The impact of the prospective payment system: perceived changes in the nature of practice and clinical education.

Teaching hospitals have undergone significant change in recent years as a result of new health care reimbursement policy. Beginning in 1984, Medicare adopted a prospective system of health services payment for hospital care. The diagnosis-related group (DRG) system changed the hospital payment mechanism from fee-for-service to a prepaid, capitated payment by diagnosis for patients receiving federal funds for their health care.[1] Many states have also adopted prospective payment systems (PPSs) implemented through state-appointed hospital budget review groups to assist private insurers in achieving similar cost control. This combined federal and state prospective payment initiative has had a substantial impact on hospital environments.

Policymakers have predicted numerous changes in the teaching hospital as a result of PPS. These systems were expected to influence physician choice of treatment options based on cost, rate of hospital budget growth, and patient length of stay.[2] With shorter hospital stays, the teaching hospital was expected to be caring for patients with more acute illness; experiencing an increase in hospital readmissions; and referring more patients to low-cost environments at discharge, such as home health agencies, nursing homes, and outpatient settings.[3] These predicted changes in the delivery of acute hospital care have been accurate in large part. Studies have documented decreased lengths of hospital stay, increased rates of readmission, more complex case mixes, and increasing numbers of patients discharged in unstable condition.[4-7] Early efforts to assess the quality of health care in the face of these changes have suggested that the quality of health care, as measured by 30-day post-hospitalization mortality rates, has not diminished, although many questions remain to be answered.[8]

The teaching hospital has been particularly vulnerable to these health policy changes. The case mix of patients with more complex diagnoses, the inefficiencies produced by the teaching function of these institutions, the increasing volume of uninsured patients, and the proliferation of technology have contributed to the comparatively high cost of care in these settings.[9,10] Historically, Medicare has allowed for these additional costs by providing an extra payment to teaching hospitals, an indirect medical education adjustment, This extra payment, determined by Congress, has varied each year since 1984 and in 1990 was paid at a rate of 7.7%.[11]

Documented changes in physical therapy practice patterns within the teaching hospital environment have been limited. Physical therapy utilization data under PPS suggest that the rate of patient referral to physical therapy may have increased,[12] the mean number of visits per referral has decreased slightly,[13,14] and patients are functioning at a greater level of dependence at discharge,[7] leading to increases in referrals to aftercare settings.[5,15,16] Patients' length of stay has decreased with 7-day physical therapy coverage, although length of stay varies considerably with diagnosis.[17]

These changes in the teaching hospital have influenced physical therapy practitioners and students within this setting. Practitioners have been encouraged to understand the changes that are under way and to participate in the change process so as to position the profession most effectively within a new health care delivery system.[18] Physical therapy practitioners are also making more difficult decisions regarding the availability of resources and the distribution of these resources in an equitable and efficient manner.19 Health science students within this practice environment have found that Clinical Instructors (CIs) may have less control of the environment in providing special instructional opportunities for students having difficulty.[20]

Changes in the teaching hospital in recent years seem clear from this literature. This study addressed specific questions regarding these changes: (1) In what ways has the practice of physical therapy in acute care teaching hospitals in northern New England changed following the initiation of PPSs in these settings? and (2) In what ways have these changes in the practice of physical therapy influenced the physical therapy clinical education process for students in these settings?

An environmental assessment approach was used in this study because the introduction of PPSs can be seen as a macrosystem adjustment that affects organizations and individuals. Two frameworks of environmental assessment were utilized in this study: the organizational structure framework and the environmental climate framework.[21] These frameworks of analysis expose environmental shifts early in the change process, which is suitable to this study of recent change in health care finance policy.

The combination of these two frameworks or perspectives on environmental assessment allows examination of both the organization and the interaction between the organization and individuals within it. An organizational structure perspective examines change through demographic differences in the environment and relies primarily on objective, quantifiable data. An environmental climate perspective examines change through the interaction between organization and individual. This approach relies heavily on perceptions about the organization and how people function within it, producing data of a more subjective nature.[21]

The combination of these frameworks offers an evaluation of how the teaching hospital physical therapy environment has changed quantifiably and how that change is perceived by those in the environment. Different vantage points for these perceptions have been sought by using CIs, Center Coordinators of Clinical Education (CCCEs), department managers, and hospital administrators to increase the richness of the study results rather than to compare perspectives.

Method

Sites

Hospitals in northern New England with teaching as a primary function were sought for this study. Four criteria were used to select these sites. Sites were (1) to function as a primary and tertiary medical center in their state or region, (2) to have a primary medical school affiliation, (3) to have a multiservice physical therapy practice available for clinical education, and (4) to have a well-established physical therapy clinical education program. Three teaching hospitals in this geographic region met these criteria.

Subjects

From each of the teaching hospitals, six subjects were identified based on their role within the institution: the hospital administrator responsible for the physical therapy service, the physical therapy department director, the CCCE, and three staff members or CIs. Each CI was required to have at least 4 years of experience at that institution and was selected based on availability. Each subject gave informed consent prior to participation in the study.

Data-Collection Instruments

Demographic data were collected from department records during the 4-year period (1984-1988) regarding the following: department organizational structure, staff size, the number of vacant positions, productivity targets, recruitment efforts, new capital equipment (single items costing more than $500) and physical therapy department space acquisitions, new or different responsibilities in the job descriptions, physical therapy case mix, organizational changes in the student program, number of CIs employed, number and level of students accepted, number of contracted schools, student productivity targets, and efforts to recruit students as future employees.

Perceptions about both organizational and professional environments were collected using three survey instruments: the Capacity for Change index, the Social Climate Scale, and the Standards for Clinical Education in Physical Therapy instrument. The first two assessment instruments were identified from the organizational environment literature and modified for use in this study. The third instrument was selected from the physical therapy practice and education literature. This survey instrument examined perceptions about the physical therapy practice and teaching environment within the organization.

The Capacity for Change Index identifies subjects' perceptions of the following organizational characteristics: occupational specialization, specialized knowledge, the hierarchy of decision making, occupational autonomy, financial rewards, and emphasis on efficiency and effectiveness. Participants indicate the degree to which these characteristics are present in their environment. High scores in these characteristics suggest a complex organizational environment. The creators of this instrument have shown that the complexity of organizations leads to more difficulty in the change process, with resulting dysfunction when change occurs too rapidly.[22] The instrument was modified slightly by the investigator to reflect appropriate physical therapy terminology. Four questions were added to address the physical therapy student in this environment, using the same question format.

The Social Climate Scale was developed by Moos[23] to assess the psychosocial climate in hospitals. Moos and colleagues have developed several instruments, all with the same framework, relationship dimensions, personal development dimensions, and system maintenance and change dimensions. The Social Climate Scale used in this study was adapted from Moos's Ward Atmosphere Scale, which has descriptors most relevant to the hospital setting.[23] Social climate is defined as the fit between organizational tenets and individuals' needs, as has been developed from early work on the effects of environmental pressures on human behavior.[24] This instrument provides 50 descriptors of interaction between individuals and the organization, allowing the participants to indicate their agreement with each. Social climate assessment is useful when environmental change is taking place, as the impact of the change may be reflected early in the climate of the environment.[23] This instrument provides perceptual data from those in the setting about how individuals within different roles interact with one another, how the service helps individuals grow professionally, and how the service sustains itself during times of change. This instrument was modified slightly by the investigator to reflect appropriate physical therapy terminology.

The Standards for Clinical Education in Physical Therapy instrument was adapted from work done by Barr et al.25 The instrument provides participants' perceptions about the practice environment as those perceptions relate to standards for student education in these clinical settings. These standards include both organizational and educational expectations for physical therapy practice.

Subject interviews expanded on perceptions identified by the survey instruments. These semistructured interviews consisted of four major questions with several specific follow-up questions. Interview questions are listed in the Appendix.

Procedure

Prior to implementation, the demographic data-collection tools, survey instruments, and interview guidelines were reviewed by a panel of five experts addressing study design and content area. Several changes in the demographic data-collection tool and the interview questions were made following this review. A physical therapy educator with expertise in descriptive analysis independently reviewed the data-collection instruments in relation to the research questions to provide content validation of the data obtained with these tools. Again, minor modifications were made in the interview questions. This procedure established face validity of the data. No effort was made to test the criterion-based validity or reliability of data obtained with the modified instruments.

Data were collected by a single investigator in the following order: demographic data from department records and statistics, three environmental assessment survey instruments completed by the subjects, and a 1-hour semi-structured interview with each subject. All data were collected during a 1-week period at each of the three sites.

Department records and statistics were reviewed, and data were extracted using a data-collection form and then discussed with the department manager or CCCE to confirm their accuracy. For each of the three surveys, subjects were asked to respond twice to each item--once to indicate their response to the item in the present environment and a second time to indicate their response to the item as they perceived it to be prior to the introduction of DRGs in their institution. All survey responses were collected on optical scanning sheets for data-reduction purposes. Interviews were conducted individually with each subject after completion of the surveys. Each interview was tape-recorded for later transcription.

Data Analysis

Demographic data were reviewed for changes over a 4-year interval (1984-1988). Where appropriate, means and ranges were calculated to describe changes in variables. The nature of changes noted was further elucidated through description of each change.

Each of the survey instruments used a five-point Likert scale to elicit responses for each item, which produced ordinal data. Data were entered from optical scanning sheets for computer-assisted data reduction. Each set of item pairs (responses for past and present on each item from all subjects) was analyzed for mean score, frequency count, sign test (two-tailed) result, Spearman rank-order correlation coefficient, and the number of subjects who expressed no change in item score from past to present.

Differences between scores for past and present within each set of item pairs were calculated using a sign test. Sets of item pairs that did not demonstrate significant differences were analyzed for agreement between responses for past and present. Two tests were applied sequentially: the Spearman rank-order correlation coefficient to determine a relationship between responses for past and present within the item pair (P<.05) and a comparison of actual item scores for each subject within each item pair. In the latter, a minimum of 66% (2/3) of the subjects demonstrating no difference between scores for past and present within the item was considered clinically significant. These statistical and clinical measures allowed individual items on each of the survey instruments to be placed in one of three categories: changed from past to present, unchanged from past to present, or unable to meet criteria for the first two categories.

Transcribed interview data were read by the investigator. A qualitative research software package,(*) was used to assist in the labeling and sorting of interview data.26 The investigator organized recurrent comments into coded categories called "themes." A theme is defined as a common belief, assumption, or meaning stated through comments by subjects.27 Themes were developed if common statements were found at all three sites and by at least one third of the participants. Verbatim statements were selected from the transcripts to amplify and clarify the subjects' meaning and to demonstrate how the themes were abstracted from the interviews. No efforts were made to compare institutions or categories of subjects with one another in this study.

Results

Demographic Data

Changes were noted over the 4-year period in six demographic characteristics--four involving practice and two involving clinical education. Three demographic characteristics did not change during the 4-year period, Table 1 summarizes the demographic data. [TABULAR DATA 1 OMITTED]

Survey Data

A survey response rate of 100% was achieved, although some subjects left individual items blank if they felt they were unable to respond. This was noted particularly in the Standards for Clinical Education in Physical Therapy instrument and did not exceed two missing values for any one survey item (ie, n [is greater than or equal to] 2:l6).

In the Capacity for Change Index, none of the 13 items were found to be unchanged when the previously described criteria were applied. Five items demonstrated a statistically significant difference from past to present. Mean scores for past and present, sign test results, and probability values are presented in Table 2. All scores indicated stronger subject agreement with the statement at present than in the past or that the statement had become more accurate from past to present. in the Social Climate Scale, 11 of the 50 descriptive statements were found to be unchanged. For these unchanged items, mean scores for past and present, the number of subjects with scores unchanged from past to present, and the correlation coefficients are shown in Table 3. Significant differences were found in 7 descriptive statements. Mean scores for past and present, sign test results, and probability values of these items are listed in Table 4. in each of the 7 items, sign test results indicate a positive shift from past to present, indicating a favorable change in the environment. [TABULAR DATA 2, 3 AND 4 OMITTED]

The Standards for Clinical Education in Physical Therapy scale demonstrated generally low mean scores, which suggests that subjects felt standards were met in large part. Fourteen of the 20 standards were unchanged from past to present. Mean scores for past and present, number of subjects with unchanged scores from past to present, and correlation coefficients are given in Table 5. A significant difference was noted in only 1 standard, as shown in Table 6. [TABULAR DATA 5 AND 6 OMITTED]

Interview Data

Interview data produced 13 themes--in 8 the area of practice and 5 in the area of clinical education. In many cases, these themes were found to be far more prevalent in the interview data than the criteria demanded. The practice themes addressed the practice environment and issues created by the interaction between environment and practitioner. Clinical education themes addressed the learning environment and instructional issues. Practice and clinical education themes are outlined in Table 7. [TABULAR DATA 7 OMITTED]

Practice

Increased illness acuteness. When questioned about increased severity of illness, interviewees identified two factors that yield a more acutely ill patient population: technology to sustain life under more critical circumstances and earlier discharge of subacutely ill patients, yielding a sicker population in the teaching hospitals. Interviewees commented

Patients are more acute when they

come in, they are more acute when

they leave, and we have a shorter time

to work with them.

These are people who should have

been dead or would have been dead

4 years ago.

Earlier discharge planning. All interviewees acknowledged the role of physical therapy in discharge planning to be earlier and more influential from past to present. The CIs and administrators commented

I feel that we have gotten an increased

volume [of patients] since prospective

payment went into place because I

think physicians and nursing are recognizing

that we are instrumental in

expediting a discharge.

Sometimes it means that [the patient's]

anesthesia hasn't [even] worn off yet,

and you are already in there.

The emphasis in our practice now is

on evaluation and discharge planning

from the very first day, with a varying

amount of time between those two

[points]: the evaluation and the discharge

date.

Streamlined hospital mission. Hospital administrators and department managers commented particularly on the changing hospital mission. They described this changing mission as a very conscious effort to increase the efficiency of the hospital in the face of scarce financial resources.

It's not just efficiency, ... but efficiency

and effectiveness need to be components

of what it is that [we] do.

I think it's team members working

together with ... clearer role responsibilities,

but hopefully a more cooperative

spirit to get patient care first.

Concerns over quality of care. More than two thirds of the interviewees commented specifically on quality-of-care issues. Comments addressed not only perceptions of quality of care but the shortcomings in measuring quality of care. Although comments were in agreement that practice was different, there were varied feelings about whether the quality of care had improved or diminished.

The worst consequence [of PPS] is that

we are just not having as much time as

we'd like to be able to perform quality

treatments, or maybe we need to redefine 

what quality is.

I am no less comfortable with the

practice of physical therapy here. I

think we have increased challenges in

terms of acuity of the patient, length of

stay, and so forth, but ... I've got a

good staff and the coordination among

therapists assisting each other and

communicating [is good].

The other [benefit of PPS] might be a

greater formal attention to quality of

care, and that relates to the development

of those standards and certain

measured expectations. So we are

asking our departments that in the past

might not necessarily have had such

formal programs for the measurement

of quality ... to now have such [a

program].

Greater professional development opportunities. Two thirds of the interviewees, primarily CIs and department managers, commented on the opportunity that acute care creates for the right individual. The opportunity includes clinical specialization and experiential learning in a dynamic, fast-moving environment. Two CIs commented

I think the growth of specialization ...

and also just the growth of the individuals

within the department.

The best [part of this environment] is

that it is extremely dynamic and challenging.

You can direct a lot of your

[own] learning.

Who is the right individual for this environment? One department manager said

Their skills, their knowledge base, and

practical application of physiology has

to be, I think, keener than it was before.

Intellectually more capable. Physically

more capable ....

New ethical dilemmas. Time constraints, technology, and large numbers of patients have combined to create uneasiness and ethical questions for a majority of the CIs and department managers interviewed. Most CIs and department managers addressed earlier discharge and the lack of sufficient follow-up services in the community and the existence of waiting lists for physical therapy services in the teaching hospital. Comments included

I have concerns that the moving of a

patient out of the hospital too early is

not matched by the support in the

community to take that kind of patient.

That makes me uneasy.

I think it is awful that physicians can

identify that a patient needs a service,

and because we don't have sufficient

staff to provide the service, then people

go without [because of early hospital

discharge].

Increased accountability. increases in accountability were expressed by every interviewee and described in regard to patients, the institution, and other professionals. Such increases were viewed as a positive consequence of PPS, although being accountable was not always easy and created stress for physical therapists.

I frequently feel that physical therapists

take on a tremendous amount of responsibility

patient advocates, more

than they should, and frequently alone.

I was always concerned with patients'

lack of initiative in ... taking charge of

their own condition, and I think maybe

DRGs have helped that a little bit.

More emphasis on patient education,

early discharge, getting them ready

right from day 1.

I think we can't take things for granted

as much. We have to really examine

closely what we are doing. We have to

try to be more efficient with our time,

be really clear as to what our goals are.

The need for PPS fine-tuning. Although interviewees recognized the need for cost-containment and the benefits of greater efficiency, all expressed some concern for the patient in the transition to PPS and feared that individual situations of inadequate service had occurred. The CIs commented

The downside for the patient is,

frankly, I get to you when I get to you.

I can't guarantee anything.

I worry a lot about [PPS pressures]

clouding the judgment of the people

who make surgical decisions, medical

decisions, discharge decisions.

Clinical Education

Clinical education themes addressed both the learning environment and the instructional process.

Acute care a valued learning environment. Acute care as a learning experience for students is still viewed by practitioners as valuable and unique. Growing strain on this relationship between student education and acute care, however, is noted. Two CIs commented

I think it is important for students to

be able to experience this setting because

they may work in this setting.

They have to have a taste for it, but

what they need is the guidance to

understand how to cope with this

setting and how to find favorable

things in it.

What is difficult is when [the students]

are ... beginning, if they are not quick

learners, because they [cause al drag in 

the system. [This is] especially [true

when] there is very little backup for

patient care if you don't get it done

yourself.

Recruitment of students seen as a benefit. Another reality of this learning environment is that clinical education has been increasingly recognized as an effective recruitment strategy. Primarily hospital administrators and department managers commented that part of the real value of clinical education is to create a source of potential employees. Although interviewees did not feel that students were used inappropriately as staff, they acknowledged that chances of employing these students and other new graduates were enhanced by a student program. One department manager summarized it this way:

I think that [the hospital administrator]

fully recognizes the value of a student

program ... in terms of recruiting.

Word gets out if you have a good program

and a good department. Word

gets out via the students to their peers

that [this hospital] might be a good

place to consider [for a job].

More is expected of students. All interviewees addressed the changing student performance expectations. New student expectations were cited in terms of precision and readiness in performance and the ability to be more independent in their learning. Students must adapt to their environment more quickly, apply clinical skills more readily, and demonstrate decision making more aptly. The CIs commented

We kind of expect them to adapt ...

and be quite clear in their goals and

their plans for the patient. They are

also more involved in the team meetings

and team interactions.

It is very demanding, in terms of being

able to integrate the different complexities

of each patient into what [each

patient] needs.

Asked about the characteristics of a successful student in this setting, CIs commented

To ... use the teaching/learning process

for themselves and also with their

patients.

... good communications, both verbal

and written, organized, assertive,

[good] listening skills. A sense of humor 

would help.

Student learning experiences constrained. More than two thirds of the interviewees commented on the changing nature of student supervision in the acute care setting. Clinical instructors and department managers agreed that students receive more direct supervision, less opportunity for exploration and trial-and-error learning, and greater emphasis on efficiency of treatment and patient outcome. A department manager and a hospital administrator commented

I suspect that the amount of time in

direct supervision is probably longer

than it has been because the patients

are so much sicker.

There is much more reluctance in

letting [the students] just sort of try

things several times until they get it

right.

Rewards of clinical instruction remain intrinsic. Given this increasingly austere backdrop, motivation to teach students in the clinical setting comes mostly from within. Department managers and CIs agreed that a primary motive for clinical education in acute care is personal--the satisfaction in seeing students learn under their direction, the obligation to their profession, and the learning they derive from the clinical instruction process. Although other benefits such as recruitment were noted by department managers and administrators, CIs see it this way, and a department manager commented on the growth of his staff:

One of the big rewards is having the

person become independent and function

as a peer. I like [the person] to

achieve the [level] of peer relationships.

When I see somebody's light go on, ...

that learning experience is what makes

it all worthwhile.

My perspective ... has always been

[that] you need to put something back

into the profession, so I am willing to

take [the students] and work with their

skills to the point where we hope they

can be clinically competent.

I think the greatest reward is seeing

the growth and development of CIs, in

terms of both their clinical teaching

ability and the ripple effect that it has

on their professional life.

Discussion

These results can be considered in two categories: changes in acute care physical therapy practice in these teaching hospitals and changes in clinical education within these environments.

Physical Therapy Practice Changes

Physical therapy in the acute care environment requires an increasing amount of specialized knowledge and, according to the subjects of this study, places growing emphasis on the quality and the efficiency of practice, as evidenced by the data obtained with the Capacity for Change Index. Interview data confirm that more critically ill patients are in the acute care environment and that physical therapists are more involved with these patients. Practitioners are more sensitive to the tension between quality of care and productivity. The widening gap between student preparation and clinical performance expectation noted by subjects is likely the result of this changing aspect of practice as well.

Physical therapists in these acute care settings describe a more central and independent role in patient management for which they feel more accountable. Accountability is a recurring theme in the interview data, emphasizing the need to justify recommendations for treatment intervention, length of hospital stay, and disposition. Physical therapists describe themselves as more eminently involved in such health care decisions. The intensity of work and interdependence of the professional staff noted in the Social Climate Scale support the conclusion that responsibility is believed to have increased in this professional role. Literature cited and demographic data in this study support the growing utilization of physical therapy in an acute care atmosphere otherwise focused on constraint.[12,13,17]

Physical therapists are increasingly challenged by the ethical dilemmas involving financial constraints, distribution of resources, and quality of care for patients. Interview data support the common belief that acute care hospitals are under pressure to contain health care costs in the face of more sophisticated technology, increasingly acute patient case mix, and growing health care personnel shortages. Results of the Capacity for Change Index indicate a perceived increased emphasis on quality and efficiency of operations. These findings combine to support the notion that such pressures have increased the struggle with ethical dilemmas perceived by those in the environment. Subjects have noted that these ethical dilemmas are very real, with some patients' needs remaining unmet. These physical therapists have also indicated that they are uncomfortable with their ability to manage these conflicts. Greater supervisory responsibilities for senior staff, noted in the demographic data, and greater involvement of staff in department problem solving, as seen in the Social Climate Scale data, exemplify efforts to support practitioners facing difficult decision-making responsibilities.

Physical therapists in this study agreed that their role with patients has changed, focusing more on evaluation, treatment planning, and discharge and less on provision of patient treatment. Interview data confirm earlier discharge planning and a more focused mission of the institution. These changes in acute care affect those providers who serve the patient later in the medical course of care (eg, rehabilitation hospitals, skilled nursing facilities, outpatient services, and home health care). Subjects interviewed share the concern expressed by various authors[7,15,16] about whether these post-acute care providers respond to the changing locus of care.

Subjects in this study described an increasing attention paid to the interpersonal and professional development needs of physical therapists in the acute care setting. Data from the Social Climate Scale support the idea that these acute care physical therapy environments are more sensitive and caring for the human resource needs of its staff. Interview data clearly identify the perception that opportunity exists in terms of professional growth for those in the acute care teaching hospital. It is the belief of these physical therapists that this opportunity increased over the 4-year period of this study.

Clinical Education Changes

Student clinical performance expectations appear to have increased in accordance with the changing acute care physical therapy environment, yet interview data suggest that student preparation is unchanged. Changes in the nature of physical therapy practice in acute care settings have previously been discussed. These changes should necessitate adjustments in student performance for greater clinical readiness and independence in learning. This may explain the findings of closer supervision and less flexibility in learning experiences for students, greater perceived stress on students in this environment, and the recent limitation of affiliations to seniors only in these environments. Ironically, the Capacity for Change Index results indicate that these acute care settings are less flexible to adjust to individual student needs.

Resources for clinical education are unchanged. In the midst of significant environmental change in acute care, the structure, size, and resources of the clinical education program in each of these settings are unchanged according to interview and demographic data. Although the need to support clinical education is recognized by these hospital administrators and department directors, little has been done to change the student education program, as evidenced by the demographic data. Given the previous observation regarding the increased expectations in student clinical practice performance, this lack of additional resources or assistance is seen as a concern by CIs and CCCEs.

Students in the acute care environment must be active in directing and assessing their own learning experience. Characteristics of acute care noted in the survey and interview data, such as shortened patient length of stay, emphasis on efficiency, and increasing patient complexity, cause the acute care setting to be both a rich and stressful learning environment for students. Activities that take the physical therapist away from direct patient care, such as teaching, are increasingly difficult to justify and have been challenged by hospital administrators and insurers. Continued heavy utilization of physical therapy and emphasis on efficiency cause physical therapy work loads to remain high. Clinical Instructors defined through their interview comments those students who are most likely to succeed in this environment as people who are mature, self-motivated, and assertive in their communication style.

Participation in clinical education remains highly valued by those in the acute care environment. Clinical Instructors and CCCEs have described through the interviews their motives for participation in clinical education as largely intrinsic. They express this as part of their own development and professional obligation. Department managers and hospital administrators commented candidly about the positive impact that clinical education has had on new staff recruitment. The Social Climate Scale data also indicated a supportive environment for students and new staff. Clinical education in these acute care environments appears to be in no immediate danger of discontinuation. All participants in the study acknowledge that this clinical learning experience will continue to occur in the acute care setting, whether as a part of the educational program or through early job experiences. It is the belief of these subjects that the specificity of an acute care clinical education experience is essential to the preparation of physical therapists.

There are limitations of this study that should be acknowledged: 1. The study was based on individual

perceptions and was retrospective.

To the extent that perceptions have

been affected by time or personal

bias, these data may be flawed. 2. Generalizing of the findings is

limited to the participating institutions;

however, the themes and

conclusions identified serve as a

basis for comparison with other

institutions and as a framework for

future study. 3. The methodology has considered

the three sites as one group without

efforts to compare the individual

institutions with one another.

The data may be confounded

where differences exist among

these institutions. 4. The survey instruments from the

organizational environment literature

were adapted for this study.

Although face validity exists for

their use, caution should be exercised.

Environmental assessment

instruments more applicable for

physical therapy settings need to

be identified. 5. Introduction of PPS policy was a

significant environmental factor

during the period of time studied.

It was not, however, the only

source of change. The changes

cited in this study cannot be solely

attributed to PPS.

Conclusions

Using demographic, survey, and interview data collected from CIs, CCCEs, department managers, and hospital administrators in three New England teaching hospitals, the changing nature of physical therapy practice and clinical education in these environments has been described. These changes are noted at a time during which dramatic modification of the acute care environment is under way, necessitated by spiraling health care costs. These results indicate significant change in the role of the physical therapist within these settings and suggest how these changes influence the clinical education of physical therapy students in these teaching hospitals. (*) Ethnograph software package, distributed by Qualitative Research Management, PO Box 30070, Santa Barbara, CA 93130.

References

[1] Rolph E, Lindsey P. Medicare's Prospective Payment System: The Health Care Community's Reaction and Perception. Santa Monica, Calif: Rand Corp; 1986. [2] Greenberg W, Southby RM. Health Care Institutions in Flux: Changing Reimbursement Patterns in the 1980s. Arlington, Va: Information Resources Press; 1984. [3] Lohr KN, Brook RH, Goldberg GA, et al. Impact of Medicare Prospective Payment on the Quality of Medical Care: A Research Agenda. Santa Monica, Calif: Rand Corp; 1985. [4] DesHarnais S, Kobrinski E, Chesney J, et al. The early effects of the prospective payment on inpatient utilization and the quality of care. Inquiry. 1987;24:7-16. [5] Morrissey MA, Sloan FA, Valvona J. Medicare prospective payment and post-hospital transfers to subacute care. Med Care. 1988;26: 685-698. [6] Berman RA, Greene J, Kwo D, et al. Severity of illness and the teaching hospital. J Med Educ. 1986;61:1-9. [7] Kosecoff J, Kahn KL, Rogers WH, et al. Prospective payment system and impairment at discharge. JAMA. 1990;264:1980-1983. [8] Ruberstein LV, Kahn KL, Reinisch EJ, et al. Changes in quality of care for five diseases measured by implicit review: 1981 to 1986. JAMA. 1990;264:1974-1979. [9] Schwartz WB, Newhouse JP, Williams AP. Is the teaching hospital an endangered species? N Engl J Med. 1985;313:157-162. [10] Thorpe KE. Why are urban hospitals so high? The relative importance of patient source of admission, teaching, competition, and case mix. Health Serv Res. 1988;22:821-836. [11] Vanselow NA. The financial status of U.S. teaching hospitals. Acad Med. 1990;65:560-561. [12] Dore D. Effect of the Medicare prospective payment and the utilization of physical therapy. Phys Ther. 1987;67:964-966. [13] Davis KD, Gwyer J. The Impact of the Prospective Payment System on the Delivery of Physical Therapy Services. Alexandria, Va: American Physical Therapy Association; April 1986. [14] Holt P, Winograd CH. Prospective payment and the utilization of physical therapy service in the hospitalized elderly. Am J Public Health. 1990;80:1491-1494. [15] Fitzgerald JF, Fagan LF, Tierney WM, et al. Changing patterns of hip fracture care before and after implementation of the prospective payment system. JAMA 1987;258:218-221. [16] Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with hip fracture: changes since implementation of the prospective payment system. N Engl J Med. 1988;319: 1392-1397. [17] Rapoport J, Judd-Van Eerd M. Impact of physical therapy weekend coverage on length of stay in an acute care community hospital. Phys Ther. 1989;69:32-37. [18] Brown GD. Changing health care environments: implications for physical therapy research, education, and practice. Phys Ther, 1986;66:1242-1245. [19] Purtilo RB. Saying "no" to patients for cost-related reasons. Phys Ther. 1988;68:1243-1247. [20] Kautzmann LN. An assessment of the impact of the Medicare prospective payment system on level II fieldwork. Am J Occup Ther. 1986;40:470-473. [21] Conyne RK, Clack RJ. Environmental Assessment and Design. New York, NY: Praeger Publishers; 1981. [22] Hage J, Aiken M. Social Change in Complex Organizations New York, NY: Random House Inc; 1970. [23] Moos R. Evaluating Treatment Environments, New York, NY: John Wiley & Sons Inc; 1974. [24] Moos R. Conceptualizations of human environments. Am Psychol. August 1973:652-665. [25] Barr JS, Gwyer J, Talmor Z. Evaluation of clinical education centers in physical therapy. Phys Ther. 1982;62:850-861. [26] Seidel J. Ethnograph Manual, Version 3. Littleton, Colo: Qualis Research Associates; 1988. [27] Bogdan RC, Biklen SK. Qualitative Research in Education: An Introduction to Theory and Methods. Boston, Mass: Allyn & Bacon Inc; 1982.

Appendix. subject Interview Questions(a)

1. In what ways has the provision of physical therapy in this department changed over the

past 4 years?

A. What do (you/the individual physical therapists) do differently in the provision of care

to (your/their) patients? 2. How have these changes in the provision of care made you more or less comfortable in

(your/the) practice of physical therapy in this hospital?

A. In what ways have these changes been good or bad for patients? 3. How have these changes in practice that we have been talking about influenced the

teaching of physical therapy students in this hospital?

A. In what ways have the goals of the student program and the goals of the patient

care service become more or less compatible? 4. How have these changes in the clinical teaching of physical therapy students made

you feel more or less comfortable about clinical education?

A. In what ways has (your/the) management of the student in the physical therapy

department changed, and are these changes beneficial? Note: Each of the major interview questions and one example of a follow-up question are presented. During the interview, all subjects answered four or five follow-up questions after each major question. All subjects were asked the same major and follow-up questions.

Commentary

The author of this report has provided extensive data with which the reader can evaluate the status of clinical education in three teaching hospitals, prior to and subsequent to the implementation of the prospective payment system of hospital reimbursement of patients receiving Medicare. This topic is of considerable interest to academic and clinical educators in physical therapy, as hospital-based clinical education continues to comprise a large portion of our clinical education programs nationwide.[1] Emery's study provides us the opportunity to examine the effects of a major change in health care reimbursement for a component of the health care industry and to predict the future of educational activities in these institutions. I appreciate the opportunity to comment on the method of inquiry used in this study and on the interpretation of the data and to reflect on further implications of these data for physical therapy education.

The theoretical framework used to guide this research appears to be a positivistic one, utilizing a descriptive research design and both direct and indirect methods of data collection (ie, survey and interview). I point this out because the interview data are summarized into conceptual themes and supported by narrative data taken from the interview transcripts, which would appear to suggest a phenomenological approach to the development of this segment of the study. The methods the author describes for development of the conceptual framework of the study, for development of the research instruments, and for data collection, however, do not reflect a true qualitative approach to the investigation of this research question. Although conducted in the natural setting, this research does not reflect the appropriate efforts to utilize the investigator as the primary data-gathering tool, the rich description of the environment reflective of long-term participation in the environment, or the interdependence of data collection and data analysis that would characterize a qualitative approach to the question.[2] Although a quantitative approach was appropriately used in this study, I wish to clarify this distinction only as it may contribute to understanding the lack of agreement I found in some of the interview data and proposed themes.

I would agree that the information generated from the personal interviews provided the most interesting data in this study. As the author mentions, the introduction of the prospective payment system is not the only source of change to which the results of this study can be attributed. This is especially true of the interview data, given that none of the interview questions appear to have reinforced the concept of identifying change attributable specifically to the initiation of the prospective payment system. This does not represent a significant limitation to my understanding of these data; however, the title of the article might more appropriately refer to the changes in teaching hospital practice and clinical education over a 5-year period, attributable to a wide range of causes. The potential determinants of these changes would have been an interesting additional research question for this study.

I had difficulty interpreting three of the themes of the interview data in the area of practice, based on the narrative data that were provided. Mr Emery states that the teaching hospital mission has been more clearly delineated and streamlined, but the data provided illustrate neither concept. There is no clear understanding from these data regarding the current missions of the teaching hospitals in this study, and particularly whether or not their missions include the education of anyone in health care. The data indicate that the administrators in this study appreciate the recruitment value of their clinical education programs, but will this suffice to maintain a strong commitment to the teaching mission in periods of decreasing health care reimbursement?

I did not find a sufficient amount of data reported to allow the reader to conclude, as the author did, that the quality of patient care does not appear to have diminished. The data reported as supporting the themes of ethical dilemmas and the need for fine-tuning the prospective payment system seem to me to be strong indicators of the decreased quality of health care offered to these subjects' patients, both within the setting and throughout an episode of care.

The practice theme related to fine-tuning the prospective payment system does not communicate a clear construct as written in the article. Perhaps the data available to the author do suggest a specific concept of change needed in the reimbursement system, but the examples of data provided here do not help to clarify or support this confusing theme.

Of the clinical education themes, I had difficulty with two important concepts purported to be findings by the author: the complementary themes of an existing strain in the relationship between the acute care practice setting and the student education program, and the student readiness for practice in this environment. The data reported to support these themes do not seem to adequately describe the strained relationship discussed by the author. Although data are clearly identified that describe increasing expectations of students in the acute care setting, what data indicate that students are coming into these clinical settings by and large unprepared to meet these expectations? Though the remainder of the interview data may be replete with this sentiment, I did not find the data reported to be convincing of the author's conclusion that there exists a widening gap in what is expected of students in this setting and the students' ability to perform during these affiliations.

If these themes emanating from the interview data provide an accurate description of the status of physical therapy clinical education in teaching hospitals, the implications for education programs are significant. How can students best be prepared in the academic setting to succeed in such affiliations? For example, should students be able to perform efficient and appropriate evaluations and be competent in discharge planning prior to their first acute care affiliation? When should teaching hospital affiliations be sequenced in the rotation of full-time or part-time clinical affiliations? How should academic and clinical educators adjust clinical education objectives for student performance, given the increasingly specialized knowledge utilized in this practice setting? A thorough understanding of some of these implications may allow better use of the teaching hospital as a clinical education resource than currently exists.

One additional idea warrants further discussion. A Clinical Instructor in this study commented that students must have a taste for the acute care setting, ". . . but what they need is the guidance to understand how to cope with this setting and how to find favorable things in it." This comment reminds us that we must integrate into this analysis the students' perception of their ability to learn in teaching hospitals, When reflecting on my personal evaluation of clinical education in acute care settings, I have a perplexing dilemma correlating conflicting feedback. Although the data reported here, describing the acute care setting as an increasingly challenging and intellectually stimulating practice setting for physical therapists, are consistent with my feedback from practitioners in acute care hospitals of varying sizes, students with whom I come into contact often have a different perspective. As the Clinical Instructor in this study tells us, it is often hard for the student to find "favorable things" about acute care physical therapy practice, My observations indicate that that student's perceptions are disproportionally weighted with instances of routine and cursory patient evaluations and protocol-driven, technically based treatments. Perhaps the author has other data from this study that would confirm or disconfirm the existence of this conflict between the Clinical Instructor's and the student's perceptions of the level of practice in acute care settings. Janet Guyer, PhD, PT Assistant Professor Graduate Program in Physical Therapy Duke University Durham, NC 27710

References

[1] Current Patterns for Providing Clinical Education in Physical Therapy Education. Alexandria, VA, American Physical Therapy Association, 1985. [2] Jensen G. Qualitative methods in physical therapy research: a form of disciplined inquiry. Phys Ther. 1989;69:492-500.