Abstract
Background The availability and role of physical therapists in critical care is variable in resource-poor settings, including lower middle-income countries.
Objective The aim of this study was to determine: (1) the availability of critical care physical therapist services, (2) the equipment and techniques used and needed, and (3) the training and continuous professional development of physical therapists.
Methods All physical therapists working in critical care units (CCUs) of state hospitals in Sri Lanka were contacted. The study tool used was an interviewer-administered telephone questionnaire.
Results The response rate was 100% (N=213). Sixty-one percent of the physical therapists were men. Ninety-four percent of the respondents were at least diploma holders in physical therapy, and 6% had non–physical therapy degrees. Most (n=145, 68%) had engaged in some continuous professional development in the past year. The majority (n=119, 56%) attended to patients after referral from medical staff. Seventy-seven percent, 98%, and 96% worked at nights, on weekends, and on public holidays, respectively. Physical therapists commonly perform manual hyperinflation, breathing exercises, manual airway clearance techniques, limb exercises, mobilization, positioning, and postural drainage in the CCUs. Lack of specialist training, lack of adequate physical therapy staff numbers, a heavy workload, and perceived lack of infection control in CCUs were the main difficulties they identified.
Limitations Details on the proportions of time spent by the physical therapists in the CCUs, wards, or medical departments were not collected.
Conclusions The availability of physical therapist services in CCUs in Sri Lanka, a lower middle-income country, was comparable to that in high-income countries, as per available literature, in terms of service availability and staffing, although the density of physical therapists remained very low, critical care training was limited, and resource limitations to physical therapy practices were evident.
Sri Lanka is a lower middle-income country, with health indexes that are among the best in South Asia1 and among its income category. The country's public health sector is well established and effective in reaching much of the population.2 As a result, many of the basic health indicators, such as those related to maternal and child health, have been kept at a low level.3,4 However, with the changing of health care needs and the improving of health care standards, quality improvements extending beyond basic health care are necessary to maintain this position. Critical care is one such segment that needs improvement, especially in view of the growing population above the age of 60 years and the increasing morbidity levels related to growth in noncommunicable diseases (NCDs). The critical care system on the island, while distributed unequally, is extensive.5
During the past few years, several initiatives have been undertaken to improve the delivery of critical care services on the island, which include the setting up of a critical care patient registry and bed availability system and the initiation of critical care–focused training for nurses involved in critical care provision.6,7 Physical therapists, who are now considered an integral part of the critical care workforce,8 are another target group for this process. However, little information is available regarding the availability and variations in physical therapist service provision on the island, which poses a barrier to focused quality improvement initiatives. This paucity is not unique to the island itself. Rather, this is a general issue for the countries in the lower middle-income category.9 At the same time, similar studies carried out in high-income countries, where the role of physical therapy in critical care is well established,10–12 have revealed an ongoing variation in physical therapy education, in the physical therapists' role in patient management, and in their workload.13 For example, physical therapy care is routinely provided to all patients in some settings, whereas in other settings, the patients have to be referred for such care by the medical staff.14 Thus, it is reasonable to expect similar or even greater irregularities in a resource-poor setting. The few available surveys regarding physical therapists and the practice of physical therapy in resource-poor settings present findings that support this hypothesis.9,15
The purpose of this study was to determine: (1) the availability of critical care physical therapist services, (2) the equipment and techniques used and needed, and (3) the training and continuous professional development (CPD) of physical therapists.
Materials and Method
A descriptive cross-sectional study was carried out with the participation of all physical therapists working in the state sector critical care units (CCUs) of Sri Lanka. We have defined CCUs as units equipped with at least one ventilator and where patients are admitted for at least 24 hours.5 A list of 54 hospitals employing physical therapists was obtained from the Government Physiotherapists' Association (GPA). Physical therapists were contacted individually via telephone from numbers obtained from the physical therapy departments of these hospitals. Any physical therapists who had not worked in a CCU during the years of 2012 and 2013 were excluded from the study.
An interviewer-administered questionnaire (eAppendix) was used as the data collection tool. The draft questionnaire was prepared collaboratively. In addition, 2 physical therapists with extensive work experience in CCUs and 2 senior physical therapists working in the capacity of instructors, nominated by the GPA and the School of Physiotherapy and Occupational Therapy administered by the Ministry of Health, were consulted regarding the design, structure, and content of the questionnaire. The consultation was used to develop categories and questionnaire items.
The questionnaire was administered over the telephone to each of the participants after informed verbal consent was obtained by explaining the aims and method of the study. The questionnaire was administered from beginning to end during the same telephone call, and the average duration of the interview was approximately 20 minutes. The questions were closed-ended, except for the problems and suggestions section, where the responses were noted down by the data collectors and later grouped under the categories of lack of staff and facilities, inadequate training, heavy workload, perceived lack of infection control in the CCU, and financial and administrative difficulties. Data were collected from April to July 2013.
Data regarding CCU characteristics, including number of functioning beds and admissions, were obtained from a study done in 2011.5 All physical therapists who were either exclusively allocated to CCUs or dividing their time between CCUs and non-CCU units were included in the study. For the purpose of the study, “on-call physical therapist services” were defined as physical therapist services provided after 4 pm on any day of the week by a physical therapist not expected to be continually present in the hospital. Such services extending into the next day were considered “on-call night services.” The number of beds per physical therapist was calculated as the number of functioning beds divided by the number of physical therapists serving at the same facility. Descriptive statistics were used to analyze the categorized information, using SPSS, version 16 (SPSS Inc, Chicago, Illinois).
Role of the Funding Source
This study was supported by the Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
Results
A total of 213 physical therapists were interviewed, and all of them fulfilled the inclusion criteria for the study. Sixty-one percent (n=130) of the participants were men. Ninety-four percent of the participants (n=201) had at least a diploma in physical therapy, and the remaining 6% (n=12) held bachelor's degrees that were not primarily in physical therapy. The mean age of the participants was 37.7 years (SD=9.8, range=25–59), and the mean working experience was 11 years (SD=10.1, range=3 mo–38 y). The critical care experience ranged from a month to 36 years, with a mean of 10 years (SD=9). Three percent of the participants (n=6) had less than 3 months of experience working in CCUs. The working experience of physical therapists is summarized in Table 1.
Critical Care Unit (CCU) Working Experience of Physical Therapistsa
All CCUs included in the study had the services of at least one physical therapist, and a single physical therapist was sometimes found to handle more than one CCU situated within the same hospital. Thirty-one (15%) of the participants covered 3 or more CCUs within the same hospital. The distribution of CCU physical therapists by type of CCUs and type of hospitals is summarized in Table 2. Table 3 shows the number of functioning beds, number of admissions, and the variation of physical therapist services among CCU categories and hospitals.
Distribution of PTs in Sri Lankaa
Distribution of Functioning Beds, Admissions, and Deaths in CCUsa
Referral
A majority of the physical therapists (56%, n=119) accessed patients following referral from the medical staff, whereas some therapists (28%, n=59) needed no such referral. A few therapists (15%, n=32) accessed patients both ways.
Availability of Physical Therapist Services
Table 4 shows the work pattern of the physical therapists. One hundred twenty-seven (60%) of the interviewees worked exclusively in CCUs, and the rest (n=86, 40%) divided their attention between non-CCU and CCU patients. Almost all of them had worked on weekends (98%, n=209) and public holidays (96%, n=205) at least once within the previous 3 months, and most (90%, n=192) had provided on-call physical therapist services at least once during the same period. One hundred sixty-four therapists (77%) had provided on-call services at night at least once during the preceding 3 months. These services were counted for the calculation of overtime pay as remuneration. The majority of on-call service provisions (72%) were in response to requests by the CCU staff, with 60 physical therapists (28%) acting in a resident capacity (physical therapists stayed in the hospital) during the night shift. A summary of the CCUs with 24-hour physical therapist services obtained by the National Intensive Care Surveillance (NICS), Sri Lanka, is shown in Table 5.
Work Patterns of PTsa
Availability of 24-Hour PTs in CCUsa
Physical Therapy Equipment and Techniques
Overall, most of the CCUs had hyperinflation bags (99%, n=210), suction equipment (97%, n=207), and spirometers (80%, n=170), although only 61% (n=25) of the surveyed pediatric CCUs had spirometers. The physical therapists received help from nurses and health care assistants for activities such as patient positioning, mobilization, and postural drainage during their work. Activities carried out by the physical therapists and availability of equipment are summarized in Table 6.
Availability of Equipment and Practices Used in CCUsa
CPD
Over the course of the preceding year, a majority (68%, n=145) of the physical therapists had been involved in some form of CPD. One hundred seven (50%) of the 213 participants had attended national-level workshops or training programs, although information regarding specific CPD programs was not collected. The numbers of individuals with research experience was very low (5%, n=10), and fewer still had published papers in journals (1%, n=3) or presented at conferences (1%, n=2).
Factors Influencing Standards of Care
Thirty-seven percent (n=79) of the participants identified lack of specialized training in critical care physical therapy skills as a problem influencing quality of service provision. Fifteen percent (n=32) of them cited lack of staff and resultant heavy individual workload as a major problem. They described the lack of adequate physical therapy coverage in peripheral hospitals and delays in filling vacancies due to retirement or transfers as adding to the workload. Problems with equipment were sighted by 13% (n=27) of the participants as a hindrance to service provision. These problems included nonfunctioning and malfunctioning equipment (eg, spirometers and hyperinflation bags) and unsuitable equipment (eg, nonadjustable beds) for certain activities. Nineteen participants (9%) voiced concern about the lack of basic equipment for infection control and inadequacies in universal precautions, and 17 participants (8%) were concerned about the lack of teamwork within the CCU teams. Five percent of the participants (n=11) pointed to the lack of facilities for on-call service providers (eg, lack of transportation and rooms for those working in an on-call capacity). Low salaries and inadequate income were mentioned by only 2 (1%) of the participants.
Discussion
In this cross-sectional survey, critical care physical therapy services in Sri Lanka were found to exceed those reported for other lower middle-income countries,16,17 and techniques used were similar to those reported in high-income countries.14
There was a 100% response rate among the physical therapists contacted, thus enhancing the validity of the findings.16,17 The availability of physical therapist services in Sri Lankan CCUs also was 100% in comparison with other non–high-income countries, with Mongolia and Malaysia reporting 14.3% and 65.9%, respectively.16,17 Likewise, the weekend coverage of physical therapist services in Sri Lanka (98%) was high and similar to that of high-income countries.17–19 Although all CCUs had access to a physical therapist, the density of physical therapists was very low (1.2 per 100,000 population) in comparison with high-income countries such as Australia and Canada with ratios of 60.4 and 51.1 CCU physical therapists per 100,000 population, respectively.20,21 No data for comparison were available from other low-income countries or low- and medium-income countries. However, even this figure from our survey is likely to be an effective overestimate given that only 60% of the physical therapists worked exclusively in CCUs. Overall, Sri Lanka had 182.8 CCU admissions per physical therapist per year (corresponding figures from other countries were not available for comparison).
The role of the physical therapists in CCUs worldwide is not well-defined, and responsibilities and techniques vary across countries.13–15,22 Similar to most non–high-income countries,9 the study participants reported that routine assessment of all CCU patients in Sri Lanka was not done, with only 28% of the physical therapists independently assessing patients for suitability for therapy.14,23 Further investigation is needed to explore the appropriateness of the referral from doctors and whether patients who might benefit from physical therapist intervention are missed when not referred by a doctor. In addition, if physical therapists were to assess all CCU patients independently, their workload would most likely increase beyond the level that would be sustainable without significant additional recruitment.
The techniques used by the physical therapists in our survey, for the most part, were comparable to those used in high-income countries.14,22,24 However, although techniques such as manual hyperinflation were routinely utilized, other techniques such as incentive spirometry were used rarely despite widespread availability of the equipment (79.8%). This finding may have been due, at least in part, to the awareness of the lack of beneficial effects of incentive spirometry on patient outcome even when used in isolation.20,25 We did not gather information on any anticipated risks when applying manual hyperinflation or on any precautions; these factors warrant further investigation. Another shortcoming of the study is that it did not examine mobilization and exercise therapies, considering their positive effects on patient outcomes.
As expected, the number of physical therapists employed by tertiary care hospitals was comparatively greater than at provincial general, district general, and base hospitals. Although this finding was due, in part, to the greater number of CCUs in these hospitals,5 the actual number of physical therapists per CCU also was low. The teaching hospitals were more likely to have physical therapists allocated exclusively to either CCU or non-CCU work, whereas physical therapists in other settings commonly divided their time between CCU and non-CCU work. Physical therapists working exclusively in non-CCU settings were excluded from the study, which likely contributed to the apparent anomaly. However, this limitation can be countered by taking the number of physical therapists per CCU bed as a measure of workload, giving more comparable results for both tertiary care and non-tertiary care settings.
Nearly half of the respondents had engaged in some form of CPD. Data regarding their participation in critical care CPD activities were not collected. It is recommended that all health care staff should update their knowledge and skills regularly to provide the best care for their patients.8 Lack of CPD may have contributed to the nonoptimal use of available equipment, perceived lack of cooperation from the CCU team, and minimal audit and research output. Furthermore, the lack of training opportunities is likely to affect morale among the therapists. Partly in response to these observations, the NICS of the Ministry of Health has already commenced structured training programs for CCU staff.7,26,27
The lack of basic equipment for infection control, the inadequacies in universal precautions, and the defects in available physical therapy equipment also were identified as significant problem areas by the physical therapists. This finding may have been due to disparity in the facilities available in different CCUs across the country; overall availability of necessary equipment, as we report, is high.
Although we were able to reach all physical therapists working in CCUs in the country, a limitation is that we did not provide details on the proportions of time spent by the physical therapists in the CCUs, wards, or medical departments. This limitation is of relevance because in larger hospitals, most physical therapists divide their time between several CCUs or wards. This paucity of information limits our ability to discuss the physical therapy staffing details among CCU categories any further. In addition, although we report on physical therapists engaged in CPD, we are unable to provide details of how specific this training was to critical care. This specificity of training needs to be investigated and monitored in parallel with any critical care physical therapy training program. Future studies also are needed to address physical therapist service provision in non-state (private) hospitals in Sri Lanka to demonstrate any further disparities. The effectiveness of these physical therapist services, their impact on patient-related outcomes, and any changes in these parameters after a regulated training program are other areas for future work.
Information such as the availability, roles in patient assessment, commonly performed treatment modalities, workload, and problems faced in day-to-day practice is critical for both short-term quality improvement initiatives (eg, skills training) and long-term strategies to modernize and update the physical therapy workforce. However, there is a marked lack of opportunities for CPD. Information regarding how this lack of opportunities affects the physical therapy workforce, both in skill and knowledge enhancement and in morale, is unavailable. The survey also was designed to address this gap in knowledge. It is hoped that the information gathered through the survey will eventually be used to create a focused quality improvement strategy for the critical care physical therapy workforce that addresses the lack of structured training and CPD opportunities.
Although the focus of the survey is limited to Sri Lanka, a country in the lower middle-income category, many of the reasons that prompted the survey are not unique to the island nation. The paucity of information regarding practice of physical therapy and its utilization is common beyond the resource-rich setting. Therefore, we believe that the methods utilized during the survey and the survey findings will prove useful as a basis for similar initiatives elsewhere.
Our study highlights a lower middle-income country with a free health care system, providing critical care physical therapist services across the country. This can be a seen as a model for other countries in the region and for those with similar health care needs. The training difficulties and problems related to equipment or facilities are likely to be representative of resource-limited settings and are a measure of the challenges encountered in the provision of these services.
In conclusion, physical therapist services in state CCUs in Sri Lanka, a lower middle-income country, were better in comparison with those services in other low- and middle-income countries, as per available literature, in terms of service availability and staffing. However, the density of physical therapists remained very low. Organized opportunities for CPD and critical care skills training were limited and emerged as the most concerning issue for the study participants, followed by the low staffing levels and resultant heavy individual workload.
Footnotes
Ms Sigera, Mr Tunpattu, Mr Jayashantha, Dr De Silva, Dr Athapattu, and Dr Haniffa provided concept/idea/research design. All authors provided writing. Ms Sigera, Mr Tujnpattu, and Mr Jayashantha provided data collection. Ms Sigera, Mr Tunpattu, Dr De Silva, and Dr Athapattu provided data analysis. Ms Sigera, Mr Jayashantha, Dr De Silva, Dr Athapattu, and Dr Hanniffa provided project management. Mr Tunpattu provided participants. Mr Tunpattu, Dr De Silva, and Dr Athapattu provided facilities/equipment. Mr Tunpattu, Mr. Jayashantha, Dr De Silva, Dr Athapattu, and Dr Haniffa provided institutional liaisons. Ms Sigera and Mr Jayashantha provided administrative support. Ms Sigera, Mr Jayashantha, Dr De Silva, Dr Athapattu, Professor Dondorp, and Dr Haniffa provided consultation (including review of manuscript before submission).
The authors acknowledge the Government Physiotherapists' Association, all of the physical therapists who participated in the study, and the staff of the National Intensive Care Surveillance for their kind assistance.
Ethical clearance for the study was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Colombo.
This study was supported by the Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
- Received July 18, 2015.
- Accepted January 25, 2016.
- © 2016 American Physical Therapy Association
References
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