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Everything you Wanted to Know about the CPI: Now you can ask
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1. Everything you Wanted to Know about the CPI: Now you can ask
2. History of the Development of the CPI Prior to the late 70s and early 80s each Physical Therapist and Physical Therapist Assistant Program had its own Clinical Performance/Evaluation Form.
Some Clinical Education Sites developed their OWN evaluation instrument.
80s & 90s Clinical Education Consortiums began to develop and some regional forms were developed.
3. November, 1993, APTA appointed a 10-member Task Force to develop consistent clinical education evaluation instruments to measure student performance outcomes in PT and PTA clinical education.
4. Task Force Members Physical Therapy members: Sherry Clark,MS, Susie Duesinger, PhD, PT, Barbara Gresham, MS, PT, Pamela Gramet, PhD, PT, Bella J. May EdD, PT, FAPTA, Kathryn Roach, PhD, PT, Babette Sanders, MS, PT
Non PT Members: Rebecca Lewthwaite, PhD, Paul Hagler, PhD
Michael J. Strube, PhD (Consultant)
5. Design Characteristics Must measure a performance of multiple skills and behaviors of the PT and PTA on multiple levels (Novice to Entry-Level)
Content and protocol of the instrument must be responsive to the clinical AND academic communities.
Psychometrically sound (valid and reliable)
6. Process Task Force met in 1994.
Review of numerous instruments both within and outside the profession (nursing, OT, Speech, medicine) and international instruments (Canadian and Australian).
50 Person Sounding Board was formed to respond to the initial draft of the Task Force.
7. The first draft was written based on: A Normative Model for Physical Therapist Education, the Guide to PT Practice, Part One, the Evaluative Criteria for PT and PTA Education Programs and reference to the commonly used evaluation tools for clinical performance at that time.
8. Format Designed to use Professional Judgment in a complex clinical environment
Performance Criteria were broad with specific Sample Behaviors given to guide the evaluation of the criteria. The Sample Behaviors were just that, a sample, and not all inclusive.
9. Format Performance Dimensions were to be used to describe performance of behaviors of each criteria.
Quality
Supervision/Guidance
Consistency of Performance
Complexity of tasks/environment
Efficiency of Performance
10. The VAS was chosen as the means of recording the level of observed behavior for each item in the CPI.
Horizontal line of 100 mm represents a continuum of performance from Novice to Entry-Level (Draft 1 had Expert as end point). VAS
11. VAS Continuous scales can recognize degree of change better than categorical scales. (Clinicians often used the +/- in other scales)
No numbers on the scale made it more likely that meaning would not be attached to the numbers. Use of the VAS scale encourages rating based on the end anchors and not numbers.
12. VAS Entry-level is defined in each clinical setting and the rater uses professional judgment to determine the degree to which a student meets that criteria.
13. Instructions for use Specific instructions were written for the use of the form and that was included in the first draft.
Task Force believed that a therapist should be able to READ the instructions and be able to use the form.
14. Sounding Board The sounding board of 50 people were sent the first draft including instructions for use and changes were made in the instrument based on this feedback for the development of Draft 2.
15. Draft Two Pilot study of Draft 2 between October 1995 and June of 1996.
Concurrently, regional forums were being conducted by the task force and structured feedback was solicited.
Concurrently, copies of Draft 2 were sent out to academic programs and clinical educators with a feedback form included.
16. Draft 3 Data from Pilot Study
Feedback from forums
Feedback from multiple communities of interest
Consultation of Psychometrician
Development of Draft 3, the Field Study version.
17. Draft 4 Current version of the CPI
Based on results of Field Study of Draft 3
Feedback from communities of interest
Consultation of Psychometrician
Changes in terminology of current APTA documents
18. Dissemination The Physical Therapist Student version of the CPI was approved by the APTA BOD in November 1997.
The Physical Therapist Assistant Student version of the CPI was approved by the APTA BOD in March 1998.
Currently 95% of PT and PTA education programs have purchased the right to use the CPI
19. Thanks for the Memory Reference The Development and Testing of APTA Clinical Performance Instruments. Anticipated Publication in April 2002, Physical Therapy.
Roach K, Gandy J, Deusinger SS, Clark S, Gramet P, Gresham B, Hagler P, Lewthwaite R, May BJ, Rainey Y, Sanders B, Strube MJ.
20. With Sherrys comments as background, I am now going to move into implementation. I will present some of my observations related to both the initial and ongoing training and educational needs of clinical faculty related to use of the CPI.
My frame of reference is that of an ACCE in a physical therapist program and thus my examples will be from the PT instrument. Perhaps during the discussion those of you who are PT Assistant educators can comment on similarities or differences in your experience with the PT Assistant CPI. With Sherrys comments as background, I am now going to move into implementation. I will present some of my observations related to both the initial and ongoing training and educational needs of clinical faculty related to use of the CPI.
My frame of reference is that of an ACCE in a physical therapist program and thus my examples will be from the PT instrument. Perhaps during the discussion those of you who are PT Assistant educators can comment on similarities or differences in your experience with the PT Assistant CPI.
21. I will focus my comments on 3 areas addressing what I am referring to as the entry-level construct laid out for us in the CPI
Then offering some observations related to use of the Visual Analog scale
And ending with a few questions Ive been grappling with related the impact of the training were doing on the use of the instrument.I will focus my comments on 3 areas addressing what I am referring to as the entry-level construct laid out for us in the CPI
Then offering some observations related to use of the Visual Analog scale
And ending with a few questions Ive been grappling with related the impact of the training were doing on the use of the instrument.
22. What about the entry-level construct
As Sherry just described the 24 items in the PT instrument are all consistent with our professions current description of practice. And while there are certainly differences from setting to setting in what form they take, the broadly constructed items of the CPI can be considered elements of practice for all clinicians including those just entering the profession.
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The educational need in this arena that I have encountered has to do with items frequently being marked not observed, even in a final clinical experience and at times accompanied by comments indicating that they are Not Applicable for entry-level clinicians in that clinic.
For example, in a study we recently did in our program in which we analyzed VAS scores form 2 classes of students across their 3 full-time clinical experiences these 2 items were found to be marked N/O on What about the entry-level construct
As Sherry just described the 24 items in the PT instrument are all consistent with our professions current description of practice. And while there are certainly differences from setting to setting in what form they take, the broadly constructed items of the CPI can be considered elements of practice for all clinicians including those just entering the profession.
CLICK
The educational need in this arena that I have encountered has to do with items frequently being marked not observed, even in a final clinical experience and at times accompanied by comments indicating that they are Not Applicable for entry-level clinicians in that clinic.
For example, in a study we recently did in our program in which we analyzed VAS scores form 2 classes of students across their 3 full-time clinical experiences these 2 items were found to be marked N/O on
23. This slide is an example of an actual response Ive received on the CPI for the item relating to consultation
This slide is an example of an actual response Ive received on the CPI for the item relating to consultation
24. Let me move on to a couple of thoughts related to the Visual Analog Scale.
As a measurement scale most of us are accustomed to the use of the VAS clinically to measure a subjective experience such as pain, in which we lay out a continuum for our patients by defining the two end points no pain at all through pain as bad as it could be.
And even though they are being asked to rate a subjective experience that of pain we do expect that they will consider the same continuum each time they report a rating to us. SO in a sense we are using this as a criterion referenced rating. Were not interested in our patient deciding that for a rainy Friday in February this pain isnt all that bad so Ill give it a 3, but if it was a warm sunny day in June this much pain would deserve a 6. Let me move on to a couple of thoughts related to the Visual Analog Scale.
As a measurement scale most of us are accustomed to the use of the VAS clinically to measure a subjective experience such as pain, in which we lay out a continuum for our patients by defining the two end points no pain at all through pain as bad as it could be.
And even though they are being asked to rate a subjective experience that of pain we do expect that they will consider the same continuum each time they report a rating to us. SO in a sense we are using this as a criterion referenced rating. Were not interested in our patient deciding that for a rainy Friday in February this pain isnt all that bad so Ill give it a 3, but if it was a warm sunny day in June this much pain would deserve a 6.
25. So the training needs Ive identified related to the use of VAS on the CPI include:
Defining the anchors
What does that right hand anchor really look like in my practice setting for this particular item?
Keeping the right hand anchor current Ive had CIs tell me that they werent able to do that at werent expected to to that when they finished school so they really cant expect it of their students.
And finally related to anchors is the issue of the left hand anchor. What level of performance is it? Does a students performance really move through this entire range? I often find what seems to be a reducing of the scale to the midpoint up (or at least the second third)
And the last training need I would like to mention has to do with the issue of criterion vs. norm referencing. Have any of you ever heard that for a first clinical experience this student is doing great and then see scores all approaching entry-level?
So the training needs Ive identified related to the use of VAS on the CPI include:
Defining the anchors
What does that right hand anchor really look like in my practice setting for this particular item?
Keeping the right hand anchor current Ive had CIs tell me that they werent able to do that at werent expected to to that when they finished school so they really cant expect it of their students.
And finally related to anchors is the issue of the left hand anchor. What level of performance is it? Does a students performance really move through this entire range? I often find what seems to be a reducing of the scale to the midpoint up (or at least the second third)
And the last training need I would like to mention has to do with the issue of criterion vs. norm referencing. Have any of you ever heard that for a first clinical experience this student is doing great and then see scores all approaching entry-level?
26. Let me mention just a few training strategies Ive found used and you can share your when we move to discussion
I find it helpful to read the definitions of the anchors together. If you take this definition literally, the bar is set pretty high and I would argue appropriately so. Isnt this pretty much what we need a therapist to do in the clinic even the new graduate? This discussion can help to deal with the issue of keepin gour definition of entry-level current.Let me mention just a few training strategies Ive found used and you can share your when we move to discussion
I find it helpful to read the definitions of the anchors together. If you take this definition literally, the bar is set pretty high and I would argue appropriately so. Isnt this pretty much what we need a therapist to do in the clinic even the new graduate? This discussion can help to deal with the issue of keepin gour definition of entry-level current.
27. The sample behaviors and performance dimensions are tools for making the items observable I like to encourage and facilitate a collaborative process among the therapists in a given facility and get them to identify the behaviors that best represent their practice expectations in a given area. This can help tremendously with the N/O items perhaps the sample behaviors related to consultation need to be customized for that practice setting.
And, finally, I find it important to manage both CI and student expectations related to the fact that scores across the full continuum are to be expected as this is a developmental process. The sample behaviors and performance dimensions are tools for making the items observable I like to encourage and facilitate a collaborative process among the therapists in a given facility and get them to identify the behaviors that best represent their practice expectations in a given area. This can help tremendously with the N/O items perhaps the sample behaviors related to consultation need to be customized for that practice setting.
And, finally, I find it important to manage both CI and student expectations related to the fact that scores across the full continuum are to be expected as this is a developmental process.
29.
At this point, I would like to offer some insights into the use of CPI from the CCCE/CI perspective.
It is fair to say, that long before the CPI, CIs struggled with the process of comparing student performance to a standard in order to evaluate clinical performance. Defining and describing entry level behavior has been a key component of the CI role since the first students was evaluated.
At this point, I would like to offer some insights into the use of CPI from the CCCE/CI perspective.
It is fair to say, that long before the CPI, CIs struggled with the process of comparing student performance to a standard in order to evaluate clinical performance. Defining and describing entry level behavior has been a key component of the CI role since the first students was evaluated.
31.
The changing nature of our current practice environment has resulted in a somewhat dyanmic quality of the entry level anchor.
Our understanding of cognitive, affective and psychomotor skills have expanded to include areas like: cultural competence, advocacy, and evidence based decision making.
What are the student behaviors that describe these areas at entry level?
Does that mean for a given CF patient we should expect students to be able to provide evidence that support the use of one specific test and measure of aerobic capacity over another and to support their decision to recommend OPD pulmonary rehab with outcome studies?
To what level do we believe that entry level students should develop the cognitive and affective skills to work with the team to optimize the outcomes for a homeless patient who has been described in the record as non-adherent?
In addition, the clinics are challenged by changes in entry level curriculum that are sending students into the clinic with a good deal more theoretical knowledge and generally higher expectations for their performance at entry level. These expectations are not necessarily consistent across academic settings. It can seem at times that entry level is a somewhat moving target.
The changing nature of our current practice environment has resulted in a somewhat dyanmic quality of the entry level anchor.
Our understanding of cognitive, affective and psychomotor skills have expanded to include areas like: cultural competence, advocacy, and evidence based decision making.
What are the student behaviors that describe these areas at entry level?
Does that mean for a given CF patient we should expect students to be able to provide evidence that support the use of one specific test and measure of aerobic capacity over another and to support their decision to recommend OPD pulmonary rehab with outcome studies?
To what level do we believe that entry level students should develop the cognitive and affective skills to work with the team to optimize the outcomes for a homeless patient who has been described in the record as non-adherent?
In addition, the clinics are challenged by changes in entry level curriculum that are sending students into the clinic with a good deal more theoretical knowledge and generally higher expectations for their performance at entry level. These expectations are not necessarily consistent across academic settings. It can seem at times that entry level is a somewhat moving target.
32.
Given all the before mentioned variables, there seems one obvious question that needs to be addressed by clinical sites:
What is a realistic expectation for entry level practice?
And as Sherry noted earlier, the answer needs to be:
Entry level practice is what constitutes safe and effective practice in your specific clinical environment.
The follow up questions to this becomes:
In a given setting, how can we increase the consistency with which CIs assess clinical situations and draw similar conclusions?
Given all the before mentioned variables, there seems one obvious question that needs to be addressed by clinical sites:
What is a realistic expectation for entry level practice?
And as Sherry noted earlier, the answer needs to be:
33. Clinical sites need to engage leadership and clinicians who will be working with students and who are familiar with current curricular and practice changes in a process of describing entry level performance in behavioral terms.
Using the sample behaviors as a starting point, they need to determine whether these behaviors accurately and completely describe practice for their setting..
The group needs to identify examples of how each item might be seen in clinical practice. These examples may differ across different practice sites within the same setting.
Clinical sites need to engage leadership and clinicians who will be working with students and who are familiar with current curricular and practice changes in a process of describing entry level performance in behavioral terms.
Using the sample behaviors as a starting point, they need to determine whether these behaviors accurately and completely describe practice for their setting..
The group needs to identify examples of how each item might be seen in clinical practice. These examples may differ across different practice sites within the same setting.
34. For example, for item number 10:
Screens patients using procedures to determine effectiveness of and need for PT services. Behaviors that might be associated with B) selects appropriate screeing procedures include:
In an inpatient setting: skills related to medical record review, consultation with other professionals on the immediate status of the patient, and a level of patient interview . It would also involve what constituted the standard for gross screening/systems screening procedures for patients in your inpatient setting for things like ROM, strength, posture, and balance, etc.
In an OPD setting, it might involve the ability to administer and interpret a patient administered health status questionnaire or functional assessment tool, a more specific patient interview, review of available diagnostic tests and determination of need to consult with the referring MD. It would include what is considered standard for screening non-involved body parts or body systems
Without some discussion and understanding of what constitutes the behaviors associated with this item, I have more than once had a CI check this item as not observed.. For example, for item number 10:
Screens patients using procedures to determine effectiveness of and need for PT services. Behaviors that might be associated with B) selects appropriate screeing procedures include:
In an inpatient setting: skills related to medical record review, consultation with other professionals on the immediate status of the patient, and a level of patient interview . It would also involve what constituted the standard for gross screening/systems screening procedures for patients in your inpatient setting for things like ROM, strength, posture, and balance, etc.
In an OPD setting, it might involve the ability to administer and interpret a patient administered health status questionnaire or functional assessment tool, a more specific patient interview, review of available diagnostic tests and determination of need to consult with the referring MD. It would include what is considered standard for screening non-involved body parts or body systems
Without some discussion and understanding of what constitutes the behaviors associated with this item, I have more than once had a CI check this item as not observed..
35. This process I have described includes two components: first to describe entry level behaviors and then to assign a level of student performance to that behavior. An understanding of the process of skill acquisition has been helpful in my setting as we approached this task.
The acquisitions of clinical knowledge is in part developmental. It involves the integration of theoretical knowledge and clinical experience and it requires practice with many patients. No book can adequately prepare a student for the first time they encounter a patient who is S/P brain tumor resection and undergoing chemotherapy. To the extent that students can allow theory to mix with their experience with patients in the moment clinical knowledge develops.
The literature describes this as a developmental process in which a clinician moves from: relying on rules..to relying on experience(falling BP)
focusing on tasksfocusing on the whole person(teaching seesion)
situations(listing all impairments and treating them all vs. detemining which one is most limiting the patient and focuing treatment)
CIs need to set expectations for performance with the idea that the process is in part developmental..
This process I have described includes two components: first to describe entry level behaviors and then to assign a level of student performance to that behavior. An understanding of the process of skill acquisition has been helpful in my setting as we approached this task.
The acquisitions of clinical knowledge is in part developmental. It involves the integration of theoretical knowledge and clinical experience and it requires practice with many patients. No book can adequately prepare a student for the first time they encounter a patient who is S/P brain tumor resection and undergoing chemotherapy. To the extent that students can allow theory to mix with their experience with patients in the moment clinical knowledge develops.
The literature describes this as a developmental process in which a clinician moves from: relying on rules..to relying on experience(falling BP)
focusing on tasksfocusing on the whole person(teaching seesion)
situations(listing all impairments and treating them all vs. detemining which one is most limiting the patient and focuing treatment)
CIs need to set expectations for performance with the idea that the process is in part developmental..
37.
So what are the challenges to using the CPI in the absence of specific CI training?
Instructions are lengthy and take time to fully appreciate.
Absolute need for clarity on the part of the CI around the behaviors that describe entry level practice
CIs often will ask for help with how to incorporate the performance dimension into decision making. In a setting high on the complexity of task and environment there is an interrelationship between the dimensions. The complexity will increase my need for supervision and decrease my efficiency if I want to maintain any degree of quality and consistency of performance. So what is an acceptable level of productivity and supervision for entry level in the NICU or if I am dealing with complex spine patients? How do I rate the students performanceif the caseload is mixed and they show different levels of skill with extremity and spine patients?
And finally, back to an earlier point. As practice continues to evolve, the behaviors describing the left anchor of the CPI will need to change. We wont ever really finish the discussion around this topic for more than a short period of time.
So what are the challenges to using the CPI in the absence of specific CI training?
Instructions are lengthy and take time to fully appreciate.
Absolute need for clarity on the part of the CI around the behaviors that describe entry level practice
CIs often will ask for help with how to incorporate the performance dimension into decision making. In a setting high on the complexity of task and environment there is an interrelationship between the dimensions. The complexity will increase my need for supervision and decrease my efficiency if I want to maintain any degree of quality and consistency of performance. So what is an acceptable level of productivity and supervision for entry level in the NICU or if I am dealing with complex spine patients? How do I rate the students performanceif the caseload is mixed and they show different levels of skill with extremity and spine patients?
And finally, back to an earlier point. As practice continues to evolve, the behaviors describing the left anchor of the CPI will need to change. We wont ever really finish the discussion around this topic for more than a short period of time.
39. Four major areas of focus:
Clinical faculty training and use.
Interpretation and grading of the CPI.
CPI use in program and curriculum evaluation.
CPI as a tool to facilitate student development and self-evaluation.
40. CPI Interpretation and Grading Many variations exist between academic programs.
Performance expectations for various clinical levels
CPI interpretation
Weighting of criteria
Grading processes.
41. CPI Interpretation and Grading The Novice to Entry level VAS moves the evaluation of student performance beyond considering primarily the amount of supervision needed.
Requires a change in the academic mindset.
Performance standards must be reestablished.
Expected rate of progression to entry level must be considered.
42. CPI Interpretation and Grading The specifics of performance issues are not always immediately obvious.
Performance Criteria such as Treatment/Intervention (PT version) or Patient Interventions (PTA version), cover many component skills and behaviors.
Sample behaviors not all-inclusive
Performance dimensions not broken out
43. CPI Interpretation and Grading CI written comments:
should indicate the specific performance issues identified.
should be consistent with the VAS.
Wide variation seen in the quality and quantity of CI written comments.
44. CPI Interpretation and Grading Tendency for CI inflation of student performance continues.
Interpreting the VAS line and comments may necessitate a call to the CI or CCCE.
45. CPI Interpretation and Grading Should special significance be given to red flag items 1-5?
Should other performance criteria be weighted or considered as equal?
What to do with criterion marked as not observed?
How to structure grading matrices?
Much can be gained by academic programs comparing approaches.
46. Program and Curriculum Evaluation
Academic programs need data regarding student performance on clinicals to evaluate and modify curricula.
47. Program and Curriculum Evaluation Data gathered from VAS scores may show linkage to the broader categories of the Performance Criteria.
However, the CPI does not provide specific information on the performance dimensions or the knowledge, skills and behaviors involved.
48. Program and Curriculum Evaluation Academic faculty must look for other ways to capture the more specific information needed for thorough curriculum evaluation.
CI comments must also be recorded and evaluated.
Triangulation of data continues to be important.
49. Facilitating Student Development - The CPI as A Roadmap Students need a tool to assist them with self-assessment, goal setting, and self-directed learning.
Student memories of verbal feedback and discussions with CI/CCCE can be short and unreliable.
50. Facilitating Student Development Entry level performance is a multi-dimensional construct and may not be readily understood by students.
Students must be trained in the use of the CPI in order to make use of it as a tool for ongoing development and self-assessment.
54. Where do we go from here? What are the questions we most need to answer?
What are some research ideas?
55. Studies Study published in the Journal of PT Education using the CPI to compare the outcomes of student performance in multiple short-term vs. single long-term experience.
56. 2002 CSM Relationship between GPA & clinical performance of PT students using the CPI
Hewson,Ryglewicz, Michaels, Neemuchwala, and Liebeck
Analysis of data from the CPI for students in beginning, middle, and final clinical experiences
Knab & Portney
57. 2002 CSM An evaluation of the reliability & validity of the CPI
Adams, Fish, Hughes, Roberts, Viricel & Geher
Essential PT clinical experiences
Ingram, Montgomery, Reese & Stone
58. Purpose The primary purpose of this study was to identify the essential physical therapy clinical experiences, as defined by the Academic Coordinators of Clinical Education (ACCE), that all students must experience and/or attain entry level performance prior to graduation.
59. Methods Subjects
185 ACCEs of U.S. CAPTE accredited programs
60. Survey Instrument Systems
Cardiopulmonary
Integumentary
Musculoskeletal
Neuromuscular Life Span
Infants
Toddlers
Children
Adolescents
Adults
Older Persons
61. Survey Instrument
Corporate Health Centers
Occupational Environments
Athletic Facilities
Fitness Centers
62. Survey Instrument Roles
Primary Care
Secondary/Tertiary Care
Fitness & Wellness
Consultation
Education
Critical Inquiry
Administration
63. Survey Instrument Demographic Information
Type of program
Size of program
Funding of program
State of program
Direct access
Number of years of experience as an ACCE/DCE
64. Scale 5 = absolutely essential
4 = mostly essential
3 = essential
2 = mostly not essential
1 = absolutely not essential
65. Results 107 ACCEs responded (57%)
63 had direct access
43 did not have direct access
53 had >5 years experience
54 had <5 years experience
66. ACCE Opinions of Systems Students Should Experience and Attain Entry-Level (median responses)
67. Ranked Order of Mostly to Absolutely Essential For Systems Experience
Musculoskeletal
Neurological
Cardiopulmonary
Integumentary Entry Level
Musculoskeletal
Neurological
Cardiopulmonary
Integumentary
68. ACCE Opinions of Settings Students Should Experience (median responses)
69. ACCE Opinions of Settings Students Should Attain Entry-Level (median responses)
70. Mostly Not to Absolutely Not Essential For Settings Experience
Hospice
Corporate Health
Entry Level
Hospice
Corporate Health
71. ACCE Opinions of Life Span Students Should Experience and Attain Entry-Level (median responses)
72. Life Span Categories Having experience and gaining entry level with adults and older persons were rated more essential than with children
73. ACCE Opinions of Roles Students Should Experience and Attain Entry-Level (median levels)
74. Mostly Essential to Absolutely Essential For Roles Experience
Secondary
Critical Inquiry Entry Level
Secondary
Critical Inquiry
75. Analysis Mann Whitney U: Utilized to determine difference among demographic groups
Years of experience as ACCE
The following significant differences were found:
ACCE with 5 years or less experience rated the following items higher than the ratings of ACCEs with greater than 5 years experience:
Entry-level in hospital setting (.04)
Experience in outpatient setting (.04)
Experience with older adults (.049)
Experience and entry-level in secondary/tertiary care (.03 and .01 respectively).
T-test comparing experience with entry-level
No significant differences found
76. Recommendations for Future Study Survey ACCEs regarding actual required experiences
Identify a method for CIs to report to ACCEs the assessment of student performance in systems, settings, and life spans. Roles are addressed currently in the CPI.
Survey clinicians regarding their opinions
77. What are your recommendations? What are the themes that have been expressed today?
What suggestions would you make?
