Strive to understand the feedback and implement it if possible or, if not, explain why the board cannot implement it to ensure that the speakers know the board is listening to them, they are being heard. It is essential to build trust and transparency.

Boards also must look at research and data to see if sanctions are harsher for minorities. Some of the empirical data shows attendees of remedial training are disproportionally PTs and PTAs educated outside of the United States, often because they have some trouble adapting to a different health care environment. State boards should analyze this data. Some resources include the Physical Therapy Minimum Data Set (PTMDS) and the Healthcare Regulatory Research Institute (HRRI), an FSBPT-created nonprofit regulatory research organization. While jurisdictional legislation may prevent specific data collection, there should still be some available options.

Expanding a state board's diversity and ensuring marginalized voices are represented takes courage in leadership and courage for under-represented groups to ask difficult, challenging questions. However, this courage is necessary. Boards cannot protect the public if members of the public do not feel comfortable accessing PT services or reporting claims to the board. They need to know the board will accept and listen to them to feel comfortable. Therefore, diversity is critical to a board's mission of public protection.