The effect of hospital restructuring on the role of physical therapists in acute care.

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

Growing competition, shrinking reimbursement, and a demand for increased accountability are pressuring American hospitals to reduce costs and alter their business practices. In response to this pressure, hospitals are making major organizational changes, including hospital restructuring, while attempting to maintain the quality of patient care delivery. As a result, increased demands are being placed on professional caregivers, including physical therapists, to meet the changing needs of patients and institutions, as well as their own personal and professional needs.

Conflicting views of the merits of hospital restructuring exist in the health care literature. Although the management literature most often extols the virtues of hospital restructuring,[1-3] the professional literature generally provides anecdotal, yet often conflicting, evidence that hospital restructuring is changing the roles of professional caregivers.[4-9] To begin to clarify this confusing picture, we need to understand more fully the effect of hospital restructuring on clinical practice and identify strategies that can be used to assist professionals to function more effectively within this turbulent environment. Additionally, we need to understand how, or even whether, these organizational changes are affecting outcomes for patients, hospitals, and the caregivers themselves.

Elements of Hospital Restructuring

Hospital restructuring can involve all aspects of patient care delivery. Usually, it is intended to (1) decrease costs related to structural inefficiencies, overutilization of services, overspecialization of staff, and compartmentalization of care, (2) enhance physician efficiency, (3) improve the patient's quality of care, and (4) create a working environment that will attract and retain staff.[3,5] To meet these goals, four principles, described in the Table, are often implemented: (1) patient aggregation, (2) process simplification, (3) service redeployment, and (4) cross training. Patient aggregation, or grouping of patients with similar clinical problems, does not appear to be problematic for professional caregivers because hospitals have traditionally grouped patients with similar diagnoses based on similarities in their need for specific resources.

Table.
Basic Principles of Hospital Restructuring

Principle                  Description

Patient aggregation     Grouping of patient populations to
                          create a critical mass of patients
                          with similar clinical problems

Process simplification  Reducing administrative tasks that
                          take caregivers away from patient
                          care activities

                        Moving the required services closer
Service redeployment      to the patients

                        Broadening skills of individual staff
                          members through multitasking and
Cross training            training across disciplinary
                          boundaries

Principle               Purpose

Patient aggregation     To ensure a stable census and predictable
                          workload for the staff members
                        To better utilize similar services,
                          equipment, and supplies
                        To facilitate administrative tasks
                        To enhance the efficiency of physicians

Process simplification  To reduce the amount of time caregivers
                          devote to nonpatient care tasks such
                          as documentation and other forms of
                          paperwork, transportation, and scheduling

Service redeployment    To reduce the amount of travel time
                          required by both staff in delivering
                          services and patients

Cross training          To utilize fewer stain members to
                          deliver services to specific groups
                          of patients

Likewise, process simplification appears to pose few problems. Documentation, scheduling, and patient transportation are the most obvious targets for simplification because they generally infringe on the time caregivers devote to patient care. In part to simplify documentation, many hospitals have instituted care pathways that serve as a "road map" for the delivery of care and help identify the appropriate level of personnel to provide that care. Some caregivers, however, perceive these pathways as reducing their control over clinical practice.[10]

Service redeployment and cross training, where they are being implemented, are generally more problematic because they can alter the roles of professional caregivers. Service redeployment, or moving the required services closer to the patients, creates problems for caregivers in areas such as service accountability and supervision, activity coordination and delegation, caregiver communication and teamwork, and team member training.[6,10-12] These problems may be created through mechanisms such as multiple reporting relationships or isolation from traditional professional colleagues, which may cause role ambiguity and role conflict, thus altering the caregiver's sense of professional identify or role boundary[11,13-16] Service redeployment, however, is not problematic in all instances. For example, some caregivers express a feeling of increased competence in clinical decision making and increased professional identity with the assumption of a "specialist" role within the patient care team.[5,7,11]

Cross training is the most controversial and least understood of the four principles because of two major implementation problems. First, it is difficult to identify the appropriate level of personnel who can or should perform a specific task.[6] Second, determining the appropriate number of patients who can be managed effectively by a care team is also difficult[10,17] With today's emphasis on efficiency, there is fear that insufficient personnel will be available for the provision of highquality care.

Although not usually a principle of hospital restructuring, reduction of staff is often an underlying goal. Like other aspects of restructuring, staff reductions take several forms and can affect the roles of professional caregivers. Some hospitals achieve reductions through staff redeployment and cross training and generally target support staff. Other hospitals eliminate entire levels of management, a strategy that can disrupt professional caregivers' sense of professional identity or professional boundary, can decrease opportunities for professional development, and can increase concerns regarding the maintenance of clinical excellence.[5,18]

The Effect of Organizational Change

Based on a theoretical model of the dynamics of planned organizational change proposed by Porras and Hoffer,[19] a conceptual model of the effect of hospital restructuring on the physical therapist's role is proposed (Fig. 1). In general, this conceptual model proposes that organizational intervention (hospital restructuring) acts on the organizational work setting (the physical therapy department) to produce changes in the work behavior of organizational members (roles of physical therapists). Porras and Hoffer described the organizational work setting as an environment consisting of four broad interrelated systems: (1) organizing arrangements or the formal organizational elements such as structures, policies, and procedures necessary for coordination and control, (2) social factors or the individual and group characteristics and processes, which include communication, decision making, and organizational culture and values, (3) physical setting, which includes the size, shape, and location of work space and related activities, and (4) technology, which involves the tools, equipment, technical procedures, and systems used in the transformation of inputs into outputs. Together, these elements provide the organizational members with cues regarding appropriate work behaviors that not only shape what they do but also affect their attitudes and beliefs. The resultant work behaviors in turn affect organizational outcomes, including organizational performance and individual development. Thus, individual behavioral change is of primary concern because it is critical to changes in organizational outcomes.

[Figure 1 ILLUSTRATION OMITTED] The importance of individual behavior expressed in this model is consistent with Katz and Kahn's view that organizational effectiveness results from congruity between organizational expectations and an individual's role perception.[20] But how do organizational members, such as physical therapists, develop or even alter their role perceptions? How are cues regarding appropriate behaviors transmitted, learned, and integrated into a sense of professional responsibility? How are these behaviors influenced by hospital restructuring? The purpose of this study was to begin to address these questions by describing how the role of physical therapists working in acute care hospitals has changed as a result of hospital restructuring.

Methods

Because of the variability in the implementation of restructuring in hospitals, a case study of one acute care hospital and its physical therapy department was undertaken to begin to understand the effect of this change process on the role of inpatient physical therapists as viewed by those involved. Additionally, the study was further focused on only the inpatient acute care services. A case study methodology was well suited to this study, with its goal of a priori specification of constructs, triangulation of multiple sources of data, and theory generation and building in an area where little data or theory exists.[21,22] Furthermore, a case study permits the researcher to understand the dynamics present within a representative organization, referred to as theoretical sampling,[21] by providing a thick, rich description of phenomena of interest occurring in the setting. The overall idea is to become intimately familiar with the case, that is, to become emersed in the "lived experience" of the participants and to see the phenomena through their eyes.[23]

This particular hospital, which will be called Lakeview Hospital, was chosen for the study because it represented a typical acute care facility that had undergone restructuring within the past 5 years. In addition, this hospital had a physical therapy manager and staff who consented to participate in the study.

Data Sources

Data were gathered through (1) observation of physical therapists engaged in the major aspects of departmental operation, (2) collection of documentation pertaining to the restructuring process maintained by the physical therapy department director, and (3) open-ended, semistructured interviews with four key employees who worked at this facility throughout the restructuring process.

Five observation sessions lasting from 2 to 4 hours preceded the interviews to gain broader insight into the operation of the department and communication processes. These sessions were scheduled to allow observation of characteristic periods in the daily routine of the therapists. They included an early morning planning and organizing session, morning and afternoon treatment sessions on the primary inpatient floors, a departmental meeting, and a lunchtime socializing and reorganizing session. Brief notes written unobtrusively during the observation sessions were expanded and transcribed into field notes at the end of each session. All data gathering and analysis were done by the researcher.

A review of documents (memorandums, meeting minutes, and notes taken by the physical therapy director) covering the restructuring period was undertaken prior to the interviews to better understand how the departmental change fit into the organizational change in the hospital. Furthermore, these documents were used to gain insight into the administrative perspective behind the restructuring process itself.

Three interviews lasting approximately 1 hour each were conducted with the primary informants. The interviews consisted of semistructured, open-ended questions designed to elicit information and perceptions about the changing role of physical therapists within this facility. To verify their clarity, applicability, and comprehensibility for this study, the primary questions used for the interviews were reviewed beforehand by three physical therapy clinical managers who were involved in similar restructuring processes at other hospitals. Follow-up, probe questions (eg, "Can you give me an example of ...?" and "Can you explain what you mean by ...?") were used to clarify responses to the initial questions and to gain further insight into the process. Each interview was tape recorded and transcribed along with field notes taken after the interviews. Any perceived discrepancies between the interviews and observation/document collection were addressed with the participants through a follow-up telephone call.

The informants interviewed for this study were chosen because each informant possessed a unique perspective on the effect of the change on the role of physical therapists. Prior to the interviews, each informant signed a consent form to participate in the study. The director of physical therapy was chosen because she was responsible for the physical therapy services, had implemented the changes within the department, and had been involved in the hospital-wide planning process. A nurse coordinator was selected to participate in the study by the physical therapy inpatient coordinator because she was most familiar with the physical therapy services prior to and following the organizational change and could provide an external perspective on the process. The director and the nurse coordinator were interviewed separately. The third interview involved two staff therapists who were chosen because they currently were working in the inpatient acute care area. They had worked in the facility throughout the change process, and they had experience working in all of the units of the hospital where physical therapy care was provided.

There were no major problems encountered regarding access to the participants for this study, although time constraints were clearly an issue because of the informants' busy schedules. Departmental staff members were willing to share their experiences and feelings about the department, the institution, and the change and to have the researcher observe treatments or interactions, or as they called it, "to be a fly on the wall."

All names and references specific to the facility or participants in this study were altered to maintain anonymity. In addition, because direct quotes from each informant were used extensively throughout the discussion, the identity of the speaker and the location of the quote from the data were indicated in parentheses following each quote. The informants were designated as follows: "D" represents the director, "N" represents the nurse coordinator, and "T1" and "T2" represent the two therapists.

Data Analysis

To begin the search for underlying themes, an initial coding scheme guided by the initial conceptual model (Fig. 1) was developed from open coding of the data from the interview transcripts and the field notes.[24,25] This coding scheme was further refined through more in-depth analysis of the data to ensure that the categories accurately represented the informants' perspectives and were exhaustive, mutually exclusive (data went into only one category), and independent (categories did not overlap).[26] Themes were then developed by combining thematically similar categories (axial coding).[25] The themes and related categories were used to create a revised conceptual model of the effect of hospital restructuring on the roles of physical therapists.

To limit researcher bias and ensure that the data were credible and dependable, a second qualitative researcher reviewed the coding scheme and categories, a member check was used, and data from all three sources were triangulated in the search for underlying themes.[26,27] Data triangulation involves using multiple sources of evidence to corroborate the existence of the underlying themes.[22]

Findings and Discussion

The Setting

Lakeview Hospital is an acute care facility located in the suburbs of a major metropolitan area and is a member of the Lakeside Health Corporation. The hospital is a large medical complex with 260 acute care beds, a 30-bed rehabilitation unit, a 22-bed skilled nursing facility, and an extensive outpatient center. The population served is covered approximately 42% by Medicare, 19% by Medicaid, 38% by managed care, and 1% by private pay.

The inpatient physical therapy services are located on the ground floor of the hospital. The services occupy two small offices, a wound care treatment area, and a large, open gym that is used for the treatment of patients from the medical floor who require a gym-type setting, for staff meetings and in-services, and for the early morning and lunchtime planning and coordinating activities. The inpatient services are generally staffed by a coordinator, eight physical therapists, one physical therapist assistant, and three aides and transporters.

Hospital Restructuring

Organizational change at Lakeview Hospital, called "Work Redesign," began in 1992 and was intended to change the fundamental nature of the organization within a 2- to 3-year time frame (CEO memorandum to hospital management team,June 1992). Work redesign was precipitated by changes in the external health care environment, a decreasing census, and a decreasing length of stay for patients in the hospital. As the director commented,

"At the beginning, there was a decreasing census. The

last 2 years we have leveled out on our average daily

census, which everybody projected to continue to drop,

but it hasn't. Our admissions have gone up. Our length of

stay has continued to shorten, but our admissions are

creeping back up..." (D:36-41)

The goals of work redesign were to enhance clinical efficiency, to decrease patient length of stay, and to decrease labor costs "by reorganizing the whole hospital ... by moving the patient less and having fewer individuals in contact with the patient" (D:31-33, notes from planning task force meeting, October 1992). Thus, Lakeview Hospital reorganized where patients were located (patient aggregation); decentralized ancillary and support services (service redeployment); cross trained personnel; especially personnel on the patient floors; and decreased the overall staff size. Additionally, diagnostic specific treatment paths (critical pathways) were instituted. Key departmental managers throughout the hospital, including the director of physical therapy, were involved early in the work redesign process.

Because of the expansion of the health care system of Lakeside Health Corporation and the positioning of the physical therapy services by the director, the physical therapy department has expanded to provide physical therapy services for newly acquired facilities or developed programs. Although there were reductions in management positions in the health care system, a departmental structure was retained for the overall planning and coordination of physical therapy across the multiple sites. As the director stated, "Physical therapists still report to physical therapy, and the manager of the physical therapy department is still a physical therapist." (Observation, Session 2:229-230)

Changes in the Physical Therapy Department

As indicated in Figure 2, the major organizational change for the physical therapy department involved the decentralization of physical therapy services to the various floors, units, or sites where care was provided. For the inpatient services, this decentralization involved not only a change in the physical setting for the delivery of physical therapy services, that is, their relocation to the patient floors, but also a redeployment of the staff to form "physical therapy teams" on the floors. This redeployment of staff involved major changes in organizing arrangements and social functioning of the department. The inpatient services, however, retained an "inpatient coordinator" who was responsible for the services provided to the surgical floor (East 1), the medical floor (West 1), the rehabilitation unit, and the skilled nursing facility and who reported to the director. Additionally, there was frequent interaction or "touching base" between the inpatient units as well as between the inpatient unit and the other service sites.

[Figure 2 ILLUSTRATION OMITTED]

A second departmental change involved the cross training of support personnel to function as combined physical therapy/occupational therapy aides and transporters. Cross training of the physical therapists to do other tasks was not considered to be appropriate by either departmental management or hospital management. As the director indicated,

"For me to expect the therapist to do another function is

really going to hinder my role, which is to provide

physical therapy services, because right now, providing

physical therapy services is challenging enough to get

enough ... personnel in here to do that." (D:588-590)

Other changes in physical therapy entailed increased focus on (1) staff productivity, with greater use of support staff, (2) functional activities in patient treatment, and (3) staff interaction to maintain a sense of professional identity. Each of these changes is discussed more fully under specific themes. Finally, the decentralization of treatment space to "mini-gyms" on the patient floors generated a complex web of issues concerning the suitability and safety of treatment space, the quality of patient care as seen through the eyes of both therapists and patients, and staff productivity. Space limitations, however, do not permit an adequate discussion of this issue within this report.

Physical Therapist Role Change

Two major areas of physical therapist role change--patient care delivery and professional interaction--emerged from the data, as indicated in Figure 2. The first area, patient care delivery, included those aspects of the physical therapist's role that directly relate to "hands-on" treatment and providing physical therapy to patients. The second area, professional interaction, involved the mutual relationships and influences that developed between the physical therapy staff and other health care professionals within the institution.

Patient care delivery. Five themes emerged from the data related to changes in the therapist's role in patient care delivery. Two of these themes--"being flexible" and "being productive"--were pervasive, that is, they were underlying many of the issues expressed throughout the observation and interview sessions. The remaining three themes--"being responsible for the care of all patients," "focusing on patient discharge," and "using support staff"--were issues associated with specific patient care responsibilities and also were discussed by all informants.

Being flexible. The phrase "being flexible" was heard often and in many different contexts in this department. "Being flexible" was viewed as a response to ongoing health care changes, both from within and from outside the hospital. As indicated by the director,

"When I interview, I certainly tell them [therapists] these three

things: `If you're flexible, are willing to offer and receive

information, and are willing to work with a team, there is no

problem you can't solve.'... I feel that if the team works like

that, if any challenges come up, they can deal with it.... I think

they also have to be willing to be change agents and willing to

deal with something new because the health care environment is

dealing with something new all the time." (D:530-537)

To the staff, however, "being flexible" generally involved being open to unexpected alterations in their daily work schedule. For example, an aide commented, "You've got to be flexible when you work here" during a discussion of balancing "work loads" in the inpatient units (Observation, Session 1:65-69). Additionally, the concept of being flexible in one's work schedule was reflected by comments from the director and a therapist, who stated,

"They have to be ready to adjust their planning ... because if

you say, `I'm going to treat these five patients in this order, and

these are the times I'm going to see them ...,'you know, that's

just not going to happen..." (D:521-527)

"To work here as a therapist, I really think you have to be ready

for change. You have to be flexible.... I may be on the schedule to

be in acute care for the day, but I may be needed in the skilled

nursing facility. I have to be ready to go ahead and go over ... or

impromptu meetings, or ... I guess what I mean is that you've

got to be flexible in your job ... as it grows. You've got to be able

to go ahead and grow with it." (T2:603-619)

The responsibility of "being flexible" to an unpredictable patient volume, however, was not borne solely by the staff. Departmental management took an active role in providing additional staff support when volume fluctuations dictated:

"We have some people who are designated floaters, some of the

PRN [per diem] staff, some of the assistants, who know every

day that they are going to go where the volume is ... and it might

be different every day." (D:295-299)

and in preserving the departmental ethos that had developed:

"Now, I'm told by people who come in from the outside ... that

this staff flexibility is really unusual. They say, `Do you realize

that at other hospitals, if you are assigned to that unit

and you get a light day, you are lucky and you wouldn't think of

calling the other guy.' But, I don't know how it happened ... but

now that we have it, I am so careful to try to preserve it."

(D:323-327)

Being productive. The second theme that emerged was a shared understanding of the importance and relevance of meeting and monitoring productivity standards in this department. The concept of productivity was mentioned frequently at all levels of this department and appeared to be viewed as a shared responsibility or "team responsibility," as expressed in the following excerpt:

"There is a ratio, an expectation, and a standard for each unit ...

and they know that if they are not busy and if they have staff

sitting around, their productivity numbers will be off If they go

to another unit, they log their hours to that unit.... I don't think

any therapist would say it's necessarily bad. But I think they

see it as an accountability." (D:309 -320)

As indicated by one therapist, the need to "be productive" also was viewed as problematic:

"When we decentralize, we have a real hard time planning out

how we are going to be productive. A new hire or new grad or

[a therapist on a] new rotation may need to have a physical

therapist with experience there on the floor with them. But

then, is it productive to have two physical therapists covering

one floor if the volumes aren't high enough? But then, you can't

leave a new grad or new hire by themselves.... That's a challenge,

I think." (T1:70-77)

Finally, the staff were cognizant of the link between their "productivity" and the department's ability to get and maintain resources:

"I think each person who goes into this profession likes to be

busy and like the hands-on care to keep you going. The other

part of it ... we've had to answer to administration for our

work.... For the past couple of years, we have had to start

keeping record of how productive we are to justify having or ...

opening another position." (T2:665-669)

Being responsible for the care of all patients. A third patient care delivery theme that emerged was the belief held by staff members that they were collectively responsible for meeting the needs of all patients who required therapy and were also responsible for providing high-quality care within this environment. This belief was shared equally by all staff members and is reflected in the following comments:

"It's not just what I do, it's what we do as a team. They are not

just looking at me, they are looking at the team. I guess it has

been instilled that these therapists who run acute care are

responsible for acute care ... make it run. They're responsible

for rehabilitation ... make it run. And I think that is how we

know, `OK, I'm not busy, East 1 is swamped,...

let me go help them out so we can get all those patents treated.'"

(T2:679-689)

"I think the advantage of the types of co-workers we have ... we

feel that we are all trained to ... put our heads together and see

how the day can go. Even if we are swamped and we have 50

extra people to see today, if I do this for you and you do that

for me, then we can ... still get our work done. And we always

try to remember you do have to prioritize, and tomorrow is

another day." (T2:458-468)

"And if you can't get to them, then you just make that patient a

priority the next day.... You'd rather give them a full, beneficial

treatment than go in there and show your face for a few seconds

and rush them and get them all nervous and..." (T1:458-468)

"Call that therapy." (T2:458-468)

Focusing on patient discharge: An increased focus on patient discharge and what equipment and services would be needed was identified as the fourth major theme in patient care delivery. All informants indicated that therapists were more involved in decision making regarding patient disposition and that this involvement occurred earlier in the patient's hospital stay. As expressed by the director and a therapist,

"In acute care, we're much more involved in discharge planning.

The fact is, we are changing our whole evaluation format to

reflect ... a bigger portion on rehabilitation potential, what we

think they can accomplish here in I week, what the next

appropriate level of care would be ... much more involved in

making the decision of what is the next appropriate level of

care.... So, I'd say our role has changed drastically in that sense."

(D:390-396)

"I feel like sometimes in acute care, we're the discharge planners

because we look right away at what was the previous level of

function. What is their home setting? Who do they live with?

Cognitively, are they OK, or are they impaired or confused, or

are they safe? On the evaluation, that's a lot of what we are

looking at, besides their functional mobility. We're looking at

their safety, disposition, their rehabilitation goals. Do their

rehab goals match their disposition?... We're looking at all that

stuff on the initial evaluation in acute care ... because then we

need to immediately, if we can on the first visit, identify what is

the best plan. " (T1:501-509)

It was clearly expressed that assuming this role in discharge planning was not easy, nor a skill possessed by today's entry-level therapists, when the therapists indicated,

"I do think one of the first questions when any new person

starts in acute care is: What qualifies for rehabilitation? What

qualifies for skilled nursing? What doesn't qualify at all? And it's

really hard to make them understand until they go through it."

(T2:524-526)

"There are so many options. Is this person best to go to skilled

nursing, rehabilitation, home care, outpatient? Does this person

need therapy beyond the acute care setting? What's the

situation? And we need to be able to assess that right away in

the evaluation and document that.... And you need to be

confident, and it takes a long time for a physical therapist to get

a good feel for that. I know as a new graduate..., before I rotated 

to every setting,... I had no idea where they belonged."

(T1:507-519)

This focus on decision making and patient discharge planning stands in sharp contrast to prior roles of physical therapists, as identified by the director when she stated,

"I just remember when I started in acute care, we had one acute

care rotation that was hot packs and TENS [transcutaneous 

electrical nerve stimulation]. Did you see any modalities used on

inpatients when you were there? You know ... it's not our

emphasis anymore, and I think that we are just much more

functionally oriented." (D:551-555)

Finally, to the informants, this change in focus resulted from changes in the external health care environment, most notably changes in the insurance coverage of patients. As expressed by one therapist,

"Insurance is a big issue ... from step 1, seeing where this person

is going to need to go but also in the back of your mind being

aware of who covers what ... who needs recertification ... who

will be allowed to go to a skilled nursing facility versus which

insurance company does or doesn't have a plan with this

facility. So we need to search out another facility. And being

able to pinpoint that and let somebody know at the beginning,

to get the ball rolling..." (T2:537-542)

Using support staff. The increased use of physical therapist assistants and aides emerged from the data as a means of extending the care that could be provided by the therapists:

"The therapists may be doing less unskilled activities than they

used to do because they need to, in terms of maintaining our

productivity and cost expectations.... My expectation is that

therapists are delegating unskilled activities to the support staff,

either an assistant or an aide." (D:595-598)

The use of support staff, however, as expressed in the following quotes, was also viewed as being somewhat problematic for the therapists as they struggled with issues of delegation and their loss of the ability to "progress a patient's care":

"I think that it's becoming more and more important for us to

know the role of physical therapist assistants ... what they are

actually licensed to do for us. I think in the big picture you are

going to see more physical therapist assistants used

in facilities, and I think that's happening with us now. We are

just starting to realize that we need to know just exactly how

much we can use them and where we can use them."

(T2:467-481)

"My personal feeling is I miss the hands-on and progressing ...

and being able to see exactly how well a person is doing. You

miss it because it's kind of like a sense of satisfaction as to what

you were able to do for them ... or to see if maybe that plan

actually did work out for them ... or didn't and what needs to be

changed." (T1:275-279)

Professional interaction. Role change in the area of professional interaction between physical therapists and other caregivers emerged as two themes in this study: (1) sharing knowledge and information across disciplines and (2) helping, sharing, and coordinating work. In addition, three concepts--the centrality of physical therapy to the patient's total program changes in attitudes and perceptions of individuals involved in the interactions, and the importance of personal contact in the development of professional interaction--appeared to be common and underlying to both themes and were identified by all of the informants.

Centrality of physical therapy. Following the decentralization of physical therapy services, the centrality of physical therapy to patient care was critical to the effectiveness of team dynamics on the floors. That is, professional interaction was believed to be better on the floors where physical therapy was considered an integral or central part of the patient care being provided. For example, interaction was perceived to be better on the surgical floor, with its large proportion of patients with orthopedic conditions, than on the medical floor, where patients were sicker, were undergoing more procedures, and had more caregivers involved in their care. In reference to this comparison, the director and a therapist indicated that,

"... it [surgical floor] is kind of an orderly environment.... They

come in, they do this ... they do that ... and they go home,

whereas up on the other floor, we've got the medical patient. We

have people who are dying, we have people who have been

there for 2 months, ... it's just not as clean a delivery system."

(D:233-237)

"I think it has a lot to do with the patient situations because on

East 1, besides their medical condition, there's a major physical

therapy component on the orthopedic floor, whereas on West 1,

the patients we are seeing are a lot more dependent. And that

makes a big difference in terms of how you can approach a

situation. A lot more going on ... one doctor following the same

person versus having a whole team of doctors following him."

(T1:184-190)

Despite the fact that professional interaction following decentralization appeared to be better on the surgical floor, it was believed that, in time, it would be equally as effective on the medical floor. As the director indicated,

"On West 1, we have never been forced to work together

really.... I think that is what happens. If you see each other and

you work with each other, there is no problem. And I think that

when we have our unit open up, there it will become a

nonissue." (D:260-268)

Changes in attitudes and perceptions. Attitudes, perceptions, or the "mentality" of individuals both outside of and within the department changed to include a broader concept of the term "team" following the decentralization of physical therapy services. First, the perception of physical therapy held by other caregivers in the hospital changed. For example, the nurse stated,

"Before, when they were just downstairs, we just knew that

they were down there. You sent a patient to physical therapy,

the patient came back up. You really didn't know the extent of

what they did. Since they've been on the floor, they have

become a vital part of the team.... They are part of everyday

activity.... I really like having them on the floor. I could never

see them going back down to be just a department." (N:3-22)

The therapists themselves believed that physical therapy was regarded more highly and that physical therapists were looked upon to make appropriate and timely decisions.

"I think that, as a profession, we've gained more respect ... the

acute care team ... regards the physical therapist more highly

than they used to because I got the feeling when I first started

that, `Ah, the physical therapists are down there. Just let them

do their thing and don't bother them, and they won't bother you.'

But now I get the feeling that people really look to us to make

appropriate decisions." (D:556-562)

Second, the therapists' perceptions of the concept of "team" changed, as did their attitude toward making an effort to "fit in" on the patient floors. At the same time, they maintained the perception of themselves as a "physical therapy team." These perceptions were expressed in the following statements:

"The other difference is just who are your team members?

Instead of working with five other therapists, you might be

working with zero or one or two other therapists and nurses.

So, I think the whole team that they work with has changed a

lot. In fact, that was an interesting part of all this transition."

(D:401-404)

"Now, the next physical therapist who rotates needs to make

that effort, now that we're aware and we're involved and they

expect us. That's part of the positive advantage of being on the

floor as part of the decentralized setting. Now, you function as

part of the other team. You are still part of

a team, but you've expanded into a different set." (T1:231 -234)

The director added that the therapists also have benefited from this change in that,

"The physical therapists are better for what they are being

exposed to on the floor.... They know what else the patients go

through in their stay. They get to see and observe patient and

nurse interactions, and I think they know how to better educate

patients." (D:481-487)

Importance of personal contact. The third concept underlying increased professional interaction was that increased personal contact, "being there" and "rubbing elbows," has affected the attitudes and perceptions of all caregivers. As the informants indicated,

On East 1, we're there. They have to work with US. We see

them every day. We rub elbows with them every day." (D:240-242)

"I think the best rapport we have is on the floors where we're

present. You know, that has the most to do with how we feel ...

because we're present and we're interacting day to day with the

same nurses and that's a key." (T1:402-404)

Additionally, the nurse contrasted the change in the perceptions of the nurses toward the physical therapists:

"It wasn't on a personal basis. It was only a department

downstairs." (N:11-12)

"They [therapists] will come and introduce themselves, and I

say, `Well, here's physical therapy now.' then the patients get to

know them, too. And they get a lot closer to the patients now....

They are right here on the floor. They'll stop in...." (N:170-173)

Sharing of knowledge and information. Knowledge and information sharing between the disciplines was the most commonly discussed means of increased professional interaction and thus emerged as a major theme in this study. Although the majority of this sharing occurred between therapists and nurses on the floors, the sharing between therapists and physicians and between therapists and professionals outside of the acute care setting was also apparent.

The contrast in sharing of information prior to and following the decentralization of physical therapy services was made by the nurse in the following comments:

"I would never even think to go down there [physical therapy

department] to say, `What is going on?' or `How are they

[patients] walking?' or anything like that. I don't even remember

a doctor ever asking how they were doing in physical therapy. I

don't remember ever doing that.... It would never have even

dawned on me to call down there

and ask how they [patients] are doing, other than to see how

they are doing in the room." (N:155-163)

"Since they've been on the floor, they have become a vital part

of the team because every morning, they'll come in and I will get

reports from them on how the patients are doing. It's so much

nicer for the patients because we see their progress. We see

what they are doing with them. I can ask them, `What do you

think about this?'" (N:5-9)

Knowledge and information sharing between therapists and nurses. Knowledge and information sharing between the therapists and nurses changed in both context and content. Often, information exchange about specific patients occurred in formal meetings such as weekly discharge rounds where each patient's status and plan of care were discussed. The content of these meetings, as expressed by the following excerpt, covered a wide spectrum of care for each patient; however, the clear focus of such formal meetings was on postoperative care and preparing the patients to go home or to another health care facility:

"We have discharge rounds on Tuesdays. So we have the

physical therapists, a dietitian, a social worker, and the

discharge planners. I go to represent nursing, and we all sit there

and discuss where we are going, what is our treatment plan,

what is our discharge plan, how they [the patients] are eating

and how they are walking. And this is all done for every

patient." (N:93-97)

A great deal of information about patients also was shared in more informal circumstances, such as stopping in the hall to ask questions about a particular patient, observing how a patient was doing with his or her program, and seeking or offering assistance. The information went beyond patient status to include how a patient was motivated to do a particular task. Furthermore, it was in this context that patients were often included in the information sharing. For example, the nurse stated,

"I rely on them and the doctors rely on them for more

information. When it comes to report time, `How's this patient

doing?' ... `Well, wait a minute, let me go get them.' And they'll

give their report. Or it might be that I see them walking in the

hallway.... What motivated them? How did they get up? Were

they able to stand? Are they ready for rehabilitation? Especially

now with the insurance being the way it is. It's like, `Well, I'm

sorry, but we are going to send you home with physical therapy

in your house.' They're kind of panicky, but if the team has

said, `No, they can go home with just a ... therapist coming in,'

it's very calming for the patients to know that somebody is

going to be there with them, and that is really the valuable part

of it." (N:81-89)

Other forms of information and knowledge sharing involved treatment techniques, such as transfer techniques and postoperative precautions, or the use of equipment in patient care. This information and knowledge sharing often occurred formally through in-services, which were viewed by all informants as a means of bridging the gap between the topic of the in-service and everyday problem solving for patients. As indicated by a therapist and the nurse, in this way the in-services not only conveyed information but also had a positive carryover in terms of integrating the therapists into the acute care team:

"We do a lot of nursing training and in the end will always

remind them that physical therapy is always on the floor or

always around. Should you be strapped for an idea on how

to move this person or should you need an extra hand, feel

free to grab us and we'll come up whether we're seeing that

person or not, we'll help you problem solve. So we emphasize

that in the beginning when we do the training with

them, and I guess that helps carry it over. They keep that in

the back of their mind." (T2:396-401)

"I can think of so many occasions that I've had to go to

them. We had a hyperbaric chamber up here and thank

God they were here because I had never seen one.... They

[therapists] taught us how to deal with it, and when we had

a problem with it one day, they ... helped to troubleshoot."

(N:269-273)

Additionally, a great deal of knowledge and information sharing about techniques and equipment occurred in a more informal context, such as "being there" and "seeing how a patient was doing" or asking for help or offering assistance:

"The nurses see Mr Smith out in the hall with contact

supervision, and he was the guy they thought could never

get out of bed. So now they'll get him out of bed for that

third walk, whereas before they wouldn't even have

attempted it. Because they didn't know... And I think seeing

is believing in that case, and the nurses will observe that it

can be done ... then they are more apt to do it."

(D:491-495)

"And with the lifting and all ... they come in and help us,

and they've got a lot more ideas of things. And the

equipment they know about amazes me." (N:130-131)

Along with the information that was shared, the caregivers learned about each other's roles, which benefited the patients as well as the caregivers themselves.

"We do have an awful lot of patients with orthopedic

problems up here. And they go through the whole program.

And it is very concentrated and it's so much better

because we get a better picture of what is going on. We're

going in and looking at an incision, where they're concentrating

on getting that person moving. Just like the pharmacist 

is going to concentrate on the medications, and the

dietitian is going to concentrate on something else."

(N:39-44)

"It took us a while, believe me, to get that whole system

started. It was challenging in the beginning. It took years,

and I think it's finally at a point where we know, everyone

knows their role and everyone knows what's happening day

to day..." (T1:209-212)

Information sharing between therapists and physicians. Communication between therapists and physicians also seemed to change in both content and manner and appeared to be affected by the decreased length of stay of the patients in the acute care environment, increased restrictions placed by insurance companies on patient disposition, and an increased sense of responsibility by the therapists for a patient's care. Therapists appeared to change their approach to physicians from a "softened" approach, often presented in the form of a written note on the chart, to a more assertive, verbal, but "tactfully" direct, approach. The director described the nature of the former approach:

"So what we would do was get a list of patients from her

[charge nurse] of people who she said had mobility problems

and we'd go check the charts, and if they weren't

already getting therapy, we'd tag the charts with a note that

would say, `Dear physician...' and we always hand wrote

them. We were going to get some printed up, but I thought

that was too impersonal, so we always wrote them. It would

say, `As a result of a discussion with the discharge planner or

the nurse,' something to kind of soften it, `it's possible that

physical therapy might be indicated for this patient. If you

agree, please refer him to physical therapy.' So, I'm sitting

in my office just waiting for my telephone to ring a call

from an irate physician. You know, I don't think I got a

single call." (D:107-115)

In contrast, a therapist described the current approach taken with physicians:

"I guess the bottom line ... or one of the bottom lines for

physical therapy is your rapport with the physicians ...

knowing how to communicate ... I mean being more and

more vocal with the physicians. Instead of just letting

something slide, we now get on the phone and call them.

And we will disturb them.... When I first started here, people

were very shy about calling the physicians. They got upset if

you beeped them. But if we do that numerous amounts of

times and disturb them enough, then they are more apt to

say, `OK' Next time, they'll get this physical therapy order,

or they'll remember to put the weight-bearing status..."

(T2:733-741)

Additionally, much of the interaction between the therapists and physicians occurred in an informal context, typically when they encountered each other in a patient's room or when the nurses served as a catalyst between the physician and the therapist:

"A lot of time, the doctor will ask me [about a patient's

status], and I'll say, `Hey, wait a minute, I'll go get the

physical therapist.' And we'll stand there and discuss everything.

I rely on them [therapists] and the doctors rely on

them for more information." (N:77-81)

Information sharing beyond acute care. With the increased involvement in discharge planning for patients currently in acute care, therapists were called on to increase the information they shared with professionals outside of the institution. This interaction included direct communication with therapists and other professionals from outside of the hospital regarding the admission of a patient to the hospital or specific discharge plans:

"We're getting phone calls, and we're making the phone

calls. We're finding out that they came from a nursing

home, and our reaction used to be to do the evaluation,

make an assessment, and go from there. Now, it's like get on

the phone and talk to the physical therapist at that place to

find out what they were doing ... so we can come up with

similar goals." (T1:494-500)

"We've got the skilled nursing facility... They can't take

anybody now unless physical therapists are seeing them

[patients], evaluating them... We've got rehabilitation calling...

Now, we've got outside facilities calling ... nursing

homes, any potential placement ... issues. So you really need

to have ... specific goals ... more functional ... you've got to

have them short term, long term ... you've got to justify

them and foresee what is going to be going on at home ...

and its all got to be there." (T2:282-292)

Information sharing among therapists. Although there was a sense that information sharing between therapists and other health care professionals had improved, there was also a sense among the therapists that decentralization of the physical therapy services could decrease information sharing among the therapists themselves, especially related to the provision of services throughout the facility, therapist productivity, and patient care consistency. This perception was tied to the need for a "home base," a place where the physical therapy staff could come together to plan and organize work, to socialize with other physical therapists, and to share a sense of professional identity:

"I think it [lack of a `home base'] would mean a lot less

communication, a lot less.... I think we feel differently on a

daily basis as far as our interaction with each other ...

because a lot of our day is spent organizing, like in the

morning and right after lunch ... even just in social conversation,

we spend a lot in communication about our day and

what the needs are in different parts of the hospital. I think

if we didn't have a home ... turf to call a meeting two or

three times a day, even if it's 5 minutes, we would miss a lot

of what is going on in others areas." (T1:35-41)

The director best described the impact of this information exchange on both professional identity and departmental operation when discussing "regrouping":

"You can see how we all still kind of meet for lunch. I don't

want to ever lose that because I think that is kind of where

they regroup as a profession to be able to go back out. But

there was some resistance to not working with other therapists."

(D:407-410)

Helping, sharing, and coordinating work. The second theme under increased professional interaction that emerged from the data involved an increase in the amount of helping, sharing, and coordinating of the work to be done. Certainly, the increased focus on discharge planning discussed involved the coordination of services, not only across levels of care within this health care system but also beyond the acute care setting. The focus of helping each other in this institution, however, was on working together to meet the needs of the patient, even if that meant moving beyond one's traditional role. The portrayal of these concepts on the patient care floor were best expressed by a therapist and the nurse:

"They'll [therapists] come to me, and they'll say, 'We know

that in the morning this patient is going to be very busy with

x-rays and stuff... Is 10 o'clock OK for you that we come in

here?' I'll say, `Yeah, that will be fine.' We tell the staff

nurses, `OK, by 10 o'clock, let's have him ready for physical

therapy.' Especially if the patient tires very easily."

(N:190-194)

"We assist each other in what's happening for the care of

the patient.... So there are definite distinctions in our roles,

but at the same time, we need to think about the patient

first. So if there is something I can do that they need at that

time, then I feel that I would do it. I expand my role when

I have to take care of the patient." (T2:150-157)

Roles That Have Not Changed

Although role change is the primary focus of this study, I would be remiss to imply that there were not aspects of the physical therapist's role that remained unchanged. The informants identified several roles in the area of patient care delivery that they felt had remained unchanged, such as providing "hands-on" care and functioning as a teacher, coach, and motivator. For example, the director indicated,

"What has not changed is that we are still a hands-on

profession in terms of dealing with movement dysfunction."

(D:579-580)

As indicated previously, the nature of this "hands-on role has changed from actually providing all of a patient's treatment (de, "progressing the patient's pro gram") to evaluating patients and developing program and discharge plans.

In addition, the therapist's role as teacher was apparent to all informants and was most clearly expressed by a therapist through the following comment:

"I think we're teachers. We are always teachers. I mean we

teach the patients mobility. We teach families or caregivers....

We even teach staff. We still focus right in on

functional things, mobility, goals." (T1:385-385)

Finally, the nurse and a therapist most aptly expressed what they saw as the role of the therapist as a patient motivator and coach:

"It is not just concentrated on getting them up and getting

them walking.... They have to deal with the emotional

patient's needs as much as we do and what's going on with

the patients ... what's going to motivate them to get out to

walk in that hallway." (N:50-53)

"I think we do a lot of psychological coaching to try to

motivate the patients, to try to convince them why it's

important, getting them to see the reason for it."

(T2:425-427)

Implications for Physical Therapy

Following departmental decentralization, physical therapy management and staff perceived a need to have mechanisms to retain their professional identity while working in an environment where role boundaries were blurring. The planning and coordination of care in the morning, "regrouping" or coming together at noon, and "touching base" served not only to organize the work to be done but to "compare notes" on patients, to share treatment approaches, to seek and give advice, and to socialize--that is, to retain a sense of "sameness" with the "physical therapy team." Furthermore, this self-perception appeared to be critical to energizing and motivating the entire staff to be "responsible as a team" and "flexible" in this changing environment. Finally, for this staff, working within changing boundaries of patient care was possible because they had a "home base," that is, a place that they could actually come to together to "regroup" as a profession.

Another implication from this study is that there is a struggle occurring in the acute care environment between the demands of an evolving therapeutic role for physical therapists and an evolving health care delivery system. The nature of physical therapy practice in the acute care hospital is demanding greater skills in prognosticating functional recovery for patients and in planning and coordinating care. The development of these skills, however, takes time and expert assistance if the therapist is to feel confident in making the necessary assessments and recommendations in the limited time of a patient's hospital stay. Thus, for a "new" therapist, whether a "new graduate," a "new hire," or just a therapist rotating onto a floor for the first time, it appears to be critical to have an experienced therapist available to answer questions or to serve as a role model. Even for a more experienced therapist, it is important to have a colleague available to share ideas or perspectives on patients with difficult problems. Yet, the pressures in health care are demanding a leaner staff and greater productivity, which often means that therapists are required to work alone on a floor. Thus, managers and caregivers are forced to constantly look for creative ways to meet the needs of their patients and the hospital as well as their own professional and personal needs.

The importance of maintaining a broad view of the heath care system and the potential for physical therapy growth cannot be overlooked. Physical therapists, whether functioning under a somewhat more traditional departmental structure or in a more independent role, I believe, must seek opportunities for the expansion of physical therapy practice within the entire system and must act to develop new avenues for that program expansion. I contend that underlying this role is a need for physical therapists to view change as a potential opportunity and to embrace the concept of "being flexible" as important to their survival and growth as professionals, while maintaining standards for high-quality patient care.

All of these factors have implications for the education of future therapists. The data suggest that we must prepare our new graduates to understand the changing health care system and to be able to meet the challenges and opportunities posed. In addition, I believe, based on the data, that we must prepare them to be agents of change if the system limits them from functioning in a professional manner and providing high-quality patient care.

Conclusions

The purpose of this study was to begin to identify how organizational change in hospitals is altering the role of physical therapists who work in hospitals. A qualitative case study was chosen as a beginning step to identify the changing role of physical therapists as viewed through the eyes of the participants themselves. The data gathered through interviews and observation were limited by the time that was available to both participants and the researcher and can be considered a shortcoming. Additionally, the fact that this study represents a single facility bounded by the health care environment in a particular geographic region of the country cannot be overlooked. However, this study is a first step, and it has been useful in developing a conceptual model to begin an examination of this issue and to serve as the basis of future research. The next logical step is to reaffirm or revise the conceptual model based on data from across the country and to clarify the roles that have changed as well as those that have not changed. Finally, although multiple interview sources were used to obtain a convergent view of physical therapist role change, the fact that a limited number of therapists were interviewed also could be considered a study limitation.

At least for the facility studied, the decentralization of physical therapy services had a profound effect on patient care delivery and professional interaction of not only the therapists but also those with whom they work. Therapists have assumed greater and more demanding roles in the delivery of patient care while knowledge and information sharing have increased, and these changes have the potential to benefit caregivers and patients.

Additionally, caregivers have recognized that planning and coordinating work must occur in order to provide the necessary patient care in the limited time available. To accomplish this, caregivers appear to be moving beyond the bounds of traditional roles.

These changes have not come easily. Time and effort have been needed to change attitudes, perceptions, and behaviors, to build rapport between the previously disengaged caregivers, to learn about previously hidden aspects of care, and to learn to share in the decision making for the benefit of all involved. Additionally, in this hospital, it has taken a willingness on the part of the caregivers to view these organizational changes as challenges and not as obstacles, to respond with a sense of flexibility while maintaining the primacy of high-quality patient care. Finally, management skills have been needed to meet the needs of administrators for cost-effective delivery of care, the needs of nurses for effective and timely integration of services, the needs of patients for quality and continuity in care, and the needs of the physical therapists themselves for a working environment in which they feel that they can provide safe care of a consistent quality and in which they can retain a sense of professional identity and camaraderie.

Acknowledgments

I thank the management and staff of "Lakeview Hospital" for their contributions to this work. Without the insights that they so openly shared, this study would not have been possible.

References

[1] MacStavic RS. Product-line administration in hospitals. Health Care Management Rev. 1986;11:35-43.

[2] Hanrahan TF. New approaches to caregiving. Healthcare Forum Journal. July/August 1991:33-38.

[3] Moffitt GK Patient-focused care: key principles to restructuring. Hospitals and Health Services Administration. Winter 1993:509-521.

[4] Minnen TG, Berger E, Ames A, et al. Sustaining work redesign innovations through shared governance. J Nurs Admin. 1993;23(7):35-40.

[5] Arthur RA. Patient focused care: acute orthopedic services. PT Magazine. 1994;2(7):34-47.

[6] Bullock K Patient focused care: hospital wide. PT Magazine. 1994; 2(11):51-60.

[7] Bethel S, Ridder J. Evaluating nursing practice: satisfaction at what cost? Nursing Management. September 1994:41-48.

[8] Schoolfield M, Orduna A. Understanding staff nurse responses to change: utilization of a grief-change framework to facilitate innovation. Clinical Nurse Specialist. 1994;8:57-62.

[9] Burda D. ANA report stokes restructuring debate. Modern Healthcare. February 13, 1995:38.

[10] Gage M. The patient driven interdisciplinary care plan. J Nurs Admin. 1994;24(4):26-35.

[11] Brumfield J. Patient focused care: PT and neuroscience. PT Magazine. 1994;2(9):76-89.

[12] Porter-O'Grady T. Patient-focused care service models and nursing: perils and possibilities. J Nurs Admin. 1993;23(3):7-15.

[13] Pinder CC.. Work Motivation: Theory, Issues, and Applications. New York, NY: HarperCollins Publishers; 1984.

[14] Blau PM, Scott WR. Formal Organizations. Scranton, Pa: Chandler Publishing Co; 1962.

[15] Miner JB, Crane DP, Vandenberg RJ. Congruence and fit in professional role motivation theory. Organization Science. 1994;5(1):8697.

[16] Hirschhorn L, Gilmore T. The new boundaries of the "boundary-less" company. Harvard Business Review. May/June 1992:104-115.

[17] Baker GR, Cockerill R, Charles C, Voelker C. Regulation and hospital strategic planning in Canada. Healthcare Management Forum. 1993;3(1):13-18.

[18] Woods EN. Restructuring of America's hospitals: What does it mean for physical therapy? PT Magazine. 1994;2(6):34-41.

[19] Porras JI, Hoffer SJ. Common behavioral changes in successful organization development efforts. Journal of Applied Behavioral Science. 1986;22:477-494.

[20] Katz D, Kahn R. The Social Psychology of Organizations. 2nd ed. New York, NY: John Wiley & Sons Inc; 1978:186-207.

[21] Eisenhardt KM. Building theories from case study research. Academy of Management Review. 1989;14:532-550.

[22] Yin RK Case Study Research: Design and Methods. 2nd ed. Newbury Park, Calif: Sage Publications Inc; 1994:1-15, 91-94.

[23] Glasser B, Strauss A. The Discovery of Grounded Theory: Strategies of Qualitative Research. London, England: Wiedenfeld (Publishers) Ltd; 1967.

[24] Miles MB, Huberman AM. Qualitative Data Analysis. 2nd ed. Newbury Park, Calif: Sage Publications Inc; 1994:40-49.

[25] Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, Calif Sage Publications Inc; 1990:96-99.

[26] Merriam SB. Case Study Research in Education: A Qualitative Approach. San Francisco, Calif: Jossey-Bass Publishers; 1988:135-137.

[27] Lincoln YS, Guba KG. Naturalistic Inquiry. Newbury Park, Calif: Sage Publications Inc; 1985:305-309.

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

This study was approved by the Beaver College Committee on the Protection of Research Subjects.

This article was submitted June 15, 1996, and was accepted March 5, 1997.