Perceptions of acute care physical therapy practice: issues for physical therapist preparation.

The changing economics and organization of health care systems in the United States has led to shorter hospital stays, demanding greater efficiency in the care of both medical and surgical patients in the acute care hospital setting.[1,2] These trends directly influence the provision of health care services. This report addresses the practice and preparation of physical therapists for the changing acute care hospital practice environment.

Since the implementation of the prospective payment system, the length of patient stays has decreased.[3] Physical therapists are finding that they have fewer days to see patients to accomplish traditional physical therapy goals.[3] Feeling that one's time is not allocated properly has been shown to be a significant source of job-induced tension for physical therapists.[4]

Organizational demands for accountability for productive use of staff time may also increase perceived time pressures. Feelings of time pressures may also be due to inadequate staffing. Managers of acute care physical therapy facilities have particularly felt the effects of staffing shortages, experiencing long delays in replacing physical therapists.[5] Inadequate staff is a source of role stress, creating a conflict between providing service to all patients and providing sufficient care to meet the needs of individual patients.[4]

Recent reports[3,6] indicate that acute care and outpatient physical therapy Medicare referrals have increased significantly since the implementation of the prospective payment system for diagnostic related groups. Even though the number of these referrals has increased, the number of physical therapy visits has decreased,[7] which has had a corresponding effect on patient discharge status. Fitzgerald et al[7] reported that patients with hip fractures are more likely to be discharged at a lower level of function and are discharged more frequently to skilled nursing facilities than before the implementation of the current prospective payment system. Physical therapy services are often critical for restoring the functional mobility of patients with multisystem involvement and may mean the difference between discharge to institutional care and ability to live independently in the home setting.

Short hospital stays, staffing shortages, and increases in Medicare inpatient referrals have created a situation in which fewer experienced physical therapists are seeing a higher caseload of sicker patients for shorter periods of time. These trends lead us to question whether the preparation of physical therapists is congruent with the realities of practice in acute care settings. Basic functional assessment, time management, caseload management, and patient education are key skills necessary for acute care physical therapy practice. A key question for the profession is, Do physical therapy curricula adequately prepare new graduates for practice in acute care settings?

The experience of the clinician may play an important part in his or her ability to handle the stresses of acute care practice. Several investigators have focused on the perceptual differences of inexperienced and experienced health care providers. Benner[8] documented expert-novice differences that influence nursing practice. The expert may be more sensitive to an overall "pattern" of environmental, social, emotional, and physical cues that all fit together to influence a decision. In contrast, the novice may be more attuned to situational or case-specific "rules" of care and may somewhat ignore the bigger picture in his or her decision-making processes. Jensen et al[9] studied the interaction of experienced and inexperienced physical therapists with patients. They found that the experienced physical therapists spent more total treatment time in direct patient contact than did inexperienced physical therapists. Additionally, the experienced therapists more efficiently handled interruptions and tasks outside of direct treatment time without disrupting the treatment session.

In our experience, new graduates often seek employment in acute care settings to gain experience with a wide variety of patients. Accordingly, large institutions and teaching hospitals often serve as training grounds for inexperienced physical therapists, who work in these settings for 2 or 3 years after graduation. Acute care physical therapists who responded to a 1988 American Physical Therapy Association (APTA) survey indicated a perception that the average tenure of employment in the acute care setting was 1 to 2 years.[5] Therapists who left the acute care setting most often pursued employment in private practice and home health care settings.[5] In this survey, therapists who had recently left the acute care setting showed lower levels of satisfaction with professional status and interaction, hospital administration, doctor-therapist relationships, and autonomy.[5]

Other key questions for the profession to address are (1) Is the decision to move on to practice settings other than acute care related to beliefs on the part of new graduates that experienced therapists do not remain in acute care practice, or is this decision related to observed role stress and eventual dissatisfaction in the acute care setting? and (2) Are the demands of acute care practice in a large organization different from those in a smaller institution?

Identifying role stresses that new graduates face in acute care physical therapy practice has important implications for educating student therapists and assisting new graduates and reentering therapists to adapt more easily to the demands of the current practice environment.

Preliminary Study

In a preliminary study,[10] we analyzed data from interviews and participant observation of the acute care physical therapy process. We gathered data on therapists' perceptions of factors influencing the treatment of 24 patients selected from the acute care population at a large urban medical center.

The findings of this study documented common practices in acute care physical therapy and showed that acute care physical therapists were concerned about many areas of patient management during evaluation, treatment, discharge planning, and postdischarge follow-up. During the evaluation process, many therapists felt that there was insufficient social information in the medical record to set discharge goals. Due to limited time and large caseloads, the therapists frequently prioritized the patients' current functional status and prior level of function as important foci of the initial evaluation. Less priority was given to evaluation procedures such as detailed goniometry. Similarly, treatment goals often focused on functional skills such as gait training and transfers, with less attention to other clinical phenomena often seen with patients in acute care settings such as impaired respiratory function or pain.

These therapists felt that numerous organizational and patient factors affected their delivery of physical therapy services, including short staffing, difficulty changing treatment orders, discontinuity of care, patient medical complications, and poor patient cooperation with the physical therapy program. Older, sicker patients with multiple medical problems were often unable to participate consistently in physical therapy because of complicating medical factors or the multiple medical tests required. The therapists' preparation for and attempts to see these patients often totaled several hours per day, which was time that could not be billed to the patients.

Patient discharge frequently occurred within 1 or 2 days of referral, often lacked coordination, and occurred without communication between health care providers or between the physical therapist and the family. The therapists in this study expressed frustration that patients were seen only once or twice in the acute care setting before decisions needed to be made regarding the nature and needs of postdischarge referral. The therapists rarely felt that they had sufficient time to accomplish what they were capable of doing with their patients. Physical therapy management of patient needs in the acute care setting often required immediate referral to another practitioner in home care, a skilled nursing facility, a rehabilitation center, or an outpatient physical therapy setting. Such referral created role conflict for many therapists who wanted to provide the services themselves. Therapists also held strong beliefs about the lack of attractiveness of the acute care setting as a career choice, noting high turnover rates and trends toward increased part-time, temporary, and inexperienced staff.

Role Stress

The physical therapist's self-perceived inability to provide effective patient care (either in quantity or quality) has importance as a possible source of role conflict and job dissatisfaction, which may lead to early turnover and attrition in the acute care setting and possibly from the field of physical therapy.[10] Ethical dilemmas arise when physical therapists experience conflicts between loyalty to their patients and loyalty to their employers.[11,12] Such dilemmas are common in the constant juggling required to meet both the patient's needs and the employer's needs for productivity and efficient service delivery in today's health care environment. In addition to the sources of role stress, the size of an organization may further influence therapists' perceived control of their environment and work load. The inexperienced physical therapist may be ill-equipped to function effectively in the complex health care system and manage multiple areas of role stress.

In undertaking the study reported in this article, we hypothesized that there would be differences among physical therapists of various experience levels and among physical therapists employed in institutions of various sizes in the frequency of their reporting patient-related factors, organizational factors, and health care system constraints that interfered with their ability to provide physical therapy services. We hypothesized that inexperienced physical therapists in larger institutions would report the most frequent constraints to their practice.

The purposes of this report are (1) to describe common experiences in the acute care practice of physical therapy, based on subjects' responses to a questionnaire about their perceptions, and (2) to identify the differences in the perceptions of physical therapists with various levels of experience and in various sizes of acute care facilities about the practice of physical therapy in the acute care setting,

By studying professional practice from this perspective, we may determine any incongruity between the practices of experienced therapists and the most recent physical therapy graduates and identify the size of acute care facilities in which differences in practice may be more prevalent. With this information, educators and administrators can develop appropriate educational programs and the means to recruit more experienced staff and retain physical therapists of all experience levels in acute care physical therapy settings.

Method

Subjects

A questionnaire was sent to 500 acute care physical therapists randomly selected from APTA membership lists. Two hundred two physical therapists (40.5%) responded to the survey request. Fourteen questionnaires were not usable due to incomplete responses, leaving 188 (37.4%) for data analysis. The respondents who returned completed questionnaires ranged in age from 20 to 55 years, with an average age ([+ or -] SD) of 31 ([+ or -] 6.8) years. They ranged in experience in acute care physical therapy practice from 0.3 to 26 years, with an average of 6.2 ([+ or -] 4.8) years. The entry level of physical therapy education was the bachelor's degree level for 85% of the respondents; 7.4% were educated at the certificate level, and 8% entered at the master's degree level. Sixteen percent of the respondents held an advanced master's degree, and 1% held a doctoral degree. The therapists were employed in institutions that had an average of 378 ([+ or -] 308) acute care beds. Acute care facility size ranged from 13 to 1,300 beds. Time allocation on the job averaged 74% ([+ or -] 23%) (range, 0%-100%) in patient care activities, 18% ([+ or -] 2%) (range, 0%-100%) in administrative duties, 7% ([+ or -] 10%) (range, 0%-90%) in educational responsibilities, and 1% ([+ or -] 2%) (range, 0%-15%) in research, The therapists worked in departments with a staff comprising an average of 10.3 ([+ or -] 11.7) (range, 0-70) full-time physical therapists, 2.2 ([+ or -] 2.1) (range, 0-10) part-time physical therapists, 1 ([+ or -] 1.4) (range, 0-7) full-time physical therapist assistant(s), 1.7 ([+ or -] 2.1) (range, 0-4) part-time physical therapist assistants, 2.2 ([+ or -] 2.0) (range, 0-10) full-time physical therapy aides, and 0.4 ([+ or -] 0.9) (range, 0-5) part-time physical therapy aides.

Instrument

This survey questionnaire contained 26 items that addressed physical therapy needs of the acute care patient population, utilization of various clinical procedures, constraints encountered in the delivery of services, coordination of postdischarge care, and perceptions of staffing trends (Appendix). Each item was worded as a description of therapists' experience of practice in the acute care setting (eg, "Patients in acute care do not reach physical therapy goals because of their medical complications."). Respondents used a five-point frequency scale (1=never, 2=rarely, 3=sometimes, 4=frequently, and 5=always) to rate the items.

Following these 26 questions, there was an item to assess future career expectations (ie, "Do you anticipate that your next job will be in acute care?"). This item was rated using a seven-point scale, ranging from "definitely not" to "definitely yes." A subsequent item asked the therapists to choose the probable practice setting of their next job, if they were to leave their current position. The instrument also included demographic data items to document each therapist's age, experience in acute care practice, percentage of time spent in patient care and nonpatient care activities, entry-level degree, and size of the facility and staff in his or her institution.

The instrument was developed specifically for this study following the preliminary study,[10] which documented common experiences in acute care physical therapy practice. Content validity was established three ways, in a series of preliminary studies with acute care physical therapy managers and clinicians. First, common perceptions identified in an intrainstitutional study[10] were incorporated into a pilot questionnaire of 25 items. The pilot instrument was validated for content by a survey of 50 acute care physical therapy managers nationwide. The instrument and the results of the pilot study of the physical therapy managers were presented to an audience of 200 acute care physical therapists attending an APTA Annual Conference. These therapists, through a series of small-group processes, discussed their perceptions of the factors affecting physical therapy practice described on the instrument. Final revisions were based on feedback from the pilot study and therapist-evaluator groups, resulting in the current instrument. Test-retest reliability was not established before this study.

Procedure

The names of 500 physical therapists employed in acute care settings were randomly selected from the membership of the APTA. These therapists received a cover letter explaining the purpose of the study and the questionnaire. They were instructed to return the instrument by postage-paid return mail.

Data Analysis

Demographic data were analyzed descriptively. Frequency data were tabulated for the therapists' responses to each of the initial 26 questionnaire items. Therapists were grouped into one of three experience-level categories, based on the frequency distribution of the sample: low (0-3 years), middle (4-8 years), and high (>8 years). Similarly, the institutions at which they were employed were categorized by bed size into small (0-200 beds), medium (200-400 beds), and large (>400 beds) institutions.

Using these categories, a multivariate analysis of variance (MANOVA) and a series of two-way analyses of variance (ANOVAs) were done to analyze the effects of differences in therapist experience level and institutional size on the therapists' responses to each of the 26 questionnaire items. Post hoc comparisons were done on all significant effects using Scheffe's s test. A chi-square analysis was done to identify probable next job sites in groups of therapists with low, medium, and high experience levels. Significance for all analyses was set at the .05 level.

Results

Questionnaire Responses

Patient evaluation and physical therapy goals. The results of this study showed that fewer than 60% of the therapists surveyed frequently or always find information on social history in the patient's medical chart. Almost all the therapists frequently or always obtain information on patient physical condition and prior functional status during the initial evaluation, with only 16% performing detailed evaluation procedures such as a goniometric evaluation. Treatment priorities tend to focus on gait and transfer training, as close to 90% of the therapists responded that these two areas are frequently or always included in their goals. Much less frequently are goals focused on pain (42%) or respiratory function (15%) (Tab. 1).

[TABULAR DATA OMITTED]

Delivery of care. Only 24% of the therapists felt that patient medical complications rarely or never interfere with patients reaching their physical therapy goals. Over 37% of the respondents felt that physical therapy goals are sometimes or frequently not met because of patient unavailability for treatment, due to numerous other scheduled medical procedures and diagnostic tests. Almost 80% felt that patient cooperation or motivation was sometimes or frequently a problem.

Organizational and health care system constraints. Almost half (42%) of the respondents reported that they sometimes or frequently have difficulty changing a patient's treatment orders. Over 85% of the therapists indicated that patient referrals for acute care physical therapy were sometimes, frequently, or always made close to the patient's projected discharge date. Almost all therapists (90%) reported feeling that there was inadequate time to work with their patients.

Staffing and delegation. Sixty-four percent of the therapists felt that staffing shortages rarely or never prevented patients from reaching their physical therapy goals. Only 10% of the therapists reported delegation of patient care responsibilities to others, and only 12% felt that their time use had shifted toward patient evaluation rather than providing all patient treatment. Most therapists (97%) frequently or always felt they had a positive impact on the patients they treated.

Referral and discharge. Seventy-three percent of the respondents reported they frequently or always document their recommendations in the medical record. Patient and family education seems to be the preferred mode for helping patients reach their postdischarge goals. Seventy percent of the therapists reported they frequently or always use this intervention. Yet, only 38% of the therapists reported they frequently or always talked with postdischarge caregivers.

Turnover and recruitment. Over half (54%) of the respondents felt that turnover rates are frequently or always higher in the acute care setting than in other practice settings. Over 70% recognized a growing trend of part-time and per-diem therapists entering the acute care work force. Although very few respondents (7%) felt that experienced physical therapists are frequently attracted to work in the acute care setting, only 50% of the therapists felt that new graduates are consistently prepared to function effectively in this practice setting (Tab. 1).

Future career plans. Respondents' ratings of the likelihood of taking their next job in an acute care setting ranged from 1 to 7, with a mean score of 3.8 ([+ or -] 1.7). Only 16% of the therapists responded that it was highly likely (scores 6-7) that they would seek a future position in acute care physical therapy, whereas 22% responded that it was highly unlikely (scores 1-2) that they would seek such a position. When asked what type of practice environment they planned to seek for their next job, 28.9% of the respondents indicated acute care. An equal number (28.9%) responded that they planned to work in an outpatient private practice office. Fewer respondents reported that they would seek outpatient rehabilitation (12.8%), home health care (10%), inpatient rehabilitation (8.3%), academic (3.3%), and skilled nursing facility (1.1%) practice settings for their next position. All other settings, including public school, industry, and consulting, accounted for an additional 6.7% of responses.

Influence of Therapist

Experience and Organizational

Size on Perceptions

Therapists with 0 to 3 years of experience were placed in the low-experience group, those with 4 to 8 years of experience were placed in the medium-experience group, and those with more than 8 years of experience were placed in the high-experience group. Similarly, the size of the institutions in which the therapists were employed were categorized as small (0-200 beds), medium (201-400 beds), and large (>400 beds) based on the frequency distribution. A MANOVA was performed on the scores of all 26 items, yielding a significant main effect of institutional size. A series of two-way ANOVAs were then performed on the same scores to identify the differences in each perception in physical therapists with varying levels of experience and in institutions of various sizes (Tab. 2).

[TABULAR DATA OMITTED]

There were significant main effects of institutional size on four variables. Medical records lacking information on social history were reported more frequently as institutional size increased (Fig. 1). Patients were less frequently available to receive physical therapy services in larger institutions (Fig. 2). Therapists more frequently reported that turnover was higher in acute care than in other practice settings (Fig. 3) and that experienced therapists were less attracted to the acute care setting when they were employed in larger institutions (Fig. 4).

There were significant main effects of level of experience only on therapists' perceptions of inadequate time to treat their patients. Those therapists with the least experience reported they had inadequate time more frequently than did more experienced therapists (Fig. 5).

There were significant main effects of both therapist experience level and institutional size on the therapists' perceptions of how often they documented goals related to pain control for their patients in acute care settings. Those therapists who worked in larger institutions and those with the least experience tended to document patient goals related to pain control less frequently (Fig. 6).

Therapist experience level also had an influence on therapists' reports of their next probable job site. Only 17% of the least experienced physical therapists reported that they would seek their next job in an acute care setting, compared with 40% of the highly experienced group. In contrast, 51% of the least experienced group chose outpatient rehabilitation or outpatient private offices as their next practice site, compared with 36% of their experienced colleagues choosing these locations (Tab. 3).

[TABULAR DATA OMITTED]

Discussion

The results of this study document current trends in physical therapy practice. By examining these trends and specifically looking at the ways in which practice differs among therapists with varying levels of experience and among therapists employed in institutions of varying sizes, we can begin to compare actual practice trends with theoretically sound performance standards for acute care physical therapy practice.

Evaluation and Treatment

Information on social history is often not available in the medical record at acute care facilities. This is of concern to physical therapists because discharge planning requires that the physical therapist make an accurate assessment of patient needs for postdischarge placement, based on how much assistance is available in the home. Given the decreasing length of hospital stay, many patients who are discharged home are unable to care for themselves without assistance from family and friends. Because this information is frequently not in the medical record, physical therapists must assess the viability of their patients' social support system to meet their patients' needs, a role function more appropriately carried out by the social worker.

Therapists at all levels of experience tended to agree that goals relating to transfers and gait training are frequently or always the focus of acute care. Even though most patients in acute care settings are elderly with multisystem involvement including symptoms of pain and cardiorespiratory dysfunction, goals related to pain and respiratory function are documented much less frequently.

Apparently, in the limited time that therapists have to spend with patients, respiratory function and pain are perceived as low priorities. There could be serious consequences to these perceptions of patient care priorities. There were no differences between novices and experienced therapists in the frequency of reporting their documentation of goals related to respiratory function.

Novices did differ from more experienced clinicians in their documentation of goals related to pain control. Novices are often unable to see the whole patient and interrelate the symptoms, problems, and importance of the many cues presented to them in the acute care environment.[8]

Pain is frequently a complaint of patients who are referred for physical therapy services. Numerous courses in the academic curriculum are focused on relieving pain through the use of various heat and cold modalities, electrical stimulation, edema control, positioning, soft tissue mobilization, and exercise. Yet, inexperienced therapists focused on pain relief less frequently. We might explain this lack of focus on pain relief in that the new graduate is often faced with an overwhelming clinical picture and is unable to recognize and prioritize problems such as pain that he or she might be able to address.

Physical Therapy Goal

Incongruence 

Two thirds of the therapists reported that patients sometimes do not reach physical therapy goals because of medical complications. Similarly, over 75% of the therapists reported that they sometimes or frequently experience problems with patient motivation or cooperation. Both of these findings may reflect therapist discomfort with the complex medical, behavioral, and social problems that accompany chronic health problems. Therapists often feel powerless to effect changes in this patient population due to the many factors that are out of the therapists' control.[10] Therapists who are anxious to help their patients may experience tremendous role conflict when they realize that some patients are neither anxious to be helped nor appreciate the therapists' effort or expertise.[13] Therapists may depend on patient acknowledgment and cooperation as important sources of their job satisfaction. Some therapists may be unable to alter methods of approaching patients or treatment priorities to meet specific patient needs and then perceive poor patient cooperation as a personally threatening and negative event.[13]

Working with patients with numerous chronic medical conditions requires that physical therapists have a working knowledge of pathology, pharmacology, and radiological and diagnostic tests. Realistic goal setting is dependent on one's ability to integrate this information and plan accordingly. Dissonance between a patient's performance and a therapist's goals, perceived by therapists to be due to medical complications, may instead reflect unrealistic therapist expectations imposed on the patient in the acute care setting. With physical therapy resources at a premium, therapists must assess their patients' needs and project realistic, achievable goals to effectively prepare the patients for the next level of care, rather than achieve their long-term goals in the acute care setting.

Time Management

In addition to patient-related factors, the health care system imposes additional restrictions on the practice of physical therapy. Close to 90% of the therapists reported they felt they had inadequate time to work with their patients. Feelings of inadequate time are a significant source of job stress.[10] The findings of this study support that this is a problem, particularly for the inexperienced therapist. Of therapists with less than 3 years of experience, 45% frequently or always felt this way. In contrast, of therapists with more than 8 years of experience, only 19% frequently and 0% always felt this way. The new graduate struggles to find a balance between meeting the individual patient's needs, meeting the institution's requirements for productivity, and managing the care of the rest of the patients in his or her caseload. Novices may have expectations that are beyond what they can realistically accomplish in the few days that they may have to intervene with the average patient in an acute care setting. Therapists often feel frustrated when they are unable to deliver the services they know they are capable of providing.[4]

Expectations of practice under ideal conditions often differ from the practice skills required in today's health care environment. Time management skills are essential to achieve some degree of role satisfaction and to manage the tremendous demands on the acute care practitioner. Strategies such as prioritizing treatment activities, delegating treatment tasks, grouping patients with similar needs, referring patients to other disciplines, setting appropriate goals to prepare the patient for the next level of care, using time-efficient patient education resources, and streamlining techniques for patient documentation or billing are skills not often included in the therapist's academic preparation, but nevertheless needed continuously if one is to succeed in acute care clinical practice. We can predict that as therapists experience frustration and stress over perceived time pressures without remediation of the situation or their skills, they will eventually become emotionally exhausted and seek other work environments.[4]

Physician Communication

Forty percent of the therapists reported difficulty in adding to or changing a patient's orders. Physical therapy intervention in most health care institutions requires physician referral. Physicians may not be aware of the scope of physical therapy services that are appropriate for a particular patient when making a referral. In addition, the physical therapist, in the course of the evaluative process, may find a patient problem that has not been documented by the physician and that could affect the patient's potential to benefit from treatment, Institutional physical therapy is usually provided by physician referral, with third-party payment dependent on written evidence of physician approval of the physical therapy plan. The lengthy process of changing referral to meet the requirements of third-party payers may entail therapist documentation in the medical record. This documentation may not be acknowledged by a referring physician, despite numerous requests and "flags" in the chart requesting a physician's signature to indicate agreement with proposed changes in treatment plan.[10]

The therapist may personally interact with a physician to request such a change or telephone the physician's office. New therapists are often unskilled in establishing collegial relationships with referral sources and may feel awkward in verbal interactions with physicians.[14] Additionally, some physicians, despite the therapist's explanations and requests, may deny the therapist's recommendations for treatment plan additions or deletions.

Discomfort with talking with physicians and ineffective interprofessional communication are areas that are amenable to skill and strategy development. When physical therapists feel in control of their interactions with physicians, they actually experience more career advancement and job Stability.[15]

Underutilization of Support

Personnel

Most therapists responded that they frequently provide care to the patient rather than delegating care to others. In the presence of dwindling staffing resources and shorter patient stays, it seems critical that the acute care physical therapist distinguish between patients who require high-level, ongoing care by the physical therapist and those who could be seen by support personnel for treatment.[16]

Discharge Planning

Making referrals to postdischarge health care providers is an instrumental behavior affecting continuity of care. Physical therapists in our study reported infrequent contact with postdischarge care providers. Therapists who have limited knowledge of postdischarge care options and limited personal contacts in the community may be at a significant disadvantage in maximizing continuity of care for their patients.

Therapists frequently use patient/family education as a means to meet the patient's goals after discharge. This can be a time-consuming intervention and is usually incorporated with individualized treatment.[10] Developing more efficient means to deliver patient education, such as using preoperative group teaching sessions, and carefully selected video and written materials whenever possible may save time and decrease the need for individualized treatment. Communication with the postdischarge care provider, whether this is a family member, hired attendant, or agency-contracted staff, may be important to achieve continuity of care but may not be realistic given staffing patterns and shorter patient hospital stays.

Staffing Trends

Respondents reported a trend of increasing numbers of part-time and per-diem staff on the acute care staff. They also perceived that new graduates may not be prepared to function effectively in the acute care setting. Institutional size and therapist experience appear to affect perceptions of the desirability of long-term careers in the acute care setting. Therapists who work in larger institutions (eg, >400 beds) reported that there is more frequently a high turnover rate among physical therapists in acute care than in other practice settings. They also reported that experienced physical therapists are less frequently attracted to acute care than to other practice settings. This trend may be reflective of the culture in the individual institutions in which these therapists work, or it may be indicative of the perceptions of the group of therapists who choose to work in large organizations. It is of concern that inexperienced therapists expressed a significantly lower likelihood of taking their next job in the acute care setting than did experienced therapists.

New graduates frequently feel the stress of inadequate time to perform their jobs; they may be unable to project realistic patient goals; and they may lack effective skills in interprofessional communication, discharge planning, and delegation of patient treatment activities. Combining the expectation that practice in the acute care setting is a temporary career move with the frustration that results when one works in a highly complex environment without the skills and strategies to succeed in that environment, it is predictable that the inexperienced physical therapist will opt for a practice setting that may enable him or her to feel a greater sense of personal accomplishment and possibly lower stress levels.

Limitations of the Study

Our study's results are limited because of potential sampling biases (the response rate was less than 40%). We must question the generalizability of this information to all acute care settings. The respondents in our survey may have different perceptions than those who did not respond. Any instrument that measures the frequency of events in a constantly changing situation such as health care may also have limited generalizability to other points in time. Longitudinal data to document an individual's perceptions over the career span could provide a more accurate picture of the changes in perceptions with experience than the cross-sectional data obtained in our study. Reliability becomes more of an issue in longitudinal design, and test-retest reliability would need to be established to use this instrument with confidence.

Recommendations

Although increasing numbers of physical therapists are entering practice with graduate degrees and sophisticated evaluation and treatment skills, we believe they may lack critical skills for the acute care clinical environment in which prioritizing, time management, flexibility, and effective interpersonal skills are clearly adaptive responses and valued characteristics. Many areas of potential role stress in this study, however, were problematic across experience levels.

Within the physical therapy profession, this problem can be approached from two perspectives. As an initial perspective, one can assume that inexperienced practitioners perceive problems differently than do expert clinicians[8] and intervene by focusing more attention on the perceptual processes and factors that enter into clinical decision making. For example, academic faculty, Clinical Instructors, and supervisors in the workplace can assist the inexperienced practitioner to think by focusing attention on specific cues. This focus enables a thought process to evolve that includes organization of cues, hypotheses, pattern recognition, and deviations from expected patterns. Assisting inexperienced clinicians to use a systematic method of problem solving may improve their abilities to process information. One such model of particular relevance to physical therapy problem solving is the hypothesis-oriented algorithm for clinicians.[17]

Novices are often governed by rules and lack flexibility in making decisions. Educational interventions can target specific behaviors that affect time management and treatment activity prioritization. Identifying and interpreting critical cues that fit into recognized patterns of information help develop a more intuitive decisionmaking style and allow for more flexibility in meeting an individual patient's needs. For example, if the inexperienced clinician were able to recognize and focus on the highest-priority treatment activities, then perhaps he or she would not experience the dissatisfaction of having inadequate time to work with the patient as frequently.

A second way to approach this problem for clinicians of all experience levels is from the strategy/skill perspective. If we assume that some therapists in acute care practice lack specific skills, academic clinical education and staff development interventions can focus on developing practical strategies that assist in time management, caseload management, interpersonal and interprofessional interactions, patient education, use of community referrals, and career planning. Institutions can address issues of stress management and burnout prevention as "required" orientation content for the new staff member.

Academic course work could include more "practical" training for clinical practice. Additionally, we believe clinical educators should be trained and supported in their role as a vital link between the academic world and postgraduate clinical practice. Rather than allowing students to practice in a protected environment with limited caseloads and ample assistance to perform the essential interprofessional interactions with other health care providers, clinical educators can formally share strategies and ideas for management of problems they face in delivering needed services and dealing with change, conflict, supervisors, managers, and other team members.

Helping clinicians develop skills for practice in the acute care environment is also the responsibility of the employer. Peer support of clinicians in situations of role conflict is essential to help the therapist develop effective coping strategies. Informal group discussions to address "survival skills" may be of assistance in this area of professional development.[18]

Regardless of the societal needs for physical therapy services, numerous obstacles prevent the provision of those services by the clinician in the acute care practice setting. We must strive to make the academic curriculum and our professional development priorities congruent with the needs of clinical practitioners to effectively manage patient care responsibilities, given the constraints of the health care system and the perceptual, skill, or strategy deficits of the clinician.

We cannot afford to send clinicians into acute care practice without the practical skills to effectively deliver care. These skills are often very different from clinical skills. These "survival skills" include managing a large caseload, managing one's time, monitoring and managing stress, developing flexibility and maintaining a positive attitude in the face of change, performing required documentation, using effective means of interpersonal and interprofessional communication, and maximizing one's influence by making referrals to other resources in the health care network. With adequate preparation and support by competent educators, supervisors, and peers, young professionals can be encouraged to consider acute care physical therapy as a long-term career choice, rather than a temporary place to gain experience before moving on to a more desirable practice setting.

Future Research

Future study might include longitudinal design of the changing perceptions of a physical therapy graduate over time, after establishing reliability of the instrument. It would also be interesting to repeat this study on clinicians who work in other settings, such as rehabilitation facilities or outpatient offices, to determine how perceptions of practice differ among settings or how perceptions differ in individuals of various experience levels. One might add additional items to measure perceptions about other phenomena that affect the acute care setting such as weekend coverage, salary and benefit issues, and pressures for increased productivity or cost-containment.

Conclusion

Trends in acute care environments require that physical therapists practicing in those settings alter their approach to deliver physical therapy services in a more time-efficient manner, focusing on the discharge and referral processes. Inadequate skills for successful acute care practice and maladaptive therapist beliefs about career possibilities in the acute care setting may adversely affect physical therapist career longevity in this practice setting.

References

[1] Brown GD. Changing health care environments: implications for physical therapy research, education, and practice. Phys Ther. 1986;66:1242-1245. [2] Hicks LL. Increasing role of economic analysis in the health care industry. Phys Ther. 1986; 66:1463-1466. [3] Holt P, Winograd CH. Prospective payment system and utilization of physical therapy service in the hospitalized elderly. Am J Public Health. 1990;80:1491-1494. [4] Deckard GJ, Present RM. Impact of role stress of physical therapists' emotional and physical well-being. Phys Ther. 1989;69:713-718. [5] Recruitment and Retention of Physical Therapists in Hospital Settings. Alexandria, Va: American Physical Therapy Association; June 1989. [6] Dore D. Effect of the medicare prospective payment system on the utilization of physical therapy. Phys Ther. 1987;67:964-966. [7] Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with hip fracture: changes since implementation of the prospective payment system. N Engl J Med. 1988;319:1392-1397. [8] Benner P. From Novice to Expert. Reading, Mass: Addison-Wesley Publishing Co Inc; 1984. [9] Jensen GM, Shepard K, Hack LM. The novice versus the expert clinician: insights into the work of the physical therapist. Phys Ther. 1990; 70:314-323. [10] Martin T, Curtis KA, Sasaki M, et al. Evolving strategies for acute care physical therapy practice. Presented at the Annual Conference of the American Physical Therapy Association; June 24-28, 1990; Anaheim, Calif [11] Bruckner J. Physical therapists as double agents: ethical dilemmas of divided loyalties. Phys Ther. 1987;67:383-387. [12] Guccione A. Ethical issues in physical therapy practice. Phys Ther. 1980;60:1264-1272. [13] Curtis KA. Role satisfaction of the physical therapist in the treatment of the spinal cord-injured person. Phys Ther. 1985;65:197-200. [14] Hulme JB, Bach BW, Lewis JH. Communication between physicians and physical therapists. Phys Ther. 1988;68:26-31. [15] Curtis KA. Altering beliefs about the importance of strategy: an attributional intervention. Journal of Applied Social Psychology. 1992;22: 953-972. [16] Davis DM. Task analysis in the provision of physical therapy to the elderly client. Physical and Occupational Therapy in Geriatrics. 1991; 10:1-15. [17] Rothstein JM, Echtemach JL. Hypothesis-oriented algorithm for clinicians: a method for evaluation and treatment planning. Phys Ther. 1988;66:1388-1392. [18] Curtis KA. Survival training for the realities of clinical practice: a post-graduate staff development program. Presented at the Combined Sections Meeting of the American Physical Therapy Association; February 2-5, 1989; Honolulu, Hawaii.

Appendix. Questionnaire Items(a)

Access to Social History Information A-1. Information regarding the patient's social history is present in the medical record.

Evaluative Priorities B-1. Obtaining information regarding a patient's physical condition is a priority during the initial evaluation. B-2. Obtaining information regarding a patient's prior level of function is a priority during the initial evaluation. B-3. Performing a detailed goniometric assessment is a priority during the initial evaluation.

Treatment Priorities C-1. I document goals related to gait for my acute patients. C-2. I document goals related to transfer training for my acute care patients. C-3. I document goals related to pain control for my acute patients. C-4. I document goals related to respiratory function for my acute patients.

Constraints on Acute Care Physical Therapy Practice D-1. Acute care patients do not reach P.T. goals because of medical complications. D-2. Acute patients do not reach P.T. goals because of lack of availability. (i.e. tests, M.D. visits, x-rays, etc.) D-3. Acute patients do not reach P.T. goals because of staffing shortages. D-4. Acute patient cooperation/motivation is a problem. D-5. There is not enough time to work with my patients. D-6. I experience difficulty in changing a patient's treatment orders or obtaining additional orders. D-7. I continue to provide care to the patients I evaluate rather than delegate the care to others. D-8. Referrals for acute care physical therapy are made close to the patient's discharge date. D-9. I am required to do initial evaluations instead of patient treatment, due to short staffing or the volume of patient referrals. D-10. I view my impact as a positive one with the patients I treat.

Referrals and Discharge Planning E-1. Other services are indicated for acute patients. (ie. home care, O.T., Social Service, Outpatient, etc.) E-2. I write recommendations in the chart to assist in arranging other services. E-3. I use patient/family education to assist patients to meet unmet goals after discharge. E-4. I talk with others who will actually care for the patient after discharge.

Staffing Trends F-1. Physical therapist turnover is greater in the acute care setting than in other practice settings. F-2. There are increasing numbers of part-time and per-diem physical therapy staff in the acute setting. (vs. full-time). F-3. Newly graduated physical therapists are prepared to function effectively in the acute care setting. F-4. Experienced physical therapists are attracted to work in acute care settings.

(a) Rating scale: 1=never, 2=rarely, 3=sometimes, 4=frequently, 5=always. Note: Items are shown exactly as they were presented in the questionnaire.

Commentaries

Following are three commentaries on "Perceptions of Acute Care Physical Therapy Practice. Issues for Physical Therapist Preparation. "

It was with great pleasure that I greeted this opportunity to comment on Dr Curtis' and Ms Martin's article. It is one subject that has not been explored adequately, and certainly not at a frequency that the numbers of physical therapists in this practice setting warrant.

This article makes many good points as to why there are staffing problems in acute care. I would like to make a few comments on the impact on the practice of physical therapy in all settings if the trends as described by Curtis and Martin continue. How will our profession look if the acute care setting trains and encourages a practice that is, due to time restraints and inexperience, administered by physical therapists who can deal with function only.? This severe limitation in the scope of practice of physical therapy in the acute care environment is also a major indicator for burn-out and eventually leaving acute care. This, though, has an effect on the training of our new colleagues that could have an impact on our profession in ways we may not have dreamed of. What if acute care, and the unique skills utilized therein, are lost due to the lack of experienced physical therapists available to teach in that environment? How then will we be able to truly meet our responsibilities to our patients if we do not have the clinical experience of identification of disease and dysfunction associated with disease? This clinical experience can only occur in the acute care setting.

Along these same lines, I agree with the authors that the level of experience affects the perceptions of physical therapists. I feel that those perceptions are also influenced by how experienced physical therapists project their own perceptions of acute care. I recently asked a group of second-year physical therapy students what their practice setting goal was. None of the students indicated that they saw acute care as a practice setting that they could see themselves in for a long period of time. Yet, as the authors pointed out, because of the severity experienced by the patients, it is for many physical therapists the most professionally challenging area of practice.

I want to also comment on one of the recommendations that the authors mentioned. They discussed the need for "survival skills," listing such skills as "managing a large caseload, managing one's time, monitoring and managing stress, developing flexibility and maintaining a positive attitude in the face of change, performing required documentation ...." The authors feel that prior preparation in these areas is necessary for our newest clinicians to see acute care as a long-term career choice. I would say that these attributes are critical for survival in any setting, but that in acute care they are needed most. They are also skills that need to be developed through practice, with only the theory of these skills being able to be taught in the classroom. To call them "survival skills" though places acute care in a context that leads to the current perceptions that the authors discussed. We need to change those perceptions, the ones we have as a profession, about acute care before we can expect our newest colleagues to perceive acute care as a career practice environment. I submit that acute care practice should be looked on as the foundation of all practice, while at the same time requiring unique and specialized skills that only an advanced clinician would possess.

The authors have done a good job of discussing the issues pertaining to the perceptions of acute care. It is one that I, as President of the Acute Care/ Hospital Clinical Practice Section, deal with every day. I hope this article has the effect of not only bringing up this topic to the physical therapy community, but of making physical therapy clinicians in all settings rethink their perceptions of acute care, and its importance to the profession as a whole, and begin to role model the resultant changes in perception for the good of the profession.

James M Dunleavy, PT Chief Physical Therapist St Lukes-Roosevelt Hospital Center 1000 10th Ave New York, NY 10019 and President Acute Care/Hospital Clinical Practice Section American Physical Therapy Association

The authors have presented many issues that confront the acute care practitioner and the relation to educational preparation. I would like to add comments to a number of areas they addressed.

Acute care has not only changed dramatically over the past 10 years, but is on the verge of changing as dramatically for the foreseeable future. Many of us were trained at a time when we did not worry about how long a patient was in the hospital, nor was there the level of present-day technology to keep patients with multisystem disease or trauma alive - individuals who today require a great deal of rehabilitation. Patients were at the same time younger, less complex, and stayed longer in the hospital. We often did not have to learn how to use other personnel to assist us in our delivery of care.

Many of us trained in this environment now find ourselves as faculty for our present students. One of the questions that this article raises is, Are we, as the faculty, biasing or teaching our students to practice in relation to how it was our own framework and our own time) versus how it is? The clinical environment is shifting its needs on a daily basis. Consequently, so shifts the skills one needs to practice. It appears that we are not moving our academic perspective, including clinical experience, with the same speed.

The acute care practitioner needs talent, skill, and the ability to move quickly to readapt or modify a decision at a moment's notice as a patient's condition changes. This is a high-level, integrated thought process that the authors allude to as characteristic of the practitioner with more experience, one who can adapt quicker, be more flexible, and function better in the system.

At the same time, there is the perception of some acute care administrators (and, in fact, the reality in some acute care settings) that the new graduate, or the graduate with little experience, is or should be the mainstay of the physical therapy department. Yet, there is no place where you need the seasoned clinician more than acute care - where time is of the essence; where you need a professional to stand side by side with the seasoned physician; where you need someone who can respond to a quickly changing medical condition; where you need someone who also knows how to supervise and work with physical therapist assistants. The medical model uses the seasoned physician in the acute care settings, particularly in the teaching hospitals, to train and educate the younger staff, and this model recognizes and rewards the advanced-level, experienced physician for these skills. The setting fosters and facilitates a collegial, yet educational, relationship. We must do the same.

We also need clinicians who can communicate with and relate to other professions. The one area that apparently was not surveyed as a need, and one that I see as essential to success in the acute care setting, is the need to negotiate with the other health care colleagues. The essential need of a team to take care of the acutely ill individual is becoming more and more pointed. We must have clinicians who can function in this collegial manner and not be the individuals who "serve" the team. If we continue with the new clinician being the mainstay - and staying an average of only 2 years in acute care - we have made our "success" or lack thereof in this environment a self-fulfilling prophecy. We will not have to worry about who or what we are, because it is highly likely we will not be.

This leads us to consider, on a broader basis, whether we can afford to offer the new graduate a full salary in a highly changing environment in which skills are clearly not as finely tuned, adaptable, and capable of being brought into action. We need to, as others have said, look at this first year out and consider how and what we expect of individuals, and how it fits in with our general educational system.

I would like to offer a correction for one area that these authors have offered comment. Under physician communication was the perception by these authors that third-party payers and other regulators depend on written evidence, or physician approval, of the physical therapy plan. How these authors portray this was a cumbersome system of the physician needing to provide his or her signature to indicate agreement with any change in plans, and a lengthy communication process with numerous requests and flags in the chart requesting the physician's signature to indicate agreement. This is indeed not the case and not what is required. What is required is evidence of a communication pathway in the institution between physical therapists and physicians regarding patient care. It has been our experience in our institution (with third-party payer audits and approval and joint Commission on Accreditation of Healthcare Organizations accreditation) that as we receive a physical therapy referral for inpatients, we may

1. Be the clinicians who do the assessment and provide the treatment plan.

2. Indicate that this plan we propose will be carried out, unless otherwise indicated by the requesting physician.

3. Therefore, negate the necessity for the signature of a physician next to our plan.

This collegial relationship often results in notes of thank you or some form of acknowledgment. However, it does not require a lengthy, cumbersome system to accomplish this communication. What is required is a clear statement of policy in the institution that indicates the system of communication.

The last item I would like to comment on is one that I found most disturbing. In the survey, it was found that only 15% of the clinicians attend to the respiratory function of an individual and pain is assessed only 42% of the time. Yet, as the authors note, our patients now predominantly have multisystem disease or disability. It is essential, as members of the team, that we treat patients as a whole and not divide up a body so that we do not understand the relationship of interrelated and interactive body systems. We will be sorely remiss if we, as clinicians, do not understand the explicit duty that we hold to assess individuals as a whole and care for them in the profession of physical therapy.

Colleen M Kigin, PT Director Physical Therapy Services Massachussetts General Hospital Boston, MA 02114

I am most appreciative of having the opportunity to comment on this most needed study by Kathleen Curtis and Terry Martin. Our Association has been particularly concerned with the changing patterns of practice of physical therapists as we have continued to move increasingly away from the acute care environment. An initial and a follow-up study by the American Physical Therapy Association revealed many of the same factors related to why physical therapists leave the acute care environment. What is always challenging for us is to continue to find ways in which we can meet these problems head on with viable solutions that will maintain this all-important practice environment for physical therapists. As has often been said in the past, "When we leave a void, it will invariably be filled with someone else." I do not want to see this happen in what has been, traditionally, a very important part of physical therapy practice. I should like to take each of the important findings of this study and propose some ideas that may begin to meet the problems.

Patient Evaluation and

Physical Therapy Goals

Forty percent of the physical therapists responding to the survey found no social history information in the medical chart, which we all know is important for discharge planning. Perhaps our physical therapy departments would be well served by developing a very brief questionnaire, which the patient, if able to cooperate, could fill out at another time so that our treatment time maximally utilizes our talents. it was distressing to note, but totally understandable, that treatment priorities were predominantly focused around gait and transfer training. Our ever-increasingly aging population, prone to the kinds of interventions that occur in hospital settings, certainly should have more long-term goals as part of potential prevention and treatment programs. In addition, as our system becomes more "maintenance of health" oriented, we have a very important part to play in educating patients in the acute care setting of the appropriate follow-up interventions that they may need.

Delivery of Care

The findings in this arena are certainly not unique in this day and age. In the past, when the patient had more in-hospital time, these problems were not quite as apparent. Certain suggestions, however, may be put forth, over and above those suggested by the authors, related to educational interventions targeting specific behaviors that influence treatment and developing practice strategies.

We might consider looking more closely at the nursing model, in which small groups of students are brought into acute care settings to be involved with a master clinician. They would then have the opportunity to appropriately observe the caseload management, interpersonal and interprofessional interaction, time management, and the like. In addition, perhaps it is necessary to incorporate assertiveness training in our education programs, particularly in light of the fact that 73% of our profession is female and the reverse is true of the profession of medicine. This training might also facilitate changing a patient's treatment order. We must also educate physicians that "referral" for our services should be the same as a referral they would send to any one of their colleagues. It should be "Physical Therapy - Evaluation and Treatment" with any contraindications and/or precautions, particularly in light of the fact that over 28 states have the ability for direct access practice. This type of referral has been prevalent in certain physical therapy areas in acute care practice (ie, chest physical therapy). One thing that might facilitate this type of referral is for physical therapy faculty to provide some lecture time to medical school students as to the importance of physical therapy intervention, the appropriateness of physical therapy interventions, and the recognition of the background and skills of those who have been trained in the art and science of physical therapy.

With almost all respondents reporting inadequate time to work with their patients, we must look at alternative ways to ensure that patients receive appropriate services. One study being done at The University of Iowa will compare physical therapists' continuous intervention as opposed to teaching patients the program and making them responsible for carrying out the majority of their care. The results of this study of individuals with lower-extremity joint replacements should provide valuable information for us. In addition, we must also look to delineating those tasks that can be appropriately delegated to the physical therapist assistant in the acute care arena.

Discharge Planning

It would be very nice in this potentially reforming health care system to see the opportunity for a true continuum of care as part of the whole process so that physical therapists in the hospital would have the opportunity to ensure that patients are discharged to the most appropriate environment with all of the supportive help or equipment that is necessary. Short of that occurring, physical therapists will continue to have to work with the postdischarge caregivers.

Staffing Trends

I would hope that we shall continue to maintain the acute care environment as a very exciting, stimulating, and challenging one. But that requires that we utilize the multiplicity of skills of the experienced physical therapist over protracted periods of time. That means that our students on clinical affiliations must have the expertise and mentorship of seasoned acute care clinicians and not a physical therapist who has had 5 to 6 months' experience in that environment. It is important that our students have the role models that will make them appreciate acute care as a potential career commitment.

The differences between inexperienced and experienced physical therapists give an indication that, if we can keep experienced people in the acute care environment, we will be likely to meet the needs of this population. It would also be nice to think of the possibility one day of having physical therapy departments in the hospital owned and totally run by physical therapists. This would be analogous to the kind of practice that radiology has established in several acute care settings. Certainly, the tasks ahead of all of us involved in practice and education are vast when it comes to maintaining and promoting our rightful place in the acute care environment. Studies such as this win go a long way in helping us to address this priority area of physical therapy practice.

Marilyn Moffat, PhD, PT, FAPTA President American Physical Therapy Association Ludlam Ln Locust Valley, NY 11560

Author Response

Since data connection for this study was completed (nearly 2 years ago), changes taking place in the health care system and in the hospital setting in particular have accelerated. Economic concerns, as well as desires to improve quality of services and customer satisfaction, have led to the evolution of the "Patient-Focused Care" model and resulted in redesign of service delivery in many acute care hospitals. System changes associated with this redesign are demanding that we take a critical look at the services physical therapists are providing in this setting.

We feel that the role of the physical therapist is clearly changing to one that is more focused on the highly specialized and unique contributions that only a physical therapist can make in the patient's recovery process. More of the routine and repetitive tasks will be carried out by caregivers with less formal training. The physical therapist will then (and already has, in some institutions) assume a greater supervisory role, provide more evaluative and assessment functions, and truly serve as the "architect" and director of the patient's recovery in this setting, with an emphasis on restoring functional mobility. The skills needed to serve effectively in this capacity are seen primarily in experienced clinicians. It is of interest to note that all three individuals who reviewed this manuscript commented on the need for more experienced clinicians in this setting.

We hope that the "Patient-Focused Care" model for delivery of hospital services will positively impact some of the problems identified in this study, such as missed treatment due to scheduling conflicts and difficulties in receiving appropriate physicians' referrals. Improvement in job/role satisfaction may occur as well. We as a profession, however, need to play a vital role in the design and implementation of these changes, and to adapt our educational process, in a timely manner, to prepare new therapists for the reality of this practice setting.

Kathleen A Curtis, Phd, PT Terry Martin, PT