Personnel resources in physical therapy: an analysis of supply, career patterns, and methods to enhance availability.

Key Words: Health services research, Needs and demands, Personnel management, Personnel resources.

Analyses of personnel resources in a profession are typically constructed around a classic equation model, with an estimate of need or demand for services on one side and an estimate of the available supply of providers on the other. Elsewhere in this special issue the methodological issues related to developing the need/demand side of the equation have been described. Given the difficulties in accurately determining the need for physical therapy services of even one segment of society, one might assume that developing estimates of the supply side of the equation would be simplistic by comparison. Nuances of a professional and technical labor force composed primarily of women with varying work-force participation patterns, however, have to be considered. Physical therapy is a profession with a rapidly changing nature of practice/work, in which the role of the provider has changed significantly over the last three decades. These factors need to be considered in the context of a country experiencing economic stress, which may influence work-force participation decisions of family members on family roles and major changes in the health delivery system.

The purposes of this article are to review data on the supply of physical therapy personnel; to examine the career patterns of physical therapists; and to analyze methods that could enhance our supply of practitioners through changes in our educational practices or alterations in practitioners' career patterns, practice patterns, or distribution patterns. Suggestions for a research agenda in these areas will be used to summarize information needed to facilitate our profession's goals of meeting society's needs for physical therapy services.

Supply of Personnel

In the early years of our profession, 1920 to 1940, nearly all physical therapists were educated either by the military or under the aegis of the National Foundation for Infantile Paralysis, and the physical therapists directing these programs were said to know every physical therapist in the country by name, so that counting them was not difficult. Our numbers have grown dramatically. Our profession's success at obtaining the requirement of licensure for physical therapists in all jurisdictions by 1973 meant that our ability to estimate our potential personnel resources was enhanced. The situation for physical therapist assistants is improving, as they are now regulated in some fashion in 41 of the 53 jurisdictions.(1)

In 1993, 116,573 licenses were granted to physical therapists by 53 US government jurisdictions, including the District of Columbia, Puerto Rico, and the Virgin Islands.(1) This number is an overstatement of the physical therapist work force, because some physical therapists hold more than one license at a time. Forty-five jurisdictions reported the number of licensed physical therapists who were residents of their jurisdiction. The mean percentage of licenses held by in-state residents of those jurisdictions was 75%, and this factor was used to calculate resident licensee estimates for the remaining 8 jurisdictions. With this method, a total estimate of 89,911 licenses were held in 1993 by physical therapists residing in the jurisdiction in which they were licensed, and this number may approximate the total number of licensed practitioners available in the national work force.

Similarly, 21,603 physical therapist assistants were listed as regulated (licensed, certified, or registered) among all jurisdictions. The percentage of physical therapist assistants who hold credentials in more than one jurisdiction is not known. Applying a similar factor of 75% to the total number of regulated physical therapist assistants, an estimate of 16,202 assistants may be living in the jurisdictions in which they are credentialed. This figure may underestimate the total work force of physical therapist assistants. First, physical therapist assistants may not be as mobile as physical therapists, and, second, there is no accounting of physical therapist assistants working in the 12 jurisdictions in which they are not regulated.

The American Physical Therapy Association (APTA) estimates there are approximately 80,000 licensed physical therapists in the United States, with approximately 80% working full time, 17% working part-time, and 3% retired or not working.(2) The estimate of the total number of licensed therapists is derived by an algorithm that uses the total number of licenses reported and reduces that estimate proportionally by the number of members who report having one, two, three, or more current licenses.(3) The estimates of the percentages licensed therapists working full time, part-time, and not working are based on results of surveys of APTA members, extrapolated to the licensed population of therapists. This method of developing supply estimates relies heavily on assumptions about similarities in career status between APTA members and nonmembers. A comparison of these percentages with the results of an APTA-sponsored study of licensed physical therapist nationwide does show some differences, with 70% of licensees reporting working full time, 23% working part-time, and 7% not working.(4) This discrepancy becomes especially important in describing the pool of nonworking personnel. A more accurate assessment of the pool of nonworking personnel is needed to determine whether strategies to recruit inactive therapists or assistants into the work force would be cost effective. The Association's estimate for the current supply of physical therapist assistants is 17,000. This estimate was derived by calculations utilizing average class size, number of programs, and years of program graduations since the inception of the physical therapist assistant education programs, allowing for minimal attrition (Marc Goldstein, APTA Department of Research; personal communication; September 1994).

Approximately 4,600 physical therapist graduates and 2,000 physical therapist assistant graduates were added to the potential work force in 1993. In addition, and undetermined number of foreign-trained physical therapists apply for licensure each year, with an estimate of less than 500 candidates entering the national work force annually (APTA Department of Practice, personal communication, August 1993). Attrition rates will be discussed in the next section.

Physical Therapist's Career Patterns

A thorough understanding of the career patterns of physical therapists and physical therapist assistants is as important to an analysis of health care personnel needs as are accurate counts of the numbers of available practitioners. This assumption is based on two characteristics of our work force: (1) the numbers of men and women in the profession and (2) the perception by some that physical therapy does not require a lifelong career commitment in the manner that other professions do. These factors suggest that the number of credentialed workers is not very meaningful when determining who will be available to treat patients today. A better understanding of the career patterns of physical therapists and physical therapist assistants is needed to develop models that will predict personnel resources at any point in time.

Since the early 1950s, researchers have reported on 10 studies of career patterns of physical therapists, the majority of them cross-sectional analyses. Some of these studies, however, have not been published in peer-reviewed journals. Samples have typically consisted of APTA members or graduates of one particular school. A summary of the findings of percentages of active physical therapists is presented in the Table.

[TABULAR DATA OMITTED]

Worthingham,(5) as Director of Professional Education for the National Foundation for Infantile Paralysis, conducted a human resource study for physical therapists in 1952 and reported approximately 5,000 physical therapists practicing, with 2,522 job vacancies. This work contains the first reference to attrition for physical therapists, reported as 7% annually.

Hislop and Worthingham,(6) in 1958, described 1,800 National Foundation for Infantile Paralysis scholarship recipients, educated between 1940 and 1956. Thirty-five percent of the therapists, 14% of the men and 41% of the women, were inactive (ie, not working in physical therapy) at the time of the study. Of the inactive therapists, the median number of years worked since graduation was 2 years. Forty-eight percent of the inactive therapists were employed in another health care occupation, 25% in medicine. Of the group not practicing physical therapy, all of the men were employed as compared with only 12% of the women.

In 1966, Worthingham(7) described a cohort analysis of the graduates of physical therapy programs in 1961 and 1965. Eleven percent of the 1961 graduates and 32% of the 1965 graduates were not in practice at the time of the study. Seventy-one percent of the inactive 1961 graduates and 51% of the inactive 1965 graduates stated that they planned to return to practice within 1 year. Without the aid of longitudinal data, the accuracy of this prediction is difficult to assess, but Worthingham stated, "If similar percentages of graduates who had left the field for marriage in former years intended to return to part-time employment, it is evident that few have done [so."(7).sup.(p496)]

Gomez(8) studied 475 physical therapists in California to determine the rate of attrition from the profession and to describe the characteristics of attrition. Gomez, who did not publish her results, found a variable attrition rate over time: negligible immediately after graduation, increasing slowly until the fifth decade of the practitioner's life, then sharply increasing. The characteristics of attrition were different when analyzed separately for male and female therapists and were categorized into work-setting factors, personal factors, and educational factors. For male therapists, Gomez found that the greater the reported importance of pay and control over work methods, the greater the importance of membership in the professional organization, the more involved in non-physical therapy academic studies, and the more degrees held, the greater the likelihood of stopping practice. These variables would seem to describe the therapist who has moved out of full-time clinical practice and into a role as an administrator, educator, or researcher. Gomez also found for male therapists that the higher the salary, the greater the probability of continued practice.

For female therapists, Gomez(8) found two somewhat confusing factors to be significantly related to attrition. First, the higher the salary of practicing therapists, the greater the probability they will stop practicing. Gomez hypothesized that the higher-paid female therapists feel boxed in because of the limited career ladder and will subsequently move out of the profession. Second, the greater the number of non-physical therapy jobs the female therapists held since licensing, the greater the probability they will continue to practice. Gomez suggested that the highly motivated female therapist will do something else to realize her potential, while continuing to practice physical therapy.

Gomez(8) found no personal factors related to attrition for either male or female therapists, and she attributed this finding to the rigorous screening process of applicants to physical therapy education programs, resulting in a homogeneous group of professionals with regard to personal factors.

Studies of education program alumni provide evidence of physical therapists' career patterns during the 1960s and 1970s. Morrison et al,(9) in 1982, reported that 88% of Marquette University graduates from 1956 to 1980 were in active practice; Conine(10) reported that 73% of Indiana University graduates from 1960 to 1970 were active; and Blood(11) reported that 95% of Stanford University graduates from 1970 to 1980 were active.

In 1984, Gwyer, in her unpublished doctoral dissertation,(12) described a causal model of attrition for physical therapy practitioners, based on the available literature related to job turnover and job satisfaction for physical therapists(13)(14)(15)(16)(17)(18) and on a previously tested model proposed by Price and Mueller(19) to explain turnover among hospital nurses. Attrition was defined as the cessation of practice of the professional clinical skills of a physical therapist, and was operationally defined as work tenure since graduation. Physical therapists who were educators or researchers were considered to have left clinical practice.

The model variables' predicted relationship with work tenure was based on previous research in physical therapy or in similar professions. Three variables were hypothesized to directly influence work tenure: gender, entry-level education, and opportunity for work outside physical therapy. I hypothesized that female therapists, therapists educated at the baccalaureate level, and therapists reporting low availability of jobs outside the profession would have longer work tenures.

Two intervening variables were hypothesized to influence work tenure: career satisfaction and commitment to the profession. Those therapists expressing high career satisfaction would in turn express strong commitment to the profession and longer work tenures.

Career satisfaction, a variable based on research on job satisfaction, was believed to be dependent on an array of variables that describe the nature of the work of the physical therapist. These variables included routinization of tasks; independence or control over work methods; promotional opportunity within the profession; distributive justice, or the relation of rewards to performance; burnout, or the physical and emotional stress of the work; pay; and role conflict, or the gap between the respondents' expectations for the nature of work while in school and the real work experience. The more routine the tasks, the more burnout or role conflict experienced by the respondent, the less career satisfaction would be expected. The other variables were expected to enhance career satisfaction.

Two variables related to family responsibilities were expected to influence career commitment directly: kinship responsibility, or the degree of an individual's obligations to relatives, and kinship priority, or the importance assigned to the kinship system. The stronger these family variables, the lower the expected career commitment and work tenure.

A stratified (equally by gender and entry-level degree) random sample of 404 graduates of physical therapy programs in 1972 were the study subjects. Seventy-nine percent of all respondents were active in practice 11 years after graduation (72% of the women and 87% of the men, and 77% of the baccalaureate degree and 83% of the postbaccalaureate degree graduates). The mean work tenure for the 1972 graduates was 9.06 years (SD=2.5, range=0-11), with 42% of the graduates reporting a continuous working career since graduation. The mean work tenure was 10.45 years for currently working men and 9.6 years for currently working women, with very little difference based on entry-level degree. Sixty-seven percent of the respondents reported working 40 hours or more per week. Multiple regression and path analysis were used to examine the relative influence of the variables in the model. Results indicated that the proposition of two variables, career satisfaction and career commitment, as intervening variables that would mediate the influence of the other model variables was not supported. These intervening variables did have direct effects on work tenure and enhanced the explanatory power of the model. Opportunity for work in areas outside physical therapy was the most important determinant of work tenure. The higher the therapists' perception of the availability of jobs in a field other than physical therapy, the shorter was their work tenure. Also, the higher the commitment to the profession, the satisfaction with the rewards of the job, the satisfaction with physical therapy as a career choice, and the pay, the longer the work tenure. Gender was also found to be related to work tenure, with men having longer work tenures than women. Overall, the model's variables accounted for 21% of the variance in work tenure. This finding suggests that many other factors influence work tenure, because 79% of the variance was not accounted for.

This study would seem to indicate a substantial decrease in attrition in physical therapy as compared with the work-force participation rates of the 1950s and 1960s. The Worthingham studies(7) are the most comparable to this study in that nationwide graduates of one year were studied, so that the entire sample has the same potential work tenure. The changes are most dramatic in the work-force participation rates of women. Five years after graduation, 41% of the 1961 female graduates were inactive, whereas 11 years after graduation, 28% of the 1972 female graduates were inactive. The work tenure of those therapists who eventually stop practicing is also longer than previously reported. Hislop and Worthingham(6) reported a median number of years worked for the currently inactive 1940 to 1956 graduates of 2 years. Worthingham(7) again found a median of 2 years' work tenure for currently inactive 1961 graduates. The mean work tenure for the inactive 1972 graduates was 6.6 years (SD=3.4). Comparison of the participation rates between these two studies, however, must be undertaken with caution, as the timing of data collection was not comparable. The variable pattern of work-force participation of physical therapists further confounds this comparison, as the 1972 cohort illustrates. Fewer than half (42%) of the 1972 graduates worked continuously for the first 11 years of their potential work tenure, and one third of those active at the time of the study (1983) were working part-time. Our understanding of work-force participation patterns for physical therapists lacks the longitudinal data necessary to provide an accurate description.

The determinants of attrition identified in my study were generally consistent with previous research, with the opportunities for work in fields external to physical therapy achieving a preeminent position. The most frequently reported occupational categories of jobs available to the respondents were business/sales, teaching/education, and management and administration. An awareness of these career options and their influence on attrition in physical therapy should help us focus our goals on making the work of the physical therapist as attractive as possible. The findings of my study suggest that the nature of the work of the physical therapist should continue to be examined for characteristics that will promote career satisfaction, for example, making the rewards of pay and recognition more closely related to performance throughout the career span, decreasing the routine nature of the work, and increasing career advancement opportunities in clinical practice. These results also support the importance of a well-established career commitment among the work force to increase the work tenure. Efforts to improve available personnel resources in physical therapy should include attempts to establish a public perception of physical therapy as a professional career, rather than a career surrogate.

Expected Career Patterns of Entrants

The socialization of the work force to the norms and culture of the profession begins during the didactic and clinical education program, and continues into the early years of practice. Therefore, educators have the first opportunity to shape the work force through their selection and admissions procedures. Prior to this decision point, individuals have evaluated the profession of physical therapy and placed themselves in the applicant pool from which the education programs select students. The next logical set of research questions include the following: Do applicants to physical therapy programs have expectations of career longevity and work patterns? and Do these expectations change over the course of their education programs? These questions have been addressed by several researchers (O'Neill M and Thompson JA, unpublished research, 1989; Lee LG and Nyilis CA, unpublished research, 1991; Haag LS and Withstandley C, unpublished research, 1993), but unfortunately their work has not yet been published in peer-reviewed journals.

Lee and Nyilis (unpublished research, 1991) used a random cluster sample of entry-level programs for physical therapists, stratified equally both geographically and by entry-level degree, to obtain a sample of 472 students in their first week of classes in 1990. This sampling method served in lieu of a national random sample of applicants, which was not obtainable at that time. Eighty-five percent of the students stated that they expected to work in physical therapy until age 65 years, with 15% responding that they would not or were uncertain. Forty-eight percent of the students reported that they expected to take an extended period of time off from the profession for reasons other than vacation, with more women and older students holding this expectation. Seventy-two percent of the students stated that they expected to work part-time in physical therapy in the future, with more women (87%) than men (33%) having this expectation of their career path. The students were asked to rate a variety of personal, educational, and work-setting factors as to how they might expect those factors to influence their decisions to take an extended leave or to work part-time. Women were more likely to report family responsibilities and pursuit of educational opportunities in the field as influencing factors, whereas men were more likely to report the pursuit of educational opportunities in another field as an influencing factor. In assessing students' expectations of the nature of the work of the physical therapist, men were more likely than women to report that they expected to work greater than 40 hours per week; 76% of the men expected to work more than 40 hours per week as compared with 44% of the women.

Two years later, Haag and Withstandley (unpublished research, 1993) followed up this cohort of students as they finished their academic careers or started practicing. Three hundred seventy-eight respondents from the class that began in 1990 reported a mean expected retirement age of 61 years, with no differences in mean retirement age by gender, marital status, age, or entry-level degree. Twenty-six percent of the respondents expected to have work interruptions lasting longer than 6 months, not including vacations or maternity leaves, with more women (30%) than men (15%) holding this expectation. The most frequently rated expected reasons for a work interruption were family responsibilities and pursuing educational opportunities in physical therapy. Similar to their opinions 2 years previously, 77% of this cohort reported that they expect to work part-time during their careers. Ninety-one percent of the female respondents reported expectations for part-time work, with women reporting family responsibilities and the desire to supplement household income more frequently than men. The respondents expect to work part-time primarily during their 30s (59%) or 20s (26%). In assessing the impact of their educational experience on their career expectations, the majority of students consistently reported no change in their expectations for part-time work (59%) or for work interruptions (65%). However, 21% of the respondents stated that they now might consider part-time work, and 13% stated that they now planned to spend more time working part-time. Slightly lower, but similar, frequencies were found for expectations for work interruptions. Respondents rated the influence of their clinical affiliations most frequently as a factor influencing their career expectations.

These studies of individuals choosing to become physical therapists indicate that an interrupted work pattern is expected by entrants to the profession, by men as well as women, if for different reasons. The lack of differences in expected retirement ages due to gender in both of these studies would indicate that women do not expect to have permanent work stoppages. It may be possible to construct a projected work tenure for male and female physical therapists based on expected work interruptions that could be used in personnel resource projections. It would be important to understand how many physical therapists must be educated to deliver to society one 40-year career professional. Additional data are needed to document physical therapists' actual career patterns, and to this end 300 of the above-referenced cohort of entering students in 1990 have been enrolled in a longitudinal study of career paths. Additional studies of physical therapist assistants' career patterns would be helpful.

Enhancing the Supply of Personnel

Educational Approaches

Perhaps the most direct method of increasing the supply of practitioners is to increase the number of education program graduates. A combination of two approaches to this goal has taken place in physical therapy education over the last decade: an increase in the number of education programs (175% increase from 1970 to 1993), and an increase in class size in existing programs (physical therapist education program mean class size increased from 27 students per class in 1980 to 39 students per class in 1992, and physical therapist assistant education program mean class size increased from 12 students per class in 1980 to 22 students per class in 1992). These efforts have resulted in a consistent rate of growth, averaging 8% per year, in the number of graduates during the last decade (APTA Department of Research, personal communication, August 1993).

As reported elsewhere in this special issue, federal financial support of postsecondary education is on the decline, affecting many institutions that house our education programs. Physical therapy education was supported by federal funding of various types through the decade of the 1970s, but the majority of that funding came to an abrupt end in 1980, and has only resumed in 1990. Elwood states there is "little reason to believe that allied health could go a full decade without federal funding and not suffer painful effects."(20)(p48)

Amidst our apparent shortage, the profession continues to pursue goals that will enhance the practice and science of our profession, and thus the quality of our patient care. These goals include standardizing and potentially lengthening to some extent the entry-level education programs. This lengthening of entry-level programs may occur as a result of changes in the didactic curriculum or degees awarded, or as a result of a lengthening of the clinical practice time required before totally independent practice can be initiated by the graduate. These professional initiatives may have short- or long-term effects on the supply of personnel. A lengthened entry requirement may delay the initiation of the professional's career when longer programs are initiated and thus decrease the available supply of personnel for a brief period of time. We should, however, assess the expected effects of a lengthened entry requirement on expected career patterns to determine whether a longer or more productive career would be the result.

Two other educational strategies that have been advocated include new methods of educating physical therapy personnel. One suggestion echoes educational methods used in this country in times of national crises to train personnel in shorter than normal periods of time to meet a pressing occupational need. The educational training for physical therapists started in this country under just such circumstances, during World War I, and was increased in length gradually through subsequent years. One method of implementing such a program would entail admitting students with science or health-related backgrounds and decreasing the normal training period. Admitting physical therapist assistants to shortened therapist training programs has also been suggested; however, this strategy robs one personnel pool in order to enhance another.

The other alternative method of educating personnel, advocated primarily by employers of allied health personnel, would consist of combined or cross training of some types of personnel whose work is considered similar enough in nature to benefit from this process.(20) The reasoning follows that personnel trained to perform across a range of occupational activities could more effectively meet supply and distribution needs in health care. The concept of a multi-competent allied health practitioner has gained favor in some areas of the country and for certain occupational categories, to date primarily practical nurses, respiratory therapy technologists, ultrasound technologists, radiological technologists, electrocardiographic technologists, and medical laboratory technologists.(20)(21) It is difficult to conceive of this approach as an alternative for enhancing the supply of professional physical therapists, who play a significant role in critical decision making in rehabilitative and preventive care for patients. An examination for duplication of content in the educational preparation and role performance of physical therapist assistants and occupational therapist assistants may be of interest. However, because both categories of personnel are currently suffering from a shortage, a careful examination of the expected benefits for supply or distribution of personnel in both professions would be a necessary first step.

Alterations in Career Patterns

These studies provide some insight into the professional career of the physical therapist. Similar data, however, are not available for the physical therapist assistant. As described in the report of the Institute of Medicine's study of allied health services, the allied health labor force can be found to have a "predominance of technically competent women with a service orientation."(22) The profession of physical therapy would preferably be viewed as one consisting of professionally competent practitioners, with a commitment to a scientifically based approach to the delivery of service-oriented care. Whether this view of our profession can be attained when the career patterns of our participants resemble more closely those of female-dominated professions, or what Etzioni(23) has termed "semiprofessionals," is questionable. It will be interesting to assess the long-term impact of the influx of women into the traditional professions of medicine and law on society's viewpoint of what comprises a professional career pattern. Will the professions bend to the needs of women, or will female professionals adopt traditional male professional career patterns? Initial studies of work-force participation of female dentists and chiropractors show interrupted career patterns due to family responsibilities.(24)(25)

The physical therapy profession may also suffer from the consequences of being a profession in which the rewards are compressed into the early years of practice. Entry-level salaries, particularly in times of shortages, are artificially high, and rates of increases may not keep pace over the lifetime of the career. The professional recognition and status accorded practitioners accrue early, along with a degree of autonomy in decision making. So-called "front-loaded" occupations may experience difficulty in keeping practitioners active over the lifetime of a career as the incentives continue to diminish.

This pattern of compressed benefits for entry-level practitioners may be a particularly characteristic determinant of the practice-setting selections of physical therapists, showing a high percentage of first employment in institution-based settings (hospitals or rehabilitation centers) followed by movement into independent practice settings in private offices. Sheperd(26) urges institutions to shift their focus from recruitment of allied health personnel to retention by addressing issues related to career mobility, increased status and autonomy, flexible compensation and benefit plans, and educational benefits.

Longitudinal research is needed to determine the number and length of work interruptions physical therapists and physical therapist assistants experience, and the frequency of their return to work. Two studies of retention and attrition of physical therapists in Canada indicate that opportunities for career development are an important determinant of retention in rural areas of Ontario and that the opportunity for flexible hours would influence therapists' decisions to return to work.(27)(28) Barriers to women's return to work have been investigated informally by APTA, and subsequent programs, including reentry education programs, have been promoted regionally, nationally, and as home study. If data indicate that a significant pool of therapists are unemployed and could be encouraged to return to the work force, additional strategies should be devised to assist in this goal. We particularly need to assess this strategy as a mechanism to address the distribution problems in the work force.

I believe that we must also begin to determine the geographic career pattern of physical therapists and physical therapist assistants. We may have sufficient data to describe the relationship among a student's home, school location, and first employment, but we need to further identify the frequency with which these personnel move into and out of metropolitan and rural areas over a life-time career. Are geographical career decisions for physical therapists related to personal factors such as age, spouse's job location, or family responsibilities, or are these decisions more influenced by professional characteristics such as location of specific physician specialties or number of colleagues. Strategies to induce practitioners into geographically undeserved areas may be of either the carrot or the stick variety; the success of either is dependent on understanding factors that motivate these practice location decisions. Adjusting the location of the work force during a period of shortage is quite a daunting task, as even the most generous of employment offers can fall on deaf ears.

As the ability to assess needs for physical therapists with special skills grows, the impact of specialization on our personnel supply will require investigation. Specialization tends to decrease the interchangeability of practitioners and increase the number of practitioners required to meet service needs. For many employment opportunities, not just any physical therapist (eg, a pediatric physical therapist trained in administering developmental assessments) will do. Specialization may be seen as a natural progression for our profession, and within our professional association there are 19 special interest sections and 7 approved specialty areas in which a therapist may seek recognition for advanced clinical competence (APTA Departments of Specialist Certification and Component Relations, personal communication). The impact of specialization on career patterns should be analyzed. Will therapists who seek formal recognition of their specialty skills have increased career satisfaction and longer work tenures? The profession should continue to analyze the ways in which formalized specialization processes in physical therapy assist us in our mission to provide high-quality health care, and when too much fragmentation impedes this goal. External forces may intervene to help us decide this issue on society's behalf, as is currently happening in the health care reform debates surrounding specialization in medicine.

Alterations in Practice Patterns

There are several ways in which we can study methods of increasing the efficiency of the current work force in physical therapy, including an analysis of the various providers of care and an analysis of the type of care given. Both of these areas provide a wealth of research questions that could inform our decisions regarding personnel resource requirements.

As Bashi and Domholt commented regarding their study of the use of physical therapy aides, "... when professionals are in short supply, the use of support personnel to extend the reach of each professional becomes attractive."(29)(p421) Thus, the rationale for asking and answering the question of who can deliver services is painfully obvious in this climate of shortage. We must determine what is necessary effective care and how it can be delivered by the most cost-effective provider. Should we have been asking this question all along, and will health care reform demand its answer from us with its new rules for reimbursable health care? It appears, from this study, the accompanying commentaries, and the continuous professional debate, that we have no consensus on this important question of delegation of patient care responsibilities to the identified health care supportive personnel within our profession.

There are at least two conceptual frameworks to be considered in future studies of delegation in physical therapy. Most commonly used, as in the previous study,(29) is an analysis of technical tasks that may be delegated. Such studies would provide us with either professionals' opinions or actual observational or experimental data supporting the hypothesis that certain tasks may safely and efficiently be delegated to certain personnel, under usual conditions. It is assumed that delegating physical therapists will recognize these usual conditions and avoid delegation of even these responsibilites when their judgment indicates it would be inappropriate. This assumption illustrates the weakness of these types of data in preparing a comprehensive approach to delegation of patient care responsibilities, for the patient whose condition is complex or fluctuating, as is common in today's practice.

Another conceptual framework would guide studies of patterns of supervision among various teams of providers (eg, physical therapist-physical therapist assistant-physical therapy aide) with an emphasis on documenting the nature of the supervision, as well as the types of tasks delegated under certain conditions. In this way, we may discover types of preparation, education, and supervision that enable the safe and efficient delegation of the maximum amount of tasks to supportive personnel. Data that elucidate the factors associated with effective delegation and supervision would be of great value to individual physical therapists in analyzing their patterns of supervision.

Studies of both types of practice (ie, how we do what we do) would be enhanced by a new look at appropriate outcome measures for assessing patient safety, quality of care, and cost effectiveness of the delivery method. In this quest, as in other areas, we are hampered by the dearth of acceptable outcome measures to use in such studies. Attempts to change longentrenched practice patterns of physical therapists with data that indicate a manner of service delivery is safe and cost effective may not be persuasive if the therapist does not believe that such a change reflects high-quality patient care.

Many professions have grappled with assigning responsibility for a range of decision-making and technical tasks. Not too long ago only physicians took a patient's blood pressure--the task thought too important to delegate--and now automated blood pressure recording equipment is in grocery stores. The professional role of the physical therapist, particularly with regard to physicians, has expanded significantly over our seven-decade history. Ritchey et al,(30) in a study of physicians and physical therapists, found that our profession's role is likely to continue to expand as long as it continues to be seen as directly related to patients' needs for services and as long as it is supported by scientific research. With role expansion and complicated problem-solving requirements increasing at one end of the spectrum and increasingly better educated personnel, both internal and external to our profession, eager to assume the tasks that fall off our plate at the other end of the spectrum, we must decide what technical tasks to delegate and to whom. In physical therapy, this process must be engaged in by practitioners, therapists and assistants, and the analysis should focus not only on current patterns of delegation but also on the most creative and new patterns. For example, Sahrmann suggests we might change the role of the assistant in the patient evaluation process such that "the physical therapist assistant could gather evaluation data to present to the therapist, who then would arrive at the diagnosis,"(31)(p63) similar to the manner in years past in which the physical therapist collected evaluative data so that the physician could make a diagnosis.

I believe that we must also place in relative priority the need to study the use of competing practitioners in the provision of physical therapy services. Our relationship with each of our competing rehabilitation professionals is unique and could generate its own set of research questions. We should address these questions immediately for disciplines such as athletic training and exercise physiology, whose practitioners in some numbers currently contribute to our supportive personnel work force.

Our research agenda for analyzing practice patterns is closely linked to our agenda for outcomes research in physical therapy practice. A clearer picture of who to treat and who not to treat and of what treatment is most effective will directly affect the efficiency of our services. The general framework of outcomes research, which is based largely on assessment of outcomes for diagnostic groupings of clients, may leave us with a gap in assessing one type of physical therapy service delivery very important to society--preventive services for individuals with or without chronic health problems. This area of physical therapy practice is growing in clarity and definition and should be addressed in our research agenda on delivery and access to physical therapy services. Access to preventive health care services of all types is limited in this country, and the same is true for physical therapy. Although research that describes the predicted cost savings of preventive health care is sophisticated and difficult to perform, we should attempt to frame questions related to this growing area of physical therapy practice.

Summary

The supply of practitioners available to provide services in physical therapy is constantly modified by the fluctuating nature of our work-force participation. A better understanding of the nature of these patterns and the factors that motivate maximum participation in the work force will improve personnel supply estimates in the future. The work-force productivity of the available personnel may be adjusted through various adaptations to career paths and practice patterns. The profession will be best served if decisions related to these changes are based on research data that identify the most effective strategies. Among the research questions suggested by gaps in existing knowledge are the following:

1. What are the most effective and cost-efficient research methods for the profession to develop personnel supply estimates on state, regional, and national levels?

2. Develop a longitudinal project to describe career participation patterns for male and female physical therapists and physical therapist assistants.

3. Compare career expectations for men and women choosing physical therapy careers with those who choose the traditional professions of medicine and law.

4. What are appropriate physical therapist: physical therapist assistant: patient ratios for delivering services in various practice settings, or for various case mixes of patients?

5. Identify a method for studying cost-effective delegation/supervision behaviors for physical therapists. Investigate appropriate outcome measures for studies of delegation (eg, error/injury rates, patient satisfaction indexes).

6. Identify professional standards for prioritization of care in circumstances of inadequate service provision.

7. What is the effect of placement of education programs for the physical therapist and physical therapist assistant on geographic distribution of practitioners?

8. What is the effect of clinical education assignments on geographic and practice setting selections of therapists and assistants, in both the first practice setting and subsequent choices?

9. What is the effect of specialization in physical therapy on the distribution of personnel resources?

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This article is adapted from a presentation given at the American Physical Therapy Association/Agency for Health Care Policy and Research Human Resources Conference; Reston, Va; August 26--27, 1993.

This article was submitted May 17, 1994, and was accepted September 23, 1994.