Abstract
Purpose: The aim of this study was to explore physiotherapists’ and occupational therapists’ perspectives on how the implementation of a new model of care in the acute medicine setting has affected their practice and patient care outcomes. Method: A qualitative case study was used to gain an in-depth understanding of therapists’ experiences. Semi-structured, in-person interviews (45–60 min long) were conducted with eight clinicians (four occupational therapists and four physiotherapists). We used an iterative process of discussion and questioning to interpret the themes emerging from the data. Results: The findings are grouped into four categories – change in the therapist–patient relationship, change in therapists’ access to first-hand patient information, developing processes to enhance information exchange, and developing processes to support patient care delivery – and two themes – therapists’ expectations of patient care outcomes and redefining the value of the occupational therapists’ and physiotherapists’ role in contributing to patient care. Conclusions: Participants described the process of adapting their professional skills and behaviours as they evolved into the role of manager of therapy care. Occupational therapists and physiotherapists recognized the potential for occupational therapist assistants (OTAs) and physiotherapist assistants (PTAs) to provide more frequent and consistent care. The therapists highlighted the necessity of ensuring that effective working processes and interactions between the therapist and the OTAs and PTAs were in place to ensure high-quality patient care.
Key Words: communication, patient care, professional role, qualitative research, rehabilitation
The increasing cost of health care and an aging population are driving an interest in developing new models of service delivery that can respond to the need for patient care and still be cost effective.1,2 Interest in developing strategies to provide patients with greater access to rehabilitation is also growing as a result of an increasing awareness of its benefits, especially for an aging and increasingly medically complex population.1,3,4 One health care delivery option is to enhance the role of assistants of allied health providers such as physiotherapists and occupational therapists.5,6
In Canada, assistants who work under the direct supervision of physiotherapists and occupational therapists are called, respectively, physiotherapist assistants (PTAs) and occupational therapy assistants (OTAs).7,8 Canadian physiotherapists and occupational therapists must work according to provincial and national guidelines and standards of ethical and legal practice, which includes taking responsibility for evaluating the competency, performance, and learning needs of their assistants.9–12 Most Canadian educational programmes are designed to prepare individuals to work as PTA, as OTA, or in a combined OTA–PTA role.13 Employers are increasingly seeking individuals to work in this combined role.14
Except in Quebec, PTAs and OTAs are unregulated and are educated in diploma programmes that typically last 2 years. Recognizing that the quality of educational programmes (both public and private) varies, the Canadian Occupational Therapist Assistant and Physical Therapist Assistant Educators Council introduced accreditation standards for Canadian OTA and PTA education in 2012.15
The benefits of having therapy assistants have been well described in the literature: (1) they act as a link to all the disciplines on the inter-professional (IP) team, (2) they improve communication between nurses and rehabilitation providers, and (3) they identify with patients (also described as contributing to improved patient satisfaction).2,16,17 Research has also suggested that having OTAs and PTAs maximizes the number of patients seen for therapy and provides therapists with more time to perform activities such as assessment, consultation, and discharge planning.1,18 The direct benefits to clinical outcomes have been reported and include reducing the rate of skin breakdown, the number of ventilator days per patient, and the rate of ventilator-acquired pneumonia and overall complications.16,17 The challenges identified with having assistants include a lack of clarity about their role or scope of practice, especially among other members of the IP team.3,16,19 As a result, several studies have explored using assistants’ full scope of practice to meet the changing demands of the health care system.1,2,6,16,20
Stanhope and Pearce suggested that allied health teams consider redesigning their workforce to better meet the health needs of the population by expanding the role of assistants.2 Recently published studies in practice magazines have described expanding assistants’ roles and practice to increase health care teams’ capacity to provide therapy services.17,20 It has been suggested that assistants’ skills have not been optimized and that opportunities exist to increase workforce capacity to meet future demands.1 The support provided by assistants can give therapists more time to focus on tasks requiring more complex analysis and problem solving, thereby enhancing patients’ access to therapy services.1,20 Although interest is growing in enhancing the use of assistants as a more cost-effective strategy to improve access to rehabilitation therapy, little is known about the potential impacts on patient care and practice.
To meet the changing needs of the population of frail elderly adults, in 2011 a new model of care was introduced to the acute medicine units at a teaching hospital in the Greater Toronto Area. One of the objectives of the model was to provide more assistance with patients’ care needs, such as toileting, bathing, feeding, and ambulation, 7 days per week. The means of accomplishing this was to expand the team of assistants and introduce the combined OTA–PTA role. Our facility hired assistants who had completed a 2-year programme that included both the OTA curriculum and the PTA curriculum and were given the title of OTA–PTA. To ensure that our current staff had the required competencies of both OTAs and PTAs, the organization partnered with an existing OTA–PTA programme to develop a learning needs assessment and educational programme.
In this new model, occupational therapists and physiotherapists now manage patient therapy services provided primarily by multiple OTA–PTAs under their supervision. Traditionally, rehabilitation therapy was delivered (in most cases) by a physiotherapist or occupational therapist, with one assistant working either directly with them or under their close supervision. During the corporate design and planning phase, there was considerable fear that increasing the OTA–PTA staff would result in layoffs of occupational therapists and physiotherapists.
Given the important changes in the service delivery model, opportunity arose to explore the daily practice experience of occupational therapists and physiotherapists supervising OTA–PTAs in this new model. This article explores physiotherapists’ and occupational therapists’ perspectives on how the implementation of this new model of care in the acute medicine setting has affected their role, their practice, and patient care outcomes.
Methods
We used an interpretivist paradigm as our methodological approach and a qualitative case study methodology as our means of collecting data.21,22 These allowed us to gather a range of in-depth accounts of individual experiences.21 We then used a constructivist approach to build a detailed picture of how the occupational therapists and physiotherapists with personal experience of it understood the new model of care that had been implemented.22
The research team (RT) included two principal investigators (PIs) at the hospital site (LBL, DP), four MScPT students (WB, JD, SM, LR), and an academic faculty member (SN, who joined the RT during the secondary data analysis phase). The PIs were physiotherapists who held leadership roles in the organization; for example, they were responsible for and oversaw elements of the implementation of the new model of care. The team of students was recruited in an attempt to mitigate any bias, assumptions, or influence of the PIs on participants. All the team members were asked to consider any bias or a priori assumptions.23 This article presents the findings on the occupational therapists’ and physiotherapists’ perspectives and is part of a larger study that includes the perspectives of the OTA–PTAs.
Ethics approval for this study was obtained through the hospital’s Research Ethics Board; all participants provided informed consent.
Participants
Student team members contacted potential participants by email to explain the purpose of the study and request their participation. Interviews were conducted 18 months after the new model had been implemented, recognizing a liminal moment and the opportunity to capture the therapists’ perspectives on the changes and how they had adapted to them.
Purposive sampling was used,23 and the four physiotherapists and four occupational therapists who had experienced the first phase of implementation all participated in this study. The participants had been in clinical practice for 11–27 years.
Data collection
Interviews were used to gain an in-depth understanding of the therapists’ experiences.23 The RT developed and pilot tested a semi-structured interview guide designed to explore their perceptions of the changes in practice and strategies for adapting to them.23 Two student RT members interviewed each participant. One conducted the interview, and the other wrote field notes noting emotion, body language, and potential questions to further explore later in the interview or in subsequent interviews. The interviews were conducted in private rooms, audio recorded, and lasted 45–60 minutes. An external transcriptionist removed identifying information and transcribed the audio recordings. The RT met after each interview to explore challenges and discuss the emerging themes.
Data analysis
Conventional content analysis was used.24 All RT members read each transcript independently and identified codes (exact words from the text that appeared to capture key thoughts or concepts).24 The RT met on six occasions to define codes and discuss and interpret emerging categories (based on how the codes were related and linked). A list of 13 codes and emergent categories was developed.24 When disagreement occurred, the two RT members who had conducted the interview referred to their field notes for clarification.
The interviews were analyzed throughout the interviewing process; this allowed the team to identify two frequently discussed codes (communication and teamwork). As a result, after the first four interviews, two questions were added to the remaining interviews to explore these concepts further. The RT members were encouraged to use reflexive journaling and to consider any biases or assumptions.23 The codes were presented to the participants for feedback and clarification on two occasions. The PIs and academic team member conducted a secondary analysis to further refine the initial 13 codes, leading to the development of four categories and two themes.
Results
Our analysis of the interviews with the eight therapists generated four categories of experience categories – change in the therapist–patient relationship, change in therapists’ access to first-hand patient information, developing processes to enhance information exchange, and developing processes to support patient care delivery – and two overarching themes – therapists’ expectations of patient care outcomes and redefining the value of the occupational therapists’ and physiotherapists’ role in contributing to patient care. The participants’ descriptions of their daily experience while practising in the new model of care are represented in Figure 1. These categories capture the explicit description of the participants’ account of their experience.24
Figure 1.
PT=physiotherapy; OT=occupational therapy.
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Change in the therapist–patient relationship
Participants described challenges in developing therapist–patient relationships as a result of having less opportunity to directly engage and interact with patients and their families. The occupational therapists and physiotherapists said that the act of delivering treatment gave them the opportunity to share the specific and sometimes not-so-obvious details of a patient’s experience, allowing them to gain a deeper understanding of the individual’s personal stories, fears, motivations, and goals.
All the participants expressed concern about what they described as feeling less connected to their patients: “not as involved” (Therapist [T] 2), “not knowing the patient as well as I’d like to” (T3), “lost that rapport, lost the connection” (T6).
Likewise, the participants thought that patients were also affected by the missed opportunity to fully share their stories with, ask questions of, or engage with their therapist, with the result that they experienced uncertainty or had unanswered questions about their care. One participant clearly identified patients’ perceived struggle to trust the opinion of an occupational therapist or physiotherapist when they had not established a relationship: “They saw me a week ago and they won’t even remember. So, it’s kind of hard for them to trust your opinion” (T6).
Change in therapists’ access to first-hand patient information
Participants described the challenge to their clinical reasoning processes as a result of the limited opportunity to directly interact with their patients during treatment. As the therapists described, providing treatment had allowed them to observe and perceive subtle contextual nuances in patient performance. This is valuable information that therapists can use to inform and support their clinical judgement. The therapists stressed the challenges to their ability to make clinical decisions when using information that they received only in written form or in conversations with the OTA–PTA.
As one participant described it, the OTA–PTA also needs to be able to recognize and decide what information is relevant or important to share with the therapist:
I don’t have the first-hand information the assistants do, so I’m relying on them … it was just noteworthy in my mind that they knew more than I did, and yet I’m in charge and responsible for the patient in terms of decision making. (T5)
Another participant identified the occupational therapist’s or physiotherapist’s struggle to rely on or trust information about patient status that had been gathered by someone else:
So it is very different, like now there is a middle-man scenario. I kind of wrestled with this just because, I like to, I think everyone does, you rely on your own judgement through your own eyes and ears. So that was different. (T6)
Developing enhanced information exchange processes
Participants recognized the need to develop processes for real-time, continuous information exchange among the therapist, the OTA–PTA, and the patient because the quality of the patient care provided depended on the quality of that process:
You really have to have a good system in place where you can exchange information because, in essence, the therapy assistant becomes your hands and you have to be able to know exactly what’s happening to the patient. (T1)
Communication back and forth for me to be up to date on what a patient is able to do, that’s important that happens [because] at the end of the day it’s the [physiotherapist] or [occupational therapist] who exercises judgement. (T1)
Several participants described creating space and time for communication with the OTA–PTAs: “We have to rely on their input – at the end of rounds we sit down with the assistants, the [occupational therapist] and [physiotherapist] … and we go through the caseload again on an individual basis” (T5).
Participants described noticing skills that were important for effective information exchange. One therapist described the elements involved in effective communication: “It’s about confidence and clarity, being able to basically speak, give the information. And written communication, too, being able to chart properly” (T7).
Participants also described the need for OTA–PTAs to be able to prioritize information: “They just wait to tell us the next morning.… But for sure if there’s any urgent issues or if they need to tell me something right away, they come and talk to us” (T4).
Several participants recognized the importance of the therapist and OTA–PTA relationship:
You have to rely on that judgement [of the OTA–PTA]. You have to really know who you’re working with, and it goes both ways. (T5)
In the new model, you really have to rely on competent assistants and have a really good working relationship with those assistants to be able to analyze the patient’s abilities. (T4)
Developing processes to support the delivery of patient care
Most participants described the necessity of ensuring that each OTA–PTA on their team had the required skill level: “You have to know their skill set and what is their comfort level” (T7). Some therapists described the added complexity of evaluating the skill levels of multiple assistants in the fast-paced environment of the new model:
You have to be able to monitor a lot of things at once – now you’re not just dealing with your own skills, you’re dealing with the skills of a lot of other people. So you have to be more aware of everybody’s skill. So you’re on all the time. It took a lot of energy. Keep monitoring, monitoring, monitoring constantly. (T7)
Some participants described concern, even fear, about the regulatory responsibility of the occupational therapist or physiotherapist for the care provided by OTA–PTAs: “Should something happen to that patient, because I’m regulated, it’s on my license, so I’m responsible for what the assistant does” (T6).
All the participants thought that patients received more frequent and consistent hands-on patient care as a result of having more assistants available to implement treatment programmes. “Patients are definitely seen more often. They get used to regular faces daily – so that’s good for continuity. They are seen more often so they can progress” (T7).
Participants also gave examples of positive patient situations and outcomes, which they attributed to the fact that more therapy care was being delivered.
We’ve sent a lot less people to rehab. They’re rehabbing on the acute care floors. They’re in bed a lot less, there’s a lot less risk for their skin breakdown, pneumonia, blood clots; it’s a benefit having them there. (T6)
As noted earlier, the PIs and academic team member conducted a secondary analysis of the data that resulted in the development of two themes. Themes present the elements described by participants, constructed into broader concepts.24
Therapists’ expectations of patient care outcomes
Reflecting on the various elements of the new model of care, the occupational therapists and physiotherapists described some elements that tended to make them worry about the potential impacts on patient care and others that gave reason for optimism. Most of the therapists worried that patient outcomes might be negatively affected because they were no longer directly using their clinical observation skill set. However, many also described how they had adapted to the new model of care by developing processes to enhance or focus the observation skills of the OTA–PTAs because they were becoming, in essence, the therapists’ eyes and ears. These processes augmented collaboration and communication between the OTA–PTAs and the therapist team. Once these positive work processes and communication strategies had been put into place, the occupational therapists and physiotherapists were more optimistic about their expectations for patient care outcomes.
All the participants appeared to be concerned about the change in the therapist–patient relationship. They highlighted the difficulty of using their expertise to make clinical judgements without having the opportunity to fully understand a patient’s story and experience his or her response to treatment. However, they appeared to offset these concerns with optimism about the potential for patients to receive more frequent and consistent care.
Redefining the value of the occupational therapist and physiotherapist role in contributing to patient care
This theme sums up the therapists’ description of reconceptualising their role after reflecting on the adaptations to their practice in delivering patient care. Several participants described the personal challenge and difficulty of giving up or letting go of the role of treatment provider. They explained that being directly involved in providing hands-on care had been a meaningful activity to them because they could appreciate the direct influence they were having on patient care. Examples are “treatment has been pulled away from us” (T6) and “I just do mostly assessment, and the treatment virtually all goes to assistants” (T1).
However, other participants recognized the potential to affect patient care in their role of managing the care provided by the OTA–PTAs: “So you don’t deliver treatment anymore. Not so much hands-on but you can progress. Day-to-day, talking to the assistants, you can progress the patient to a higher level” (T2). One participant described the shift in practice as letting go of controlling one element of patient care to enable moving to a new role and developing a new perspective of providing patient care services.
By giving up control, you are directing your energy for something that is more resourceful more useful.… So okay, I’m giving up control for interventions for XYZ patients but I’m gaining more control over looking at my caseload as a whole. (T8)
Discussion
This is the first study to explore the physiotherapists’ and occupational therapists’ perspectives on the impact on their role, their practice, and patient care when assistants became the primary providers of treatment and primary point of contact for therapy care in an acute care hospital setting. A key finding related to the impact on patient care when occupational therapists and physiotherapists adapted their practice as they transitioned into the role of manager of care provided primarily by OTA–PTAs. Overall, they thought that the enhanced availability of care provided by the OTA–PTAs was beneficial to patients because they received more frequent and consistent care. They also described the difficulties of transitioning from being a provider of patient care to a manager of patient care provided by assistants.
The therapists described the strategies they had developed to enhance their communication with the OTA–PTAs and ensure that they possessed the skills required to deliver patient care. The occupational therapists and physiotherapists also explained the experience of re-defining their role in delivering patient care when they no longer acted as the primary providers of therapy care. Overall, occupational therapists and physiotherapists felt that the perceived benefits and potential for enhanced access to care outweighed the challenges they had encountered.
The first challenge our study highlights was the therapists’ struggle to provide patient care without frequent, direct contact with patients. They talked about the need to develop enhanced communication strategies with the OTA–PTAs to maintain up-to-date information about patient status and performance. This information exchange process between the therapist and assistant was seen as essential for therapists to be able to make decisions knowing that they had the most accurate patient information. The occupational therapists and physiotherapists reflected on the increased and shared demands for communication and collaboration in the new therapist–assistant dyad. They also realized that there was a greater need for trust and accountability to underpin these interactions.
The importance of communication was highlighted in a recent survey of physiotherapists and PTAs, who rated communication as the most essential competency for effective and efficient IP collaboration.25 Unfortunately, little information is available on how to enhance information exchange with rehabilitation assistants or on other elements of a positive working partnership in general.9,25 It has been suggested that the skills needed to supervise assistants, specifically communication, be integrated into physiotherapists’ formal education and further developed through clinical educational opportunities.26,27
The importance of the physiotherapist–PTA relationship is highlighted in Plack and colleagues’ description of a “preferred relationship,” one that moves beyond knowledge and skills to include trust, mutual respect, communication, feedback, collaboration, and mutual support.28 This relationship is described as essential for ensuring effective clinical decision making and high-quality patient care.28 In a description of home care practice, in which assistants work in a less supervised environment, McCready and colleagues reported that trust between therapist and assistant was essential.17
Participants noted the increased amount of time they needed to interact with their assistants to exchange detailed information about their patients while also ensuring that their assistants were performing competently. In a trial of a similar model designed to enhance capacity by increasing the number of assistants in the allied health workforce, Somerville and colleagues also found that the therapists reported increased demands on their time so that they could provide both the supervision and the training their assistants required to ensure safe and effective patient care.1
A recent survey of Ontario PTAs showed that they recognized the importance of continuous learning.27 This finding is supported by other researchers who have found that assistants are interested in continuing to learn in the workplace setting29 and that a need exists to support their learning and development in the allied health assistant workforce.1 Vo and Feenstra described developing education to support OTAs to practise in an expanded role to support patient care.20
Our study findings suggest that supervising the care provided by multiple assistants requires therapists to use different competencies and tools than those they use when they provide care directly. This finding has implications for the competency requirements of both therapists and assistants. In Canada, foundational documents describe the essential competencies (i.e., knowledge, skills, and attitudes) required of physiotherapists, occupational therapists, OTAs, and PTAs.7,8,10,12 The physiotherapy and occupational therapy professions need to incorporate the competencies required to supervise multiple assistants into their competency frameworks so that they can define the pathway to attaining these skills and help practitioners delineate their learning needs.25 Defining the essential competencies needed to be a supervisor may also help to articulate the necessary standards of practice in more concrete ways that can direct current and future professional development needs.7,8,12,30
All of the participants in our study described not knowing their patients as well in the new model as they had in the previous model. All participants considered this change in their relationship with patients to be a loss. Our results suggest that some occupational therapists and physiotherapists were able to clearly see the value of their role in delivering direct patient care while struggling to see the value of their role as the manager of patient care provided by OTA–PTAs. The interaction between patient and therapist has been described as being central to the therapeutic process and as an important determinant of treatment outcomes.31 The Theory of Expert Practice highlights the importance of the patient–therapist relationship, suggesting that assigning care to assistants has implications for the therapeutic relationship and can interfere with patient–therapist communication.31 Although the occupational therapists and physiotherapists were able to develop processes to access information about the patient through the OTA–PTA, strategies for managing the loss of the patient–therapist relationship were not identified.
Our study had two limitations. First, the experiences described by participants may have been defined by the setting of the case study and therefore may not be generalizable to other settings. Second, our study did not include the perspectives of the other IP team members or the patients. The results of our interviews with the OTA–PTAs in this study are presented elsewhere.32 A patient’s perspective on the interactions between patient and therapist would be of particular interest, given our findings that the occupational therapists and physiotherapists noticed a change in certain aspects of their patient interactions.
Conclusion
There is growing interest in developing cost-effective strategies that improve access to rehabilitation therapy. We were presented with the opportunity to explore the perceptions of occupational therapists and physiotherapists after the implementation of a new model of care in which assistants became the primary providers of treatment and the primary point of contact for therapy in an acute medicine setting. Our participants described the need to develop professional skills and behaviours to mediate their concerns about the change in their role and to meet other implementation challenges while supporting positive patient outcomes.
However, the therapists expressed overall optimism for the potential of having more OTA–PTAs available to provide more frequent and consistent care to patients. The description of the approaches and strategies the therapists used to adapt to the changes imposed by the implementation of a new model of care could be useful to others implementing similar models of service delivery. A better understanding of the role of the occupational therapist and physiotherapist as the manager of therapy provided by assistants could support them in developing the corresponding professional skills and behaviours. We also suggest that the working processes and interactions of assistants with occupational therapists and physiotherapists be investigated to identify the characteristics of a highly functioning team. This information could be used to inform the content to be incorporated into entry-to-practice-level education and into the practice environment.
Key Messages
What is already known on this topic
There is a need to support the growing number of older and increasingly medically complex patients admitted to hospital.1,3 The benefits of using rehabilitation assistants, such as occupational therapist assistant–physiotherapy assistants (OTAs–PTAs), have been well described in the literature.2,9,10 Several studies have explored developing assistants’ scope of practice to meet the changing demands of the health care system, but little is known about the potential impacts on patient care.1,2,6,9,13
What this study adds
Participants were optimistic about the potential for enhanced OTA–PTA availability to allow more frequent and consistent care to patients. They identified the challenges of changing process and changing roles, both of which can affect their perspectives on the outcomes of patient care.
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