Imagine physiotherapy treatment being provided almost exclusively by PTAs on an inpatient acute medicine unit. What is the impact to patient care? How does assignment work? What happens to the role of the PT?
In 2012, our large community teaching hospital implemented a new model of care – designed to capitalize on enhanced use of physiotherapist assistants (PTAs) in order to provide more patient care at the bedside. A key feature of this model is that physiotherapists (PTs) focus their time on patient assessment, treatment planning and discharge planning, while PTAs are responsible for implementing treatment. PTAs are now the patient’s primary point of contact for physiotherapy services.
All new hires must be dual-trained OTA/PTAs (now from accredited colleges). When the model rolled out, current staff who were single-trained were offered the opportunity to participate in a bridging program (all accepted). On any given day, we now have significantly more PTAs present in our acute medicine units than PTs. Typically, we have two assistants present full-time, seven days per week, and roughly 0.8 FTE PT. One PT could be assigning patients to as many as five PTAs.
Does this scenario make you nervous? Imagine how our staff felt when the model first rolled out.
Initially, there was a tremendous amount of fear related to the potential for job loss or replacement (note: there was no job loss for either OTs or PTs while positions were changed). There was also fear related to the process of assigning and use of assistants in the acute environment, at such high volumes. At the time of implementation of this new model, we were unable to find information in the literature describing this type of model and the processes and impacts related to patient care.
Recognizing that we were in a unique situation, we decided to capitalize on the opportunity to learn, and capture the perspective of our staff. We wanted to document the experience and perspective of the PTs and PTAs related to the impact of this change on their roles, as well as on patient care.
We recruited two groups of students from McMaster University (2013, four MscPT students, and 2015, two MScPT, 2 MScOT students), to help us execute two qualitative research studies. We also worked with our staff throughout the experience, developing tools, strategies and problem solving.
The following is a summary of some key highlights from our research and experiential findings we hope will be of interest.
The perspective of the PTAs
Assistants describe their new role as being more independent and requiring them to have a greater self-awareness of their roles and skill set. “So there was always direction. [The PT] would always directly oversee what I was doing. Whereas here, you kind of just get your assignment and you go. So it forces me to be more clinically aware of my skills, what my scope of practice is, what I can and cannot do, and when I actually need to call my OT and PT for assistance, guidance and what to do.”
As we worked with teams to develop new processes for assignment and communication, we found that PTAs were very aware of scope of practice and boundaries. One of the challenges to the PTA group in working more independently as a result of this new model was the frequent need to reinforce their role and scope of practice to other members of the interprofessional team. Examples include requests to assess patients on stairs, to comment on discharge potential, and to initiate mobility prior to assessment.
Assistants are also feeling a greater connection to patients. As described by one participant, “We’re seeing patients on a more consistent and frequent basis than any other profession really. ….so we’re able to see those changes, we’re able to see their function and how it’s improving or declining.”
The perspective of the physiotherapists
**Physiotherapists’ experience transitioning and practicing in this new model is very different from that of the PTAs. As one PT describes the transition process,
“One of the first things that pops out is that your presence on the unit is going to be reduced. That’s obviously not something that you can embrace immediately. Then again, on the other hand, having the presence of the assistants increased, that’s wonderful.”(1)
Therapists described day-to-day work as being significantly modified. “The role is now patient assessment and discharge planning, with all treatment assigned to assistants.” (T6)
Managing patient care vs. providing patient care
Physiotherapists clearly told us that not being the providers of patient treatment creates a gap between themselves and the patient. This gap includes a change in access to first-hand patient information. As one participant describes, “so I may not see them (the patient) for a while, because the treatment that I’m not doing, the PTA is doing. I feel detached from the patient; I feel that gap, so the assistants… were the ones with their eyes and ears on the patient and not so much me. So I felt like I didn’t know them (the patient) as well.”
Therapists described the experience of providing patient care without direct patient contact, through managing their assistants. Strategies to access patient information include daily rounding with PT and PTAs, enhanced tools and skills for documentation, and frequent informal communication. Therapists also described various strategies for education and monitoring performance of their assistant teams.
“You have to be able to monitor a lot of things at once – now you’re not just dealing with your own skills, you’re dealing with the skills of a lot of other people. So you have to be more aware of everybody’s skill. So you’re on all the time. It took a lot of energy. Keep monitoring, monitoring, monitoring constantly. And I still do it.”
Change in relationship with the patient
All therapists interviewed told us that not providing treatment has an impact on their relationship with patients. While therapists described strategies to cope with decreased information through enhanced communication with the assistants, the change in relationship with the patients was clearly considered as a loss. Comments from our participants included: “Not knowing the patient as well as I would like to… Not as involved with the patient…, Hard for the patient to trust…Lost that rapport… .”
More – but different – hands on deck
Despite the challenges described by the physiotherapists, the group clearly articulated that having more consistent and regular treatment provided by the PTAs was a good thing for patient care.
“they (the patients) see staff more regularly, so they feel like they are receiving care, not being left alone (2).”
“they get used to regular faces daily – so that’s good for continuity.”
“The assistants’ skills may be different from my skill set. But the patient has the care.” (2)
Could this be a reflection of the altruistic nature of health care providers, recognizing the benefit to patient care despite some of the challenges? However, this finding supports the idea that perhaps having more hands providing care is a good thing. Do we, as physiotherapists, need to focus on the question of how much care can be provided by the assistant and where is the balance?
So, where are we now?
After two years of practice in the model, we went back and re-interviewed staff. Comments from the PTAs now introduce the idea that assistants require time working together with therapists, to provide the opportunity for learning, joint problem solving and communication. Our new findings suggest that part of the PTA role requires co-treatment opportunities with the PT. Furthermore, PTAs are noticing that, while they can offer treatment, they cannot progress treatment. Frequently, PTAs are able to tell when patients are ready to progress, but if the PT is not present, this progression does not happen or is delayed. We need to find a balance between implementing treatment and re-assessment in order to progress the patient towards achieving their goals.
Physiotherapists have described to us that there is a significant difference between providing patient care vs. managing patient care. Are we ready for this as a profession? In our situation, all therapists involved in transitioning to the new model of care were very (10+ years) experienced. It is unclear how a novice practitioner would develop the skills required to manage patient care without first having the opportunity to become an expert in providing direct patient care.
It would seem that the questions raised outnumber the questions answered. However, despite the challenges it is worthy to note that our therapists still felt strongly that having, “more, but different,” hands available, was beneficial for patients. Maybe we’re on to something. We believe this is the time for physiotherapists to become actively engaged in the conversation.
Lisa Brice-Leddy, BScPT, MSc(RS), Ontario Physiotherapy Association Board Member, CPA Member since 1999, and Debbie Park, BScPT, CPA Member since 1995