Hospital Restructuring and the Changing Nature of the Physical Therapist's Role.

Background and Purpose. This study was conducted to identify role behavior changes of acute care physical therapists and changes in the organizational and professional context of hospitals following restructuring. Methods. A Delphi technique, which involved a panel of 100 randomly selected acute care physical therapy managers, was used as the research design for this study. Responses from rounds 1 and 2 were synthesized and organized into exhaustive and mutually exclusive categories for round 3. Data obtained from round 3 were used to develop a comprehensive perspective on the changes that have occurred. Results. Changed role behaviors in patient care and professional interaction, including increased emphasis on evaluation, planning, teaching, supervising, and collaboration, appeared to be extensions of unchanged role behaviors. Reported changes in the structural and professional context of physical therapy services included using critical pathways to guide care, providing services system-wide, and using educational activities and meetings to maintain a sense of community. The importance of professionalism to physical therapists' work was identified and related to specific role behavior changes. Conclusion and Discussion. The changing role of physical therapists in acute care hospitals includes an increased emphasis on higher-level skills in patient care and professional interaction and the continuing importance of professionalism. [Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist's role. Phys Ther.1999;79:171-185.]

Key Words: Clinical management, Hospital restructuring, Organizational change, Professional roles, Professionalism.

With the expectation of achieving improvements in efficiency, cost, quality, and patient satisfaction, many hospitals are restructuring patient care delivery through the implementation of new delivery models. A fundamental element of this process is workforce reform in which patient care is organized around a team structure. These teams are expected to lower costs, in part because nonprofessional workers are substituted for health care professionals.[1] Workforce reform, however, is generating great debate in the health care literature. Although some authors believe it to be a key to efficiency and cost reduction,[2-5] others point out that there is no evidence for this belief. Furthermore, they view workforce reform as a threat to the foundation of professional patient care delivery and even as a threat to the quality of patient care.[6-8] There has been insufficient systematic examination of hospital restructuring, however, to support either perspective in this debate.

Although the effects of organizational change on professional control, autonomy, and even professional identity have been documented,[8-10] we are just beginning to examine the effect of organizational change on professional practice within the restructured hospital environment.[11-13] The primary purpose of my study was to expand this line of research by identifying how hospital restructuring is changing the role of physical therapists who work in acute care hospitals in the United States. In addition, this research was intended to shed some light on the role that professionalism plays in this changing work environment. Ultimately, I hope that this research will add to our understanding of how major organizational changes affect the work and careers of professional practitioners concerning factors such as satisfaction and commitment as well as how these changes affect outcomes for patients and organizations.

This research was guided by Porras and Hoffer's[14] conceptual model of planned organizational change that I had adapted previously.[12] In general, this model suggests that hospital restructuring affects a group such as physical therapists through the implementation of processes, including patient aggregation, service redeployment, cross-training, process simplification, and staff reductions. These organizational changes alter the roles of members of an organization, such as physical therapists, which in turn affects work-related outcomes. Thus, according to this model, to understand how changes in a practitioner's role affect patient outcomes, we must first explain the relevant behaviors that make up that organizational role. Furthermore, we must identify how a concept such as professionalism influences this relationship.

Organizational Role Behaviors

The concept of organizational role behavior provides a starting point to distinguish specific aspects of roles within organizations. This concept is based on the theory that organizations are open systems of roles that are assumed by members of the organization. These roles are made up of a complex grouping of behaviors based, to a great extent, on the expectations of others in the individual's role set or immediate work group.[15,16] That is, organizational roles represent patterned, motivated, and interdependent behaviors that are produced as the individual responds to the expectations of others with whom he or she interacts. Moreover, the interrelated role behaviors exhibited by these members of the organization are shaped by systematic factors operating within the organization as a whole. No factor has a greater effect on shaping roles than a major organizational change, which often requires members of the organization to alter existing role behaviors. Altering role behaviors within an organizational context, however, is not simple, especially when role behaviors have been developed through an extended process of professional socialization or when they are considered by the profession to be core dimensions of a professional role. Thus, altering these professional role behaviors may produce adverse effects on the quality of work outcomes such as patient care.

Professionalism and Organizational Change

There is little debate that professionalism is an inherent part of physical therapy practice.[17] Physical therapists fit within Pellegrino's definition of professionals as "those whose functions bring them into direct personal contact with the vulnerable patient and call for direct participation in the healing relationship."[18] Furthermore, Strauss' 4 values of professionalism -- expertise, autonomy, commitment, and responsibility -- are reflected in the nature of the work that therapists perform.[19] Even with organizational changes such as restructuring, these values can be seen in the roles of physical therapists in the hospital environment.[12] Moreover, as Scully and Shepard[20] indicate, professional attitudes and behaviors are developed through professional socialization starting early in the clinical practice of the therapists. For example, they found that the 2 concepts of patient primacy -- a deep concern for the welfare of the patient and abiding by implicit "house rules" such helping without being asked -- are inherent in the clinical training of therapists from their first clinical experience. Thus, the role behaviors expected of therapists in today's clinical environment involve professional behaviors that are often learned implicitly and may be characterized as behaviors that go beyond the requirements specified by formal job descriptions.

To investigate the connection between changes in role behaviors and a construct such as professionalism, I believe we must identify the role behaviors that have changed following hospital restructuring by using input from a larger sample of practitioners than appeared in Lopopolo's[12] qualitative case. To this end, the following research questions are posed:

1. How have the role behaviors of physical therapists changed following hospital restructuring (ie, changed role behaviors), and how have they remained unchanged (ie, unchanged role behaviors)?

2. Has the perceived level of professionalism of physical therapists changed following hospital restructuring, and what has contributed to this change (ie, level of professionalism)?

In addition to these questions, it is also necessary to understand the processes that underlie these changes. Therefore, these additional questions are posed:

1. What is the nature of the structural or operational changes that have occurred in physical therapy departments following hospital restructuring (ie, structural and operational change)?

2. What mechanisms are used by the therapists to maintain a sense of community following hospital restructuring (ie, community mechanisms)?

3. Are there environmental factors other than hospital restructuring that are producing the changes that have occurred?

The answers to these questions could have far-reaching implications for both clinical practice and education.

Methods

The Delphi Methodology

I chose the Delphi technique for this study because it is a well-known approach used in social science research to obtain consensus from a group of experts through a series of intensive questionnaires interspersed with controlled opinion feedback.[21] In an area where expertise may be difficult to identify such as clinical management, "knowledgeable informants," or individuals who have relevant knowledge on the issue under consideration, are used to reach consensus. This survey technique is characterized by (1) the anonymity of the informants, allowing for consensus to be reached without psychological pressure from influential group members, (2) an iterative process with controlled feedback usually involving 3 or 4 questionnaires referred to as rounds, and (3) the use of statistics to reflect the opinions of the entire group on individual questions.[22,23]

Panel of Informants

Because hospital restructuring has not been implemented in a uniform manner across the country, a panel of 100 informants -- a large panel by Delphi survey standards -- was used for this study. The panel was made up of physical therapy department directors or clinical managers working in acute care hospitals throughout the United States. These panel members were chosen because of the central role they play in the integration of physical therapy services into the hospital operation and because of the knowledge they possess concerning the role behaviors of physical therapists within their respective facilities.[24,25]

The panel was selected from the membership of the American Physical Therapy Association's (APTA) Section on Administration and Acute Care/Hospital Clinical Practice Section who: (1) responded affirmatively to the invitation to participate in the study that was sent to all members of these 2 sections, (2) worked in an acute care hospital that had undergone restructuring, and (3) were in managerial positions in acute care hospitals at the time of the hospital restructuring. A broad, geographic representation was achieved by randomly selecting 25 managers from each of 4 geographic regions of the country (the West, Midwest, South, and Northeast) from an initial pool of 450 respondents.

Survey Procedure

The questionnaire and a cover letter for each round were sent to the informants with a 2-week turnaround time for their response. To maximize the response rate, a follow-up postcard was sent to each informant who had not responded by the deadline. Procedures for managing the data within each round are described in the following section.

The Delphi Instrument

The initial questionnaire (round 1) was designed to gather participants' perceptions of the effect of hospital restructuring within their own facility through the use of the following broad, open-ended questions:

1. Identify up to 3 of the most significant changes in the structure of the physical therapy department that resulted from hospital restructuring.

2. Identify up to 3 role behaviors of physical therapists working in this facility that have changed as a result of the restructuring process.

3. Identify up to 3 role behaviors of physical therapists working in this facility that have remained unchanged as a result of the restructuring process.

4. Identify up to 3 ways the therapists have maintained a sense of community with other physical therapists in the facility.

The request for a limited number of responses was intended to keep the survey response time to a minimum and to help the informants focus on the most important or characteristic aspects of the change process within their own facility. Participants were instructed in the cover letter to provide more than 3 responses if desired. The questions regarding level of professionalism and other contributing environmental factors were held until a later round to avoid confusion with the identification of the changes that had occurred within the facilities.

Demographic data about the informants and their positions within the facilities were also gathered during round 1. In addition, to obtain a sense of the overall scope of the restructuring process in the facilities represented, the informants were asked to provide specific information on the hospital restructuring process itself and its perceived effect on the delivery of physical therapy services. The round 1 survey was pilot-tested to evaluate the appropriateness, understandability, and inclusiveness of question content and terminology using a group of 5 local physical therapy directors who were familiar with hospital restructuring, but who did not participate in the study itself.

Responses provided by informants to each of the 4 open-ended questions were transcribed verbatim by a research assistant. Using an inductive coding technique advocated by Glasser and Strauss[26] and a process of check-coding as recommended by Patton,[27] 2 researchers experienced in qualitative data analysis independently coded and categorized the data from each question into meaningful and discrete descriptive units.[26,28] First, each researcher grouped the informants' responses by common themes. Second, labels for the categories were developed from the data based on the content of the categories. For example, the informants identified an increase in the therapist's role in the teaching of patients, families, and other health care providers that was labeled as "increase in educating and teaching." Third, the breadth of each category was defined through the use of low-inference data (eg, direct quotes provided by the informants) taken from the actual informants' responses. For example, low-inference data for the category "maintain a professional approach to work" included "be accountable for the work to be done," "act in the patient's best interest," "be conscientious about the job," and "maintain a professional identity."

To obtain clear, operational, reliable, and useful categories, the coding schemes and categories developed by the 2 researchers were compared and discussed until agreement was reached.[26,28] Once a uniform coding scheme was agreed on, the 2 researchers independently recategorized the informants' responses. A second check on the agreement of the categorization of the responses was conducted to ensure intercoder agreement on each question.[26,28,29] The resulting categories, including the low-inference data, served as the basis for the round 2 survey.

The purpose of round 2 was to allow the informants:

1. to review the categories of responses from round 1 for the clarification and correction of terminology to be consistent with that used in the hospital environment,

2. to add any additional responses that they felt were missing from the category listing, and

3. to identify categories of responses they considered to be the most important or most powerful in regard to physical therapy practice in their facilities.

Using a process similar to that described for round 1, the 2 independent researchers reviewed the data from round 2, incorporated missing data identified by the informants, and reorganized and clarified some of the categories based on informant input to develop categories that were independent and mutually exclusive. The revised categories were used in the third and final survey round.

The purpose of the third round was to identify the frequency with which changed role behaviors, unchanged role behaviors, structural and operational changes, and community mechanisms had occurred in the sample of hospitals. In addition to providing this composite picture of physical therapy practice following hospital restructuring, the informants were asked to indicate their perception of the effect of these changes on the level of professionalism of physical therapists within the facility, including the identification of factors that either acted to increase or acted to decrease the level of professionalism. Finally, they were asked to identify environmental factors that they felt were acting independently of hospital restructuring to produce the changes that occurred.

Results

Three of the 100 clinical managers selected to participate in the study withdrew without completing the first-round survey, resulting in an overall panel size of 97 informants. From this panel, a minimum overall response rate of 70% (52% from each geographic region) for each survey round was achieved.

Round 1

Seventy-two of the 97 informants (74%) responded to the round 1 survey. The demographic makeup of the informants is shown on Table 1. A surprising factor in this profile is the relatively low number of years (4.1 years with a quite large variability) that the informants have held their current position. The data on the nature of the position change following hospital restructuring, however, indicate that the implementation of hospital restructuring resulted in a change in positions for almost half of the informants.

Table 1.
Demographic Profile of Panel of Informants

Characteristic               [bar] X   SD   Median   Range

Sex
  Female 80.6%
  Male 19.4%
Age (y)                      40.8      7.4   40      25.0-58
No. of years as a physical
    therapist                16.8      8.0   15      1.3-35
No. of years employed in
    organization              9.6      6.3   8       0.3-27
No. of years in current
    position                  4.1      4.1   3       0.2-17.5

Nature of position change
    following hospital
    restructuring
 Narrower responsibilities                   14%
 No change in position                       45%
 Broader responsibilities                    34%
 Left organization                           7%

Table 2 provides some insight into the nature of the hospital restructuring that has occurred. Although restructuring started in the early 1980s, the majority of the hospitals represented in this study began restructuring within the last 5 years and the physical therapy departments were involved early in the process. This table also shows that 91% of the informants believed that restructuring has affected the delivery of physical therapy, with almost half indicating that the effect has been moderate to significant.

Table 2.
Profile of Hospital Restructuring and Its Effect
on Physical Therapy

Characteristic               [bar] X   SD    Median   Range

No. of years since
 implementation of hospital
 restructuring(a)              3.2     2.5     3      <1-15
No. of years since
 physical therapy
 affected by hospital
 restructuring(a)              2.7     2.7     2      <1-15
Overall effect of
 restructuring on the
 delivery of physical
 therapy
   No effect                     9%
   Minimal effect               45%
   Moderate effect              35%
   Significant effect           11%

Effect on Physical Therapy of Implementation
of Restructuring Processes

Restructuring Process     Process         Implementation
                          Implemented     Changed Delivery
                                          of Physical Therapy

Cross-training               74.6%             49.8%
Staff reductions             73.6%             59.7%
Patient aggregation
 (group patients by
 product line)               66.7%             47.8%
Service redeployment
 (movement in services
 closer to patients)         64.8%             49.3%
Process simplification
 (reduction in
 administrative
 tasks)                      27.9%             20.6%

                              Effects of Change on Delivery
                                   of Physical Therapy

Restructuring Process       Positive     Neutral     Negative

Cross-training              21.9%        17.6%       10.3%
Staff reductions             5.6%        16.7%       37.5%
Patient aggregation
 (group patients by
 product line)              30.4%        13.1%        4.4%
Service redeployment
 (movement in services
 closer to patients)        41.8%         7.5%        0.0%
Process simplification
 (reduction in
 administrative
 tasks)                      1.5%         7.3%       11.7%

(a) Using 1997 as base.

Over 60% of the informants indicated that 4 of the processes characteristic of hospital restructuring (ie, patient aggregation, service redeployment, cross-training, staff reductions) have occurred within their facilities and have changed the delivery of physical therapy services. Of these 4 processes, only staff reductions were viewed as having a serious negative effect on physical therapy delivery. Although process simplification is identified as a characteristic of hospital restructuring,[4] a number of informants indicated that administrative tasks actually increased and had a negative impact on the delivery of services.

On the round 1 survey, the informants provided over 125 individual responses to the questions on structural or operational changes and community mechanisms. These responses were reduced to 15 and 13 categories, respectively. In addition, the informants provided over 140 responses to the changed and unchanged role behavior questions, which were reduced to 14 categories each for use in the round 2 survey.

Round 2

Seventy-three percent of the informants responded to the round 2 survey and provided 27 suggested changes or additions to improve the specificity and clarity of the survey categories. For example, it was suggested that "Increase in role as consultant or clinical specialist" be modified to read "Increase in role as consultant, specialist, or advanced clinician"; this change would avoid confusion with formal clinical specialization and would use terminology prevalent in the hospital environment. In addition, many of the informants identified low-inference data within the categories that they felt were misplaced and thus altered their perception of the meaning and effect of a specific category.

As a further check on proper categorization and clarity, the informants identified the most important categories related to each of the 4 questions. For all 56 categories, only 7 were viewed as most important by 50% or more of the informants. Of the remaining 49 categories, only 33 were viewed as most important by 25% or more of the informants. An exploration of these rather low results revealed additional misplacements of categories or low-inference data that decreased the specificity and clarity of the categories themselves and decreased possible consensus among the informants. Finally, to further clarify the focus of each category for the informants, the categories were grouped by common content. For example, the categories for changed and unchanged role behaviors were grouped by "direct patient care," "professional interaction," and "other work-related activities," and the categories for structural and operational changes were grouped by "organizational structure and reporting relationships" and "physical therapy service delivery." Based on these changes, the round 3 survey was developed. In addition, a revised model with the new category groupings was developed and is depicted in Figure 1. It should be noted that the categories for community mechanism are not depicted in this figure because they may not represent actual changes in physical therapy services. All of the categories used in the final survey round, however, are included in the Appendix, with the actual response rates for each.

[Figure 1 ILLUSTRATION OMITTED]

Round 3

Sixty-eight informants (70%) responded to round 3 of the survey. To confirm the relationship between' environmental change and role behavior change posited in the conceptual model (Fig. 1), the informants were asked to identify any environmental factors other than hospital restructuring that they believed produced the changes seen within the facility. Fifty-two informants (76.5%) indicated that they felt that there were other independent factors contributing to the change in role behaviors. The majority of these informants identified changes in reimbursement and control of health care, specifically managed care and payer control, as the main factors causing changes in lengths of stay in the hospital, the movement of patients to less acute levels of care, and increased productivity expectations within the hospitals. In addition, these environmental factors were perceived to be increasing the competition among institutions and to be contributing to a change in the expectations for all providers. Moreover, they were perceived to be causing potential problems with "situational ethics," "trust within the hospital," and "the ability of a hospital to provide indigent care and remain financially viable."

Because the final round was intended to ascertain the extent to which each category characterized the facilities, the informants identified all of the categories under each question that were characteristic of their own hospital. The response rates for the categories identified by 50% or more of the informants are displayed in Figures 2 through 5. Following the conceptual model, the structural and operational changes of physical therapy services were examined first (Fig. 2).

[Figures 2-5 ILLUSTRATION OMITTED]

A great deal of variability was seen in structural and operational changes across the facilities. Overall, 11 of 17 the categories under structural and operational changes occurred in 50% or more of the facilities, with a greater percentage of the informants reporting changes in physical therapy service delivery than reporting changes in organizational structure and reporting relationships. Only 2 changes -- "providing physical therapy services beyond the hospital" and "the use of critical pathways to guide patient care" -- occurred in 70% or more of the facilities.

There was a greater overall response rate for the categories of changed and unchanged role behaviors (Figs. 3 and 4) than for the categories of structural and operational changes. For changed role behaviors, 5 of the 6 direct patient care categories and 2 of the 3 professional interaction categories had at least a 70% response rate. Only 2 of the 5 categories under other work-related activities, however, reached this level.

[Figures 3-4 ILLUSTRATION OMITTED]

The most prevalent changed role behavior was an "increased focus on the functional needs of patients," followed by an increase in "the focus on the efficiency," "patient evaluation and program planning," and "integration into patient care teams." Furthermore, a "decrease in time spent treating patients" was emphasized in 3 of the categories under direct patient care -- "evaluation and program planning," "education and teaching," and "delegation and supervision" (see Appendix) -- and was also related to the increase in the role as a consultant. Finally, although the category of "increase in administrative activities" achieved a 75% response rate, a small percentage of informants experienced a "decrease in administrative activities" as proposed in the rationale for hospital restructuring.

The pervasiveness of the role behaviors that did not change was revealed because all categories under unchanged role behaviors achieved at least a 50% response rate and, in all but 3 categories, achieved a 70% or greater response rate. The most notable role behavior that did not change was "maintaining a professional approach to work," which was reported by 91.2% of the informants.

The types of mechanisms used by therapists to maintain a sense of community were found to be similar across facilities (Fig. 5). Nine of the 12 community mechanisms were identified by more than 75% of the informants as being used within their facility, and the remaining 3 were used in at least 50% of the facilities. "Staff meetings" and "educational activities" were used most often to maintain a sense of community.

[Figure 5 ILLUSTRATION OMITTED]

Finally, round 3 was used to identify how the perceived level of professionalism has changed in this clinical environment. Of the 68 informants responding to round 3 surveys, 39 (57.4%) indicated that they believed that the changes had increased the overall level of professionalism of physical therapists within their facilities. When asked to identify the most important categories that they felt produced this increase, at least 5% of the informants identified the categories listed in Figure 6, The categories representing changed and unchanged role behaviors were believed to be most important to enhanced professionalism, with "increase in the integration of the physical therapist into multidisciplinary teams" and "increase in the role as consultant, specialist, or advanced clinician" seen as the most important factors.

[Figure 6 ILLUSTRATION OMITTED]

Conversely, 16 informants (23.5%) indicated that they believed that the changes had decreased the overall level of professionalism of the physical therapists within their facilities. The most important categories contributing to this decrease are also identified in Figure 6. Although there was less agreement on the contributing factors among the 16 informants, most of the factors represented structural and operational changes with "increased productivity expectations" identified as the most important factor contributing to the sense that the level of professionalism of physical therapists had decreased.

Discussion

This study was designed to gain a more comprehensive perspective on the effect of hospital restructuring on the role behaviors of physical therapists and to build upon the conceptual model previously developed.[12] The first question to be answered was: How well does the panel of informants reflect the perceptions of clinical managers across the country? First, although the initial population used in this study was chosen .for convenience from members of APTA, a large, stratified sample of informants from across the country was used to account for the known variability that has characterized hospital restructuring. In addition, the total response rate to each survey round was at least 70%, representing over one half of the participants from each region. This rate helps ensure a broad-based representation of perceptions. Second, the demographic profile of the informants indicates that they generally represent an experienced group of therapists who have been employed in their respective organizations for a considerable period of time and have worked within the facilities throughout the restructuring process.

A second question was: Can we characterize the changes that have occurred? Restructuring has not been uniformly implemented across the country.[30] This finding is reflected in the fact that the implementation of each of 4 restructuring processes -- service redeployment, patient aggregation, staff reductions, and cross-training -- occurred in a low of 65% to a high of only 75% of the hospitals. In addition, the implementation of process simplification was considerably lower than the other processes, which may reflect the fact that, although administrative task reduction is posited to be a key characteristic of restructuring,[4] many of the informants believed that administrative tasks performed by the therapists had actually increased following the hospital restructuring.

The variability in the implementation of the restructuring process seen across the sample was also reflected in the informants' views of the effect of the processes on physical therapy delivery. With the exception of reduction of administrative tasks, the implemented processes appeared to change physical therapy delivery 48% or more of the time. In those hospitals in which changes in physical therapy delivery occurred, the effect of these changes ranged from a positive effect of just over 41% for the movement of services closer to patients to a negative effect of just over 37% for staff reductions. The overall effect of cross-training seemed to be somewhat divided, perhaps because it did not directly involve the cross-training of therapists in most facilities.

A third question was: Are there environmental factors other than hospital restructuring that are producing the changes seen within the facilities? Although three fourths of the informants responded affirmatively to this question, the majority of the environmental factors identified related to changes in the external health care environment such as managed care, payer control, and increased competition. These findings are consistent with the conceptual model (Fig. 1) because changes in the health care environment appear to be precipitating changes in the organization of the health care delivery system as well as decreasing the lengths of stay for patients. As role theory proposes, these changes, translated through organizational expectations, are affecting the role behaviors of physical therapists.[15, 16]

Changes in the Structure and Operation of Physical Therapy Services

Although the conceptual model proposed by Lopopolo[12] identified 4 separate categories under the heading of the physical therapy department (ie, social factors, organizing arrangements, physical setting, technology), the categories under structure and operational changes more naturally fell into 2 groups as depicted in the revised conceptual model: (1) organizational structure and reporting relationships and (2) physical therapy service delivery.

For these facilities, the pattern of change in organizational structure and reporting relationships was not uniform, although the most consistent change was an expansion of service provision beyond the confines of the traditional hospital. These findings support the perception that, although the implementation of organizational restructuring is fairly specific to the individual institutions, in many cases it is a part of a larger reorganization of the health care delivery system.[30] The changes that have occurred in service delivery appear to represent mechanisms to expedite patient care and facilitate patient discharge in response to increased pressure from third-party payers. In addition, institutions have implemented measures, such as decentralizing the delivery of services, increasing the flexibility of staff assignments, increasing productivity expectations, and expanding the use of cross-trained support staff, in order to streamline operations and reduce costs while trying to meet the patients' health care needs.

Role Behaviors: Changed and Unchanged

Direct patient care. The high response rate for unchanged role behaviors indicates that physical therapists are still involved in patient evaluation, treatment, program planning, and education, with considerable emphasis on the documentation of care. Yet, when these behaviors are viewed in terms of the changes that are taking place, one can see that the emphasis of the therapist's role has shifted toward a greater focus on evaluation and treatment planning, delegation and supervision of care, and the teaching of patients, families, and other health care practitioners. At the same time, the focus has shifted away from the provision of actual, direct, "hands-on" care expressed as a "decrease in time spent treating patients." A clear underlying factor driving this shift, identified by 94% of the informants, has been an "increased focus on the functional and discharge needs of patients." This focus includes the increased involvement of the patient and family in the planning process and the more direct involvement of the therapist in the preparation of the patient for the next level of care through increased team participation and the assumption of a consultant role.

Professional interaction. All categories of professional interaction under the heading of unchanged role behaviors, except "educating groups outside of the hospital," had a 79% or greater response rate, with the highest level for "maintaining a professional approach to work." From the data, it is clear that, although the role of the therapist is changing, the importance of maintaining a professional approach to one's work -- through accountability and conscientiousness, collaboration with others involved in patient care, and education -- remains an important factor and is valued within this environment. As with direct patient care, the changes in role behaviors in the area of professional interaction are again extensions of the unchanged role behaviors that incorporate more advanced professional communication skills. That is, there has been an increase in the integration of therapists into the multidisciplinary patient care teams, and there has been an increase in the role of the physical therapist as a consultant within these teams. For example, therapists are assuming a greater and more direct role in determining discharge plans and equipment needs and in acting as patient advocates with insurance companies.

Other work-related activities. As mentioned previously, contrary to the expectations, there has been an increase in administrative activities related to both department and hospital-wide responsibilities. This increase seems to cover a range of administrative activities from operations and committee work to performing clerical tasks that do not require the skills of a professional practitioner. In regard to this latter finding, it appears that as organizations have reduced costs, they may have actually decreased the productivity of professional providers by encumbering them with clerical tasks that could be performed by a lower-cost employee. Thus, in some cases, they have reduced the professional's time for direct patient care, which is contrary to the primary objective of hospital restructuring.[4]

Finally, there has been an increase in the demands on the therapist to be flexible in work assignments, which includes both work schedules and the location of work assignments. This role behavior change appears to be the same as the concept of "being flexible" identified in previous research on therapists' roles.[12] This change also appears to be most pronounced in those facilities that have become part of a health care system where therapists may be assigned not only to various units within a hospital, but also to various sites or facilities within the entire system.

Mechanisms Used to Maintain a ,Sense of Community Within Physical Therapy

Although not unique to the restructured hospital environment, mechanisms to maintain a sense of community seem to have taken on new dimensions because 61% of the informants indicated that there had been changes in the structure of the physical therapy department. Coming together for "staff meetings" or "educational activities" seems to have a notable effect on the maintenance of cohesion among the therapists, especially when services are provided across a health care system. Again, involvement in clinical education and collegial communication seem to be important mechanisms. In addition, helping and sharing duties, including sharing weekend and holiday work, social activities, or even sharing common space, appear to play a role in maintaining a sense of staff cohesion and professional identity, which is consistent with previous findings.[12] Thus, although therapists have become a part of wider organizational teams and view this role as important, they still retain close ties and working relationships with other physical therapists in order to coordinate the delivery of care in a conscientious and professional manner and in order to fulfill some of their professional and social needs.

The Effect of the Changes on Physical Therapists' Sense of Professionalism

The importance of professionalism or the "maintenance of a professional approach to one's work" was identified by 91.2% of the informants as an unchanged role behavior. Furthermore, over one half of the informants indicated that they felt that the level of professionalism had increased subsequent to restructuring, whereas less than one quarter indicated that they felt that the level of professionalism had decreased. This disparity may well reflect differences in the restructuring processes that have been implemented in the individual facilities, differences in the length of time since the implementation of the changes, or even different interpretations of the term "professionalism" by the informants. Explanations for these differences need to be explored further.

The informants provided some insight into the factors that they believed contributed to a change in professionalism. For those who felt that professionalism had increased, the most important factors seem to lie in changed role behaviors, including tasks that require a high level of integration of clinical skills (evaluation, program planning, and consulting), coupled with a high level of communication and collaboration (integration into multidisciplinary teams), all of which relate to an increased focus on the needs of the patients.

When these factors are viewed in relation to Hall's attitudinal attributes[31] as well as Scully and Shepard's concept of patient primacy,[20] we can see the reflection of service to the public, collegial control, and autonomous decision making. Certainly, the prevalence of mechanisms used to maintain a professional community also reflect these attributes and, as posited by role theory, may well be implicit as well as explicit channels used to transmit behavioral expectations among professional colleagues. In any case, maintaining a sense of professionalism seems to be inherent in the practice of physical therapy within the hospital environment.

Some of the informants, however, felt that the level of professionalism had actually decreased. For these individuals, the effect of structural and operational changes, including the loss of direct, "hands-on" care, the increased focus on productivity, and staff reductions, seems to have diminished their perception of the status of the physical therapist within their institutions.

Study Limitations

Although this study begins to give greater clarity to the changes occurring in the hospital environment and the effect of these changes on physical therapy practice, the findings must be viewed in the context of methodological constraints as well as in the context of an extremely varied health care environment. First, the population of clinical managers used for this study may have introduced a bias that reflects the views of practice represented by association members rather than by physical therapy managers in general. Second, although a random sampling method was used to select the panel of informants, no data were available to ensure that this sample was truly representative of the entire clinical manager population. Third, the perceptions of the changing role of physical therapists represented in this study are those of clinical managers who were chosen for their unique role in this environment. These perceptions, however, may be different from the perceptions of the staff therapists themselves. Finally, although the role of professionalism in clinical practice was an important factor in this study, the informants were allowed to define professionalism in their own terms, thus introducing some interpretative variability.

Conclusions

Although we know that the practice of physical therapy along with that of other providers is changing, we still do not know the extent and permanence of these changes. It was clear from this study that there was a great deal of variability in the changes implemented among the facilities. We know that organizational changes are still proceeding, as is evident by the continued development of health care systems across the country. In addition, some changes are being eliminated and the return of facilities to older models of organization is common. Thus, we need to continue to study this phenomenon and its effect on the practice of physical therapy. Also, we need to exchange ideas on how to respond to the forces producing these changes in order to shape the future practice of physical therapy.

The clear emphasis on higher-level evaluative and planning skills as well as communication and collaborative skills has been explored in this study. Therapists, I believe, must be prepared educationally to enter the clinical setting with the ability to focus on patient needs and interact closely with other providers to ensure that patients receive the care necessary in the time allowed. Furthermore, they need to be prepared to act as consultants and educators for patients when necessary care cannot be provided within constraints of the system.

Finally, the concept of professionalism remains an important factor in shaping practice in the hospital environment. It is incumbent upon the profession and practitioners to better understand the nature of this concept and its specific relevance to clinical practice, especially when external forces within the health care environment are pressuring practitioners to do more with fewer resources.

In conclusion, this study has shown that there is general agreement regarding how the role of physical therapists in acute care practice across this country is changing as a result of hospital restructuring. In an evolving health care environment, the emphasis on higher-level skills that focus on specific patient needs is supported by the continuing importance of professionalism in clinical practice.

Acknowledgment 

Special thanks to Katherine F Shepard, PhD, PT, FAPTA, for her support and expert assistance in this endeavor.

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Appendix.
Survey Categories Used for Final Round

                   Changes in the structure or          % Responses
                   operation of physical therapy
                   services

Organizational     * Physical therapy services are
Structure and        provided beyond the hospital          72.1
Reporting          * Change in organizational
Relationships        structure                             61.8
                   * Reduction of positions or
                     supervision                           54.4
                   * Change in reporting
                     relationships or supervision          52.9
                   * Expanded responsibilities             52.9
                   * Voluntary turnover of
                     physical therapists                   45.6
                   * Minimal or no change in
                     organizational structure of
                     physical therapy department           22.1
                   * Utilize separate, autonomous
                     entity to provide
                     physical therapy                      17.6

Physical Therapy   * Use critical pathways or care
Service Delivery     paths to guide care                   75.0
                   * Change in physical therapy service
                     delivery                              69.1
                   * Increase in productivity
                     expectations                          67.6
                   * Change in schedule of service
                     provision                             66.2
                   * Cross-training of support staff       57.4
                     therapists to deliver physical
                     therapy care                          54.4
                   * Use centralized scheduling            20.6
                   * Cross-training of therapists          19.1
                   * Minimal or no change to physical
                     therapy service delivery               8.8

                   Role behaviors that have changed for
                   therapists in an acute care setting

Direct Patient     * Increase focus on functional needs
Care                 of patients                           94.1
                   * Increase in focus on efficiency
                     in the performance of activities      85.3
                   * Increase in patient evaluation        82.4
                     and program planning with decrease
                     in patient treatment                  82.4
                   * Increase in delegation and
                     supervision of the care with
                     decrease in patient treatment         77.9
                   * Increase in educating and teaching
                     with decrease in time treating
                     patients                              75.0
                   * Increase in performing patient
                     care activities other than
                     physical therapy                      36.8

Professional       * Increase in the integration of
Interaction          physical therapists into
                     multidisciplinary teams               80.9
                   * Increase in role as consultant,
                     specialist, or advanced clinician     72.1
                   * Assumes formal responsibility for
                     case management                       17.6
Other              * Increase in administrative
Work-Related         activities                            75.0
Activities         * Expanded scope of work
                     assignment or location                72.1
                   * Increase in the therapist
                     isolation during delivery
                     of care                               26.5
                   * Decrease in ability to plan
                     or control own work schedule          32.4
                   * Decrease in administrative
                     activities                             7.4

                   Role behaviors that have not
                   changed for therapists in an
                   acute care setting

Direct Patient     * Provide documentation of care         88.2
Care               * Provide patient and family
                     education                             83.8
                   * Evaluation of patients and
                     planning programs                     79.4
                   * Provide direct physical
                     therapy patient care;
                     treat patients                        73.5
                   * Delegation to and supervision
                     of physical therapist
                     assistants and support
                     personnel in provision of
                     physical therapy care                 69.1

Professional       * Maintain professional approach
Interaction          to work                               91.2
                   * Clinical education of students        86.8
                   * Therapist self-education              85.3
                   * Interaction between or
                     among therapists                      80.9
                   * Communication, collaboration with
                     other health care professionals       79.4
                   * Educate groups outside of the
                     hospital                              55.9
Other              * Administrative activities             69.1
Work-Related       * Maintain ability to plan and
Activities           control work to be done               63.2

                   Mechanisms used to maintain a sense
                   of community within physical therapy

                   * Staff meetings                        92.6
                   * Educational activities                91.2
                   * Professional or collegial
                     communication (within the
                     organization)                         85.3
                   * Socialization                         85.3
                   * Helping one another                   83.8
                   * Work on weekends or holidays
                     through a rotating schedule           83.8
                   * Involvement in clinical education     80.9
                   * Share space                           77.9
                   * Retain some form of "physical
                     therapy department" structure         76.5
                   * Committee work                        67.5
                   * Professional contact or
                     interaction outside of work setting   57.4
                   * Use electronic and other media
                     for communication                     52.9

RB Lopopolo, PT, MBA, is Assistant Professor, Department of Physical Therapy, Beaver College, 450 S Easton Rd, Glenside, PA 19038 (USA) ([e-mail]).

This study was approved by the Beaver College Committee on the Protection of Research Subjects. The rights of human subjects were protected.

This study was supported through a Doctoral Research Award from the Foundation for Physical Therapy Inc.

This article was submitted May 1, 1998, and was accepted October 13, 1998.