Abstract
Background Physical therapists have an active role in the rehabilitation of injured workers. However, regulations in Queensland, Australia, do not afford them the opportunity to participate in return-to-work (RTW) decisions in a standardized way. No prior research has explored the experiences and perceptions of therapists in determining work capacity.
Objectives The aim of this study was to investigate physical therapists' experiences with and perspectives on their role in determining readiness for RTW and work capacity for patients receiving workers' compensation in Queensland.
Design A qualitative design was used. Participants were physical therapists who manage injured workers.
Methods Novice (n=5) and experienced (n=20) therapists managing patients receiving workers' compensation were selected through purposeful sampling to participate in a focus group or semistructured telephone interviews. Data obtained were audio-recorded and transcribed verbatim. Transcripts were thematically analyzed. Physical therapists' confidence in making RTW decisions was determined with 1 question scored on a 0 to 10 scale.
Results Themes identified were: (1) physical therapists believe they are important in RTW, (2) physical therapists use a variety of methods to determine work capacity, and (3) physical therapists experience a lack of role clarity. Therapists made recommendations for RTW using clinical judgment informed by subjective and objective information gathered from the injured worker. Novice therapists were less confident in making RTW decisions.
Conclusion Therapists are well situated to gather and interpret the information necessary to make RTW recommendations. Strategies targeting the Australian Physiotherapy Association, physical therapists, and the regulators are needed to standardize assessment of readiness for RTW, improve role clarity, and assist novice practitioners.
After a workplace injury, return to work (RTW) to preinjury duties or to modified duties is considered essential to the disability prevention process.1 Research indicates that RTW to preinjury duties or to modified duties results in less time away from work, lower compensation premium rates, less disruption to productivity for the employer, and improved management of compensation costs for the insurers.2 Optimal RTW outcomes for injured workers require involvement of stakeholders from the health care system (treating medical practitioner, health care provider), the workplace (line supervisor, RTW coordinator), the legislative and insurance system (claims manager, legal and union representatives), and the individual's personal coping system (the individual and family).3,4 A unique feature of working with a compensable patient is that a third party (the insurer), likely unknown to the patient, may set boundaries on the timing, duration, and type of treatment a health care provider is able to deliver. Although the medical practitioner's role is embedded in the RTW process, the role of the physical therapist beyond providing anything more than treatment of the injury varies among different jurisdictions.5,6
Multidisciplinary interventions, which include workplace visits, have been shown to be effective in reducing the time to full RTW and are cost-effective.7–10 This multidisciplinary team approach usually is implemented between 2 and 6 weeks postinjury, and the physical therapist often is part of this team. However, the professional who initiates and coordinates the RTW, and the timing of and restrictions for RTW, varies with the injury, the workplace, and the legislative framework.11 One step to improving RTW outcomes is to develop a common understanding of the role that each stakeholder plays in the RTW process.4
Previous research with health professionals involved in the RTW of compensable patients has focused on the perceptions of barriers and facilitators for RTW12,13 or has explored their assessment and treatment of specific disorders such as low back pain.14,15 However, no study has questioned the role physical therapists play in determining RTW status or whether they believe they should have a role to play. In a study exploring the experiences of employed patients with back pain in the United Kingdom, Coole et al16 reported that general practitioners rarely discuss RTW or provide work-focused advice and that physical therapists provided work-related advice that was limited in scope and vague. In a recent Australian report, 16% of injured workers interviewed identified physical therapists as providing the most help in getting them back to work compared with physicians (22%) and someone from the workplace (17%).17 Thus, it would seem that physical therapists have a role to play in the RTW of injured workers.
Like those in many other countries, physical therapists in Australia are frontline health professionals, having gained first-contact practitioner status in 1976, and are considered primary care practitioners. The Australian Physiotherapy Council describes the practice of physical therapists as one that “involves a holistic approach to the prevention, diagnosis, and therapeutic management of pain, disorders of movement or optimisation of function to enhance the health and welfare of the community from an individual or population perspective.”18 However, the Australian Standards of Physiotherapy18 do not specifically outline the role of the physical therapist in determining RTW. This limitation is in contrast to the professional guidelines published by the American Physical Therapy Association, which comprehensively outlines the role of the physical therapist in industry.19 The absence of specific guidelines creates ambiguity about the physical therapist's role in managing compensable patients in the Australian setting.
Despite the lack of specific professional standards for the role of physical therapists managing injured workers, workers' compensation regulatory authorities in Australia outline treatment expectations of physical therapists. For example, in Queensland, the workers' compensation regulator, Q-COMP, states physical therapists have a role in the assessment and treatment of the compensable injury, determination of a person's work capacity, conducting workplace assessments and functional capacity evaluations, providing advice concerning job modifications, work conditioning, and assisting in identifying suitable duties.20 Interestingly, the workers' compensation and rehabilitation legislation indicates that all stakeholders have responsibility for an injured worker's RTW, with the employer specifically responsible for developing a RTW plan “consistent with the worker's needs and with the current medical certificate…developed in consultation with the insurer, the worker, the worker's employer, the worker's treating registered persons.”21(p s106) Thus, the workers' compensation legislation indirectly acknowledges the role of physical therapists in this process with the regulators who implement the legislation, specifically detailing this role. Yet there is scant research on the experiences and perspectives of physical therapists managing patients receiving workers' compensation. Thus, the aim of this study was to investigate physical therapists' experiences with, and perspectives on, their role in determining readiness for RTW and work capacity for patients receiving workers' compensation in Queensland, Australia.
Method
Design
A qualitative descriptive approach was used to address the aim of this study.22 This method enables a more in-depth exploration of when and how the physical therapist determines readiness for RTW and work capacity than is possible with quantitative methodologies such as surveys. Similar methods were used by Salbach et al.23
A purposeful sampling strategy was used to locate physical therapists in rural and urban regions of Queensland who regularly manage injured workers. It was important to include the experiences of physical therapists practicing in nonmetropolitan regions in order to capture possible differences between nonmetropolitan and metropolitan practice. Physical therapists were identified from a list, provided by the regulator, of 50 practices that regularly manage patients receiving workers' compensation. These practices were invited via telephone to participate in the research. Novices (physical therapists with less than 1 year of postgraduate experience) and experienced therapists who provide consultation to patients receiving workers' compensation were invited to participate. Most practices consisted of sole practitioners. Where several therapists were employed in 1 practice, the novice and experienced therapists nominated themselves or were identified by the principal of the practice after the inclusion criteria were explained.
The first author (V.J.), a physical therapist with 30 years' experience as a practitioner and researcher, facilitated half of the telephone interviews. The second author (M.N.) has a background in social work and experience in interview and focus group qualitative research methods.
Data Collection
Both authors (V.J. and M.N.) were involved in data collection. The inclusion of both authors was done to enhance the quality and credibility of the study, as the use of multiple researchers is a method of investigator triangulation.24 In addition, as thematic analysis was conducted on the data obtained and data familiarization is a necessary component of this type of analysis in qualitative research,25 it is generally recommended that researchers conduct their own data collection. In this instance, 2 researchers were involved and, therefore, both were involved in data collection.
Due to time constraints and the geographical location of the physical therapists, 1 focus group with 5 physical therapists and 20 one-to-one semistructured telephone interviews were conducted. The telephone interviews lasted between 30 and 45 minutes each. Collection of data through 2 methods was necessary for pragmatic reasons, but also enhanced the trustworthiness of the research process, as it provided a basis for comparing the consistency of data across different interview contexts.24 A combination of individual interviews supplemented by focus group data using the same interview guide has been used previously by Baril et al26 and Shaw and Huang.27
Semistructured interviews were chosen, as this is considered the best method when there is only 1 opportunity to interview someone and several interviewers will be involved.28 The inclusion of open-ended questions provided the opportunity for identifying new ways of understanding the physical therapists' role in determining RTW.
Recruitment continued until informational redundancy was reached, that is, when no new information relevant to the research questions emerged from the interviews.29 In this study, informational redundancy was determined through preliminary analysis of the interview transcripts and reflective discussion between the researchers. Through this process, which occurred on a weekly basis throughout the data collection period, it was determined that no new information arose after interviews with 25 physical therapists (ie, 20 interviews and 1 focus group of 5 participants). Similar methods were used by Coole et al.16
An interview guide with specific trigger questions was developed (Appendix). A list of topic areas was developed following a review of the literature and guidelines for physical therapists outlined by the regulator20 and discussion with 2 physical therapists and between the authors. Several iterations of the interview guide were developed and reviewed, with questions and probes to ensure a detailed and thorough understanding of participants' responses.
The focus of the study was on patients in the workers' compensation system. Thus, participants were directed at the beginning of the interview to consider patients they had treated within this system. This focus was necessary to ground their responses in this practice arena. The introductory question “What were your goals/aims of treatment?” was asked to establish that RTW was indeed a goal of treatment. This question was considered necessary, as previous research has shown the treatment objectives of therapists managing patients with work-related low back pain were to address impairments such as pain and movement restrictions rather than activity limitations such as activities of daily living and work.30 However, it was decided not to limit the physical therapists' focus to those with only LBP, as in previous studies with physical therapists, chiropractors, and medical practitioners,15,30 as the goals of treatment should be similar regardless of the location of injury.
The focus group and the telephone interviews were digitally recorded and transcribed verbatim into computer-readable text files by an independent transcription service provider. Accuracy of the transcription from recording to text was checked by both authors.
Demographic data also were collected from the physical therapists electronically prior to the focus group or telephone interview. These data included years of experience, sex, postgraduate qualifications, and amount of time spent undertaking professional development activities per month.
Finally, previous studies have suggested that health care professionals lack confidence and skills in occupational health, which may impede the RTW process.15,31 Thus, physical therapists were asked to rate their level of confidence making RTW decisions with 1 question: “How confident are you in your ability to make return-to-work decisions for your patients?” This question was scored on a scale of 0 (“not confident at all”) to 10 (“extremely confident”).
Confidentiality of participants' data was ensured throughout the research process by assigning specific codes to each transcription file known only to the principal investigator and used during data analysis. Informed consent was obtained prior to data collection.
Data Analysis
Thematic analysis, modeled on the process outlined by Braun and Clarke,32 was used to identify themes that adequately reflected the content of the textual data.25 Similar methods were used by Cote et al13 and Coole et al.16 The interview transcripts were independently reviewed by both authors (V.J. and M.N.), who familiarized themselves with the data, reading and re-reading the transcripts in preparation for initial coding and identification of preliminary themes. The authors met to review and refine these themes until agreement was reached on those that adequately reflected the textual data. Once the themes were determined, quotations were extracted under thematic headings and checked for consistency with the narrative content. Member checking confirmed the interpretation of the interview transcripts. The question on confidence to make RTW decisions was analyzed by calculating the mean score for all therapists in addition to novice and experienced physical therapists separately.
Role of the Funding Source
This work was funded by The University of Queensland via an internal research grant (Early Career Researcher Grant 006651) and was supported by Canadian Institutes of Health Research (CIHR) grant FRN: 53909.
Results
The characteristics of the participating physical therapists are presented in the Table. There was a broad distribution of ages, with both male and female therapists represented. There were 5 novice physical therapists, and both rural and urban therapists were interviewed. Fifty percent of the participating therapists indicated that compensable patients comprised 20% or more of their patient workload. Nearly half of the participants had postgraduate qualifications in a specialty area related to physical therapy. The physical therapists rated their confidence in making RTW decisions as 7.4 on a 0 to 10 scale. However, there was a difference of 2 points in the mean score when novice physical therapists were considered separately (Table).
Characteristics of Participants
The thematic analysis of the interview data identified 3 themes: (1) physical therapists believe they play an important role in RTW, (2) physical therapists use a variety of methods to determine work capacity, and (3) physical therapists experience a lack of role clarity. Each of these themes will be discussed with supporting quotations.
Physical Therapists Play an Important Role in RTW
All participants indicated that physical therapists should assess RTW readiness and that they were best placed to know the timing of such readiness. As 1 therapist stated,
Absolutely, who else would do it? I mean no one else would know the patient as well or spend as much time with them or actually know their real function. (PT-3)
The reasons offered were that physical therapists had the knowledge (of anatomy, physiology, and biomechanics), awareness of the barriers to RTW, and time to establish rapport and trust, providing them with a thorough understanding of the patient's function at any point in time. The nature of the professional relationship allows the individual to “disclose a lot of information to you.”
Although most therapists reported that RTW was the primary or long-term goal for patients receiving workers' compensation, some highlighted the use of short-term goals on the journey to RTW, such as the need to reduce pain and improve function. One therapist stated:
The 2 biggest goals are firstly to return to work and then secondly just to improve their pain and function. (PT-16)
Participants initiated discussion regarding RTW with patients during the first session, or on the second or third visit at the latest, thus ensuring RTW was the focus early in treatment. As 1 physical therapist said:
Pretty much from day 1…because that's the main goal, to get them to return to work as quickly as possible, so…that happens in the initial consultation. (PT-12)
The participants also expressed a belief that their professional role included making recommendations regarding the timing of, and appropriate duties for, the workers' RTW. These recommendations would be made to the referring physician or the workers' compensation insurer case manager or employer. However, these recommendations varied among patients and work contexts. As 1 participant commented:
Recommendations (about work capacity) to doctor and WorkCover…it varies, depending on the patient, and it depends on the environment they are going back to. (PT-19)
Physical Therapists Use a Variety of Methods to Determine Work Capacity
The participants indicated they would not rely on 1 method to determine work capacity but would use clinical judgment informed by experience, clinical measures, and discussion with the patient. As 1 therapist said:
I obviously talk to them (the patient) as well.… I talk to them and say, “Look, how do you feel (about RTW)? Are you confident you will be able to handle things?” (PT-4)
The specific assessments or skills used by participants can be broadly categorized as subjective or objective. Subjective methods include conversations with the patient during which he or she “reveals” or “volunteers” information, patient responses to specific questions, patient self-reports of functional abilities at home, and participants' personal experiences as a physical therapist and their broader life experience. There appeared to be a hierarchy of methods, as explained by 1 experienced physical therapist:
I think the gold standard is that you assess the person in the room…you have assessed their workplace, and you're matching the two together, and below that may be you've only assessed them in the room, but you have spoken to the employer and to the worker about what their duties are, and then even below that might be where you've got an employer that's not easy to talk to, and you're just assessing the patient and relying on their description of things, and there's more room for error as you as you have less information. (PT-1)
Objective methods included the use of functional tests specific to the job or customized for the worker to test the injured body part—tests that mimic the patient's physical job demands, standard clinical measures, visits to the work site, and a functional capacity evaluation. One novice physical therapist (PT-18) commented he found it “challenging” to know when a patient was ready for RTW, saying he relied on his supervisor to assist in the process. He suggested that “a simple, easy tool…would take the guesswork out of the process.” The complexity of working within the compensable industry was further highlighted by an experienced therapist who summarized how he determines when a patient is ready for RTW:
A combination of subjective and objective findings…because my background is also in chronic pain management, I tend to go a lot by what the patient is telling me and what I'm observing from their…mental and emotional state as much as their physical state.… My approach to treatment is to try and encourage early return-to-work thoughts and strategies in the patient so that as they physically improve, mentally, and emotionally, they're getting ready to go back to work as well. (PT-15)
Interestingly, only 6 of the physical therapists indicated they would conduct a work-site visit themselves, or would refer to a colleague to conduct such a visit to assist in making decisions about a patient's work capacity. This is not to say that these participants do not believe a work-site visit is beneficial to the rehabilitation process. As 1 participant stated:
I think the only hurdle when returning someone to work is if you haven't gone to the workplace and seen what they do, you're relying on their description of what they do, and sometimes what they describe and what you imagine can be slightly different, and that is where things could go wrong. (PT-2)
Reasons cited for not conducting a work-site visit were that they had not been asked to do one or that they perform them “just on request usually of the case manager from WorkCover, it's often driven by them” or “because most of the work sites are 3-plus hours away” (2 rural therapists whose patients commute to mines). Another reason could be that physical therapists do not feel confident in undertaking this task. One therapist said:
Some people are more trained in doing work-site assessments…it is often good if the treating physical therapist can actually see what they (the patient) are doing, so you're matching what they have to do at work with what they can do in your rooms. (PT-5)
In settings where the patient receives treatment early postinjury, the therapist may not need to determine work capacity or RTW readiness. In these cases, work-site visits are unnecessary, as the patient makes a quick recovery:
This is very much an acute style practice.… They get better fairly quickly, and the turnover's pretty high…they get back to work, end of story. (PT-9)
Physical Therapists Experience a Lack of Role Clarity
Despite the belief that physical therapists have an important role to play in determining RTW readiness and work capacity, participants identified a lack of understanding by other stakeholders regarding the precise function of the physical therapist in the workers' compensation system in Queensland. The workers' compensation regulator expects physical therapists to “regularly review and document the worker's work capacity and treatment progress in case notes, and where appropriate provide timely recommendations about return to work/suitable duties to relevant parties.”20 However, the physical therapists expressed concern that their role in the RTW process is not understood or communicated to other stakeholders, such as the employer or the referring general medical practitioner who ultimately makes the decision regarding RTW. This concern is illustrated by the following comment:
We're not empowered to provide anything more than an opinion in the system…because we don't have a formal place in the system here with return to work.… We fit somewhere but probably in a different spot in every case, and a different spot with every doctor, and a different spot with every case manager, some of whom seem to greatly value what we have to say. (PT-14)
This lack of clarity regarding their role was perceived as having downstream effects on their practice with compensable patients, such as creating tensions in interactions with other players in the compensation system. One therapist stated:
I'm not sure if they've (workers' compensation insurers) communicated to the doctors who make those (RTW) decisions, what they expect of the physical therapists, because they (insurers)…firmly expects physical therapists to be making recommendations regarding return to work…and are quite happy to use the physical therapist's opinion in case management, but they haven't told the doctors. I don't think that the doctors necessarily know that WorkCover is valuing the physical therapist's opinion in these cases. (PT-20)
Despite this lack of clarity of their role by other stakeholders, the therapists indicated that their opinion about a worker's functional status often is valued and sought by various stakeholders, in particular by general practitioners or staff at the workplace lacking the confidence, time, or skills to initiate an RTW. The attitude of general practitioners varied, however, with some welcoming the therapists' input:
The general practitioners that I work with normally are quite happy to take my recommendations in terms of their (the patient's) capacity to return to work. (PT-8)
On the other hand, some general practitioners do not consider that physical therapists have a role in making RTW decisions. One therapist said:
Some general practitioners consider that they make all those decisions (about RTW) and our (therapist's) job is to get the person better. (PT-17)
In Queensland, only a medical officer has the legislated authority to initiate and drive the compensable claim (including RTW process), and as such some general practitioners make decisions independent of the physical therapist.
Discussion
This is the first study to explore physical therapists' experiences with, and perspectives on, their role in determining readiness for RTW for compensable patients. The therapists who participated in this study believed they should assess an injured worker's readiness for RTW, as they are well situated to gather and interpret the information necessary to make recommendations to the treating general practitioner, case manager, and employer. They appear to use a combination of methods when making such assessments, including clinical judgment informed by experience, clinical measures, and discussion with the patient, but rarely do they visit the workplace. Discussions with the patient regarding RTW commenced within the first 3 treatment sessions. Experienced physical therapists were more confident they could determine a patient's RTW readiness compared with novice physical therapists, suggesting the latter need stronger skills and experience in identifying when their patient should consider RTW and would benefit from mentoring from more experienced therapists.
The therapists in this study indicated that discussions about readiness for RTW commenced within the first 3 treatments, suggesting that RTW was a focus early in rehabilitation. This finding is in contrast to previous research findings. In a survey of primary care clinicians (physical therapists, chiropractors, osteopaths, and medical practitioners) in Australia, Kent et al15 reported the focus of assessment in the first few consultations was on pain and physical impairment, with only 21% very frequently or often assessing activity limitation and psychosocial functioning.
Despite a stated focus on RTW, the physical therapists in this study did not use consistent methods to assess work capacity and readiness for RTW. Work disability prevention is a specialized field of practice for the health care professional, requiring skills beyond undergraduate training.3,33 Education of physical therapists on strategies to assess work capacity may standardize the assessment of readiness for RTW, improve role clarity, and assist novice practitioners working in the field. This education could include skills such as conducting a work-site assessment, communicating with employers, and using job descriptions to match current function with critical job demands. Although the responsibility for professional development rests with the practitioner, professional bodies may facilitate this process by providing opportunities for education via a specialization process,34 and technology could be used to increase and enhance learning experiences for rural and remote therapists.35 Another option may be to implement a model of service delivery that includes referral to a multiprofessional team to promote consistency in decision making in RTW. For example, a time-based continuum of care model implemented in Alberta, Canada, was shown to reduce the duration of work disability.7 In this model, workers off work 6 to 8 weeks postinjury were referred for multidisciplinary assessment and rehabilitation. Although the exact timing of this referral is important, existing evidence indicates that inclusion of workplace interventions such as a work-site assessment, work modifications, and case management involving all stakeholders are the essential components of any multidisciplinary intervention.9,10,36
A surprising outcome of this study was that so few physical therapists indicated they would conduct a work-site visit. This practice seems contrary to the evidence that a work-site visit as part of a multidisciplinary intervention can improve RTW outcomes for those with subacute nonspecific low back pain36,37 and that communication between employers and health care providers about workplace demands is important for successful RTW.38 Pransky et al31 reported a similar finding in a study of primary care physicians who were found to rarely communicate with employers, although they likewise believed they have a role to play in determining the work capacity of their patients. Possible reasons for this failure to conduct work-site visits could include lack of time or confidence, or situations where patients recover quickly or work in remote locations. It also is possible that insurers are not willing to incur these costs, especially as not every person requires a work-site assessment and distinguishing those who would benefit is difficult. However, a work-site visit would seem a necessary activity for physical therapists to undertake, contributing to their understanding of the physical demands posed by specific work contexts and to the development of work-specific rehabilitation goals to minimize the risk of exacerbation or reinjury.27 One option for the physical therapist is to adopt a stepped-care approach. In this approach, therapists use a variety of techniques, commencing with a questionnaire and semistructured interview, then objective measurement and clinical impressions prior to conducting a work-site meeting and inspection.39,40 Through this approach, the physical therapist can systematically determine the need for a work-site visit and provide a seamless transition from the clinic to the workplace.
The physical therapists also identified a lack of clarity in their role, and although they perceive they have an important role in determining RTW and currently appear to do so, they believe this is not communicated to the other stakeholders, particularly the medical practitioner. Physical therapists believe they are best placed and appropriately skilled to make RTW decisions, but these decisions will vary with every patient and with every referring physician, case manager, injury, and workplace. Their opinion is valued and sought by some stakeholders, but the weight their opinion carries also is variable. There is an expectation by the local workers' compensation regulator and insurers that physical therapists take an active role in determining RTW status. However, efforts by these physical therapists may be stifled for several reasons: the lack of detailed professional standards for their role in industry, the separation of treatment and rehabilitation functions undertaken by therapists working with injured workers,41 and the lack of specific regulations for their role in the workers' compensation system.
Policy Options
The findings of this study point to a number of policy options that may improve the clarity and communication of the physical therapist's role in determining work capacity and readiness for RTW. These policy options involve strategies targeting the profession, the legislation, and regulators. At the professional level, the Australian Physiotherapy Association, the professional body that represents physical therapists in Australia, could follow the example of other professional organizations or partner with regulators to produce position statements or best practice guidelines for therapists managing injured workers.19,42,43 This approach would demonstrate the profession's commitment to the prevention of work disability while forming strategic alliances with relevant stakeholders.
A change in legislation and policies by the regulator also is needed. Currently, the workers' compensation legislation in Queensland (and most jurisdictions in Australia) states that the medical practitioner must issue medical certificates and approve services for treatment and RTW. The latter function or part thereof could certainly be delegated to professionals such as physical therapists who have an intimate understanding of the patient's function. Until there is a role for the physical therapist in the legislation, there will always be confusion about who can (and should) offer RTW advice and guidance. This change could be achieved by the Australian Physiotherapy Association having representation on the Q-COMP board to advocate for physical therapists.
A medical practitioner is required to authorize the initial medical certificate to initiate the workers' compensation claim. However, a work capacity certificate may be a way for physical therapists to communicate their recommendations for work capacity and RTW to employers and medical practitioners. Such a certificate would not replace a medical certificate but would acknowledge the physical therapist's role in determining work capacity. These certificates are currently in use in Victoria (another state in Australia)44 and Alberta, Canada,38 where the therapist is required to complete a work capacity certificate following the first consultation with an injured worker. Financial reimbursement to complete this certificate provides an additional incentive. The certificate details the hours and duties the worker is fit to perform. As physical therapists are currently permitted to request radiographs and magnetic resonance imaging and to authorize sickness certificates for noncompensable patients in Australia, it is not unreasonable to extend this authority to a work capacity certificate. The implementation of such a certificate would require changes to legislation, but is another way policy makers can formally recognize the physical therapist's role in determining RTW of injured workers.
Strengths, Limitations, and Future Directions
This article provides an in-depth discussion of the physical therapists' experiences and perspectives on their role in determining RTW and work capacity. To undertake this analysis, the sample size was necessarily finite, and results cannot be generalized. The article focused on the perspective of one health care professional involved in the RTW process—the physical therapist in the state of Queensland, Australia. However, the physical therapist is only one of many health care providers who play a role in work disability prevention. As this study cannot speak to the experiences and concerns of other stakeholders, future studies should consider how each provider perceives his or her role and that of other stakeholder groups in RTW of injured workers, in particular the influence of the legislative framework. In Queensland, as in most jurisdictions in Australia, health care providers are not required to complete specific training to manage patients receiving workers' compensation. The introduction of mandatory training at the postgraduate level for all stakeholders may be a way achieving a common understanding of the role of each stakeholder in the RTW process. In addition, future studies might consider the relationship between additional training and confidence in making RTW decisions and whether early career therapists' confidence improves with specific training or mentoring.
Conclusion
This study offers physical therapists' experiences and views of their role in RTW of patients with a work-related musculoskeletal injury. Physical therapists believe they are ideally placed to determine a patient's readiness for RTW and work capacity and tend to make recommendations for RTW to the referring physician. These recommendations are the result of clinical judgment based on subjective and objective information obtained from the injured worker. Discussions about RTW were initiated within the first 3 consultations with the physical therapist, indicating RTW is a central focus of practice with this patient group. Although physical therapists believe they have the knowledge and skills to determine readiness for RTW, which is an expectation of the workers' compensation regulator, they also believe this expectation is not communicated to the other stakeholders, in particular, the general medical practitioner. Workers' compensation regulators need to clearly articulate the expected role of physical therapists to all stakeholders to make full use of their unique skills and position in RTW of injured people. It is recommended that strategies that target the Australian Physiotherapy Association, physical therapists, and the regulator are needed.
Appendix.
Interview Guide
Footnotes
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Dr Johnston, Dr Nielsen, and Adjunct Professor Franche provided concept/idea/research design, writing, and data analysis. Dr Johnston and Dr Nielsen provided data collection. Dr Johnston provided project management. Dr Johnston, Associate Professor Corbière, and Adjunct Professor Franche provided consultation (including review of manuscript before submission).
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Ethics approval for this research was obtained ethics from The University of Queensland Behavioural and Social Sciences Ethical Review Committee.
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This work was funded by The University of Queensland via an internal research grant (Early Career Researcher Grant 006651) and was supported by Canadian Institutes of Health Research (CIHR) grant FRN: 53909.
- Received June 13, 2011.
- Accepted June 21, 2012.
- © 2012 American Physical Therapy Association
References
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