Abstract
Background Physical therapists working in acute care hospitals require unique skills to adapt to the challenging environment and short patient length of stay. Previous literature has reported burnout of clinicians and difficulty with staff retention; however, no systematic reviews have investigated qualitative literature in the area.
Purpose The purpose of this study was to investigate the experiences of physical therapists working in acute hospitals.
Data Sources Six databases (MEDLINE, CINAHL Plus, EMBASE, AMED, PsycINFO, and Sociological Abstracts) were searched up to and including September 30, 2015, using relevant terms.
Study Selection Studies in English were selected if they included physical therapists working in an acute hospital setting, used qualitative methods, and contained themes or descriptive data relating to physical therapists' experiences.
Data Extraction and Data Synthesis Data extraction included the study authors and year, settings, participant characteristics, aims, and methods. Key themes, explanatory models/theories, and implications for policy and practice were extracted, and quality assessment was conducted. Thematic analysis was used to conduct qualitative synthesis.
Results Eight articles were included. Overall, study quality was high. Four main themes were identified describing factors that influence physical therapists' experience and clinical decision making: environmental/contextual factors, communication/relationships, the physical therapist as a person, and professional identity/role.
Limitations Qualitative synthesis may be difficult to replicate. The majority of articles were from North America and Australia, limiting transferability of the findings.
Conclusions The identified factors, which interact to influence the experiences of acute care physical therapists, should be considered by therapists and their managers to optimize the physical therapy role in acute care. Potential strategies include promotion of interprofessional and collegial relationships, clear delineation of the physical therapy role, multidisciplinary team member education, additional support staff, and innovative models of care to address funding and staff shortages.
Health services provided in acute care hospitals are typically intensive, of short duration, and specialized.1–3 Physical therapists working in acute care hospitals possess a unique set of knowledge and skills that adapt to these characteristics.2 For example, physical therapists are required to have in-depth knowledge of multiple body systems across a person's life span in order to accommodate for the variable mix of patients who are admitted to acute care.1,3,4 Moreover, patients in this setting often have a complex range of medical conditions, thus requiring multidisciplinary care.1,3 Physical therapists, therefore, must show proficiency in reading medical charts, identifying contraindications to physical therapy, and communicating with various health care professionals.1 Additionally, when delivering client-centered services, the physical therapist must assess the benefits of the physical therapy intervention against the potential risks it poses to the patient's medical condition.1 The structure and activities of the physical therapy role in acute care internationally have many similarities across health systems in the United States,1,3,5,6 the United Kingdom and Europe,7–9 Canada,10,11 South Africa,12,13 South America (particularly Brazil),14,15 India,16 Singapore,17 Hong Kong,18 Japan,19 and Australia and New Zealand,20–22 with ongoing evolution of the role across Asia.23–25
However, there may be perceptions of low desirability to start or remain working in acute care among physical therapists,3 who may be more attracted to work in the private sector than the public sector due to higher flexibility in working conditions and higher annual remuneration.26 A 1993 survey of 188 acute care physical therapists reported that only 7% of respondents felt that experienced physical therapists were “frequently attracted to work in the acute setting.”3 Furthermore, the study illustrated that a notably smaller proportion (17%) of novice physical therapists (with 0–3 years of experience) reported that they would seek their next job in an acute care setting compared with highly experienced physical therapists (40%).3
It also has been reported that hospital physical therapists have a turnover rate of 20%, which is one of the highest rates in the allied health professional workforce.26 High turnover and vacancy rates cause significant financial losses associated with recruitment, loss of productivity due to orientation time, and burnout of the remaining physical therapy staff.3,4,26 Burnout and moral distress27 are significant issues for physical therapists and their managers worldwide,28–35 and recent data suggest that burnout, along with a lack of career progression, contributes to professional attrition.3,36 Data also suggest that physical therapists with intermediate levels of experience frequently move to other occupations.26
In order to address this problem, acute care physical therapy departments have trialed different strategies, such as offering new graduates a higher salary, commencement bonuses, and more annual leave26 and the introduction of tools to reduce inappropriate referrals and workload.37 However, before concrete strategies such as these are implemented, it is worth understanding the factors identified in existing research that affect the experiences of physical therapists in acute care practice. This knowledge, in turn, may directly influence strategies selected to improve attractiveness and retention of physical therapists in the acute hospital environment.
There is a clear research gap in synthesis of studies investigating the experiences of physical therapists working in acute care, and conducting a systematic review may identify whether additional studies are necessary. Existing studies may inform understanding of the opportunities and challenges faced by physical therapists, specifically in the context of perceived desirability of the acute care setting as a workplace; factors contributing to burnout; and strategies to both attract physical therapists to and retain them in acute care. However, to our knowledge, no systematic reviews have explored physical therapists' experiences of working in acute care. A systematic review of qualitative studies was chosen, as the in-depth nature of qualitative research may better capture the complexity of experiences as a phenomenon. The review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.38
Experience, in this review, was defined as an interpretation of an event or environment that one personally encounters. Acute care was defined as a hospital setting where short-term specialized patient care is given to restore and maintain health. These settings included emergency departments; intensive care units; high-dependency units; and perioperative, maternity, pediatric, hospital pharmacy, and day surgery wards.39
The aims were to investigate the experiences of physical therapists working in the acute hospital setting. The review findings will inform the potential for managers and staff to positively influence physical therapist experiences.
Method
Eligibility Criteria
The inclusion and exclusion criteria are presented in Table 1.
Study Eligibility Criteria
Information Sources
Searches were conducted across 6 databases: MEDLINE via Ovid, CINAHL Plus via EBSCOhost, EMBASE via Elsevier, AMED via Ovid, PsycINFO via Ovid, and Sociological Abstracts via ProQuest.
Searches and Study Selection
Searches were conducted with the key words “experience,” “physical therap*,” “acute hospital*,” and “qualitative” (Appendixes 1 and 2), and sources were searched up to and including September 30, 2015. Database thesauruses were searched to find existing MeSH or EMTREE terms for key words. Synonyms and Boolean operators were added to enhance the sensitivity of the search. Two reviewers (with a third reviewer for adjudication as required), working independently, screened titles and abstracts and identified potentially relevant full-text articles for review. Included articles' reference lists also were hand searched, and full-text articles were sought where there was insufficient information in the title or abstract.
Data Collection Process and Data Items
Data extracted included the study authors and year, the aim of the study, the qualitative method used, data collection methods, participant characteristics, and study settings. Either direct participant quotes or author text were extracted where appropriate to support the themes synthesized in this review, and quotes are denoted accordingly. Key themes, any explanatory models or theories developed, and implications for policy and practice were also extracted where available.
Quality Assessment Within and Across Studies
Researchers have debated the validity and usefulness of utilizing a quality assessment tool in qualitative studies due to their variable and subjective nature.40 However, previous work has developed a summary framework for appraising qualitative studies by synthesis of existing checklists and elimination of nonessential criteria.41 We adapted this framework into a tool to assess the quality of the included articles (Appendix 3).41
Synthesis of Results
Thematic analysis was used to extract relevant concepts and interpretations from each included article. Any theoretical models developed from the findings of a research study were also analyzed. Where possible, common themes of physical therapists' experiences across the included studies were identified and categorized, with particular focus on any differences in concepts and interpretations of articles. Reasons for these differences were then investigated by considering the different contexts in which each research study was conducted, limitations of the study as identified by the study, and the quality of the qualitative research. A single researcher (B.L.) completed a detailed reading of the findings of all identified outcomes in each article. Similar outcomes were grouped together as a descriptive theme. A second researcher (M.B.) read the findings of the included studies and independently clustered key findings into themes. These themes were compared with the previously identified themes; gaps were identified and incorporated into the thematic analysis. A systematic review protocol for this review was not prospectively registered or published, as this was a systematic review of qualitative studies rather than quantitative studies.
Results
Three hundred eighty-seven articles were identified. After removing duplicates, the abstracts of 213 articles were screened. Twenty-seven articles were assessed for eligibility, and subsequently 8 studies (total physical therapist sample size, N=81) were included in the review (Figure). An example search strategy (MEDLINE) is included (Appendix 2). The characteristics of included studies are presented in Table 2. The most common method utilized was face-to-face interviews, with grounded theory the most frequently used analysis approach.
Flowchart of the search process based on the PRISMA format.
Study Characteristics
Quality assessment scores were high, ranging from 81% to 94% (see Tab. 2; full details of quality scoring are presented in the eAppendix). To further ensure rigor of the review, studies that scored the lowest were checked against the other studies. We found that the lowest scoring studies reported themes similar to those in other studies, but also offered new insights. Given the low variability between critical appraisal scores, findings in each study were given equal weighting. The most poorly described methodological aspects were: justification of sampling method and explanation of the method used to ensure participants were treated fairly and equally.
Table 3 presents the setting in which the research was conducted to identify differences in context, as well as sample size and experience of physical therapists. Studies were conducted in urban hospitals where the setting was specified. All studies used purposive sampling for participant selection. The number of participants varied from 2 to 18 physical therapists, with the majority having less than 5 years of clinical experience. Where sex was specified, the physical therapy participants were mainly women.
Participant Characteristicsa
Four studies investigated factors influencing clinical decision making by acute care physical therapists. Two studies explored differences between novice and experienced physical therapists' perceptions of clinical decision making. One study investigated experiences after major hospital restructuring, and another study explored experiences of emergency physical therapists. Table 4 presents the themes and interpretations present in the results, analysis, and discussion sections of the research reports.
Outcomes–Key Themesa
Qualitative Analysis and Synthesis
Four key themes were identified: the influence of the environment/context, communication/relationships, the physical therapist as a person, and professional identity/role of the physical therapist (Tab. 5). Frequently, outcomes in individual articles overlapped 2 common themes.
Grouping of Study Outcomes Into Common Themesa
Influence of the environment/ context.
Environmental and contextual factors that cannot be controlled by physical therapists can alter clinical decision making, priority setting, and other aspects of physical therapist practice in acute care settings. These factors also can affect physical therapists emotionally. A relevant aspect of such environmental/contextual factors is the nature of acute care:
The length of stay in the hospital was short. This affected the physiotherapists' clinical reasoning and decision making. Quick assessments and treatment interventions were chosen over those based on evidence [author text]. (Holdar et al,42 2013, page 224)
Physical therapists also must make their clinical decisions within the boundaries of the organizational structure, such as equipment provision, hospital regulations, nature and culture of the department, funding, and, in the United States, the patient's insurance coverage:
The pressure on cardiac [rehabilitation] was high, and it was not possible to let the patients continue organized [rehabilitation] in accordance with the recommendations of the National Board of Health and Welfare (Sweden). In this care, the physiotherapists had knowledge of relevant evidence but did not use it because of the economical framework [author text]. (Holdar et al,42 2013, page 224)
Other than influences on clinical decision making, physical therapists' emotions may also be affected by workload increases stemming from changes in hospital operations:
The source of the therapists' stress seemed to originate from the increasing number of patients, lack of support staff, and documentation demands [author text]. (Blau et al,43 2002, page 652)
However, there was a sense that the environments were highly dynamic; Smith and colleagues proposed that physical therapists may be able to alter some aspects of the external environment to suit their practice:
On other occasions, [physiotherapists] were able to limit and manipulate contextual factors (such as the actual timing of pain medication delivery) in order to achieve optimal decision and treatment outcomes [author text]. (Smith et al,44 2007, page 265)
Communication/relationships.
Communication between physical therapists and various health care team members is an integral part of acute care practice and occurs multiple times throughout the day. Physical therapists communicate to gather more information for decision making and to inform others of patient status and progress:
[Physiotherapists] formulated questions to gain relevant information from patients and members of the health care team and provided information to them [author text]. (Masley et al,2 2011, page 915)
They also communicate to present their recommendations about a patient to the team:
Therapists seemed to seek either validation of or agreement with their discharge decisions, depending on their years of experience in the acute hospital setting [author text]. (Jette et al,45 2003, page 232)
More generally, Blau and colleagues reported that having strong relationships with colleagues is a positive and important aspect of a physical therapist's working environment:
Participant 4 expressed: “I love 90% of the people I work with, and they're my best friends, and that's what keeps me hanging on to this job [participant quote].” (Blau et al,43 2002, page 665)
Physical therapist as a person.
Physical therapists' knowledge base can influence the clinical decisions they make. This knowledge base can come from various sources, such as knowledge and skills gained from education, direct observation of physical therapist practice, research-based knowledge, and clinical work experience. Physical therapists use their knowledge base, combined with patient data, to clinically reason and find solutions to physical therapy–related problems:
The physiotherapists related how they searched for scientific studies not only to support their clinical decisions but also so that they could argue for a certain method of treatment in discussions, primarily with physicians [author text]. (Holdar et al,42 2013, page 225)
The choice of intervention also is dependent on the physical therapist's personality and physical and psychological status. Such factors could lead to the physical therapist picking an intervention that is less demanding for him or her, but may not be the best option for the patient:
Some of the physiotherapists mentioned that their physical and psychological status affected their clinical reasoning…. One informant described how personal matters could make it more difficult to carry through an intervention. (Holdar et al,42 2013, page 226)
Furthermore, the novice physical therapist approach to clinical practice was notably different compared with the approach of a more experienced clinician:
More experienced physiotherapists made decisions with a practical certainty that was underpinned by higher levels of self-confidence about their practice and decision-making ability [author text]. (Smith et al,46 2010, page 98)
Less experienced physical therapists felt less confident and more uncertain about their decisions, and they were more likely to seek validation from other health care practitioners. They also were likely to feel overwhelmed by both their workload and the emotional aspects of their job, such as dealing with a dying patient:
At night, you go home and keep thinking “What am I doing?” and “Am I doing it right?” [participant quote]. (Miller et al,47 2005, page 148)
Professional identity/role of physical therapist.
Physical therapists enjoy the nature of their profession and are satisfied with being able to deliver high-quality care to patients. They believe the latter is an integral part of their professional duty and demonstrate this by a willingness to advocate for the patient's best interests and by participating in ongoing professional development:
Participants noted their obligation to uphold professional standards by consistently using current knowledge and theory in their care of patients and by creating written, evidence-based standards of care for physical therapy staff to reference [author text]. (Masley et al,2 2011, page 916)
Different settings appeared to have a variety of approaches to working across disciplines. These approaches ranged from a sense of interprofessional teamwork,45 where there was real collaboration across disciplines, to effective multidisciplinary communication2 to conflicts over scope of practice.48
For example, health care team members can sometimes underestimate the scope of practice of physical therapists and misunderstand how physical therapists can benefit certain patients:
We heard participants express concern about sometimes improper utilization of physical therapy in the hospital: “I feel like we can be inappropriately used as a walking service” [participant quote]. (Masley et al,2 2011, page 912)
Therefore, physical therapists feel that it is their professional responsibility to advocate their role to others and be proactive toward gaining access to patients who they think might benefit from physical therapy:
Fulfilling this responsibility [of ensuring the right patients received physiotherapy care] took the form of educating new residents and nurses about when and why to consult a physical therapist. [author text]. (Masley et al,2 2011, page 916)
Intertwined with physical therapists' professional identities, was their relationship with the patient and the patient's family. They were concerned with patient safety, and their decision-making was strongly influenced by their understanding of the patients' context and what the patients themselves brought to their treatment:
The physiotherapists considered the patients to also be responsible for their treatment. They mentioned how the patients' participation in their treatment affected their decisions [author text]. (Holdar et al,42 2013, page 226)
Overall, physical therapists enjoy their line of work. They find that they have the ability to deliver high-quality care to patients. These 2 factors, alongside having positive relationships with colleagues, are identified by Blau and colleagues as the “silver lining” that allowed physical therapists to remain in acute care work despite many negative perceptions of their changing workplace:
Although the majority of feelings associated with change in this setting were negative, the physical therapists valued their profession and their colleagues and took pride in providing excellent patient care [author text]. (Blau et al,43 2002, page 656)
Discussion
Strong relationships between physical therapists and their colleagues contribute to positive feelings about the workplace. The impact of peer relationships on physical therapists' contentment may be due to the collaborative nature of the acute care setting. In particular, Blau et al43 highlighted that high-quality care, strong interprofessional relationships, and the impact of collegial relationships facilitated physical therapists to work in acute care despite many negative perceptions. Similar findings are reported in acute care nurses, where higher job satisfaction was associated with “professional pride,” development of friendships and interprofessional cohesiveness, and “making a difference to the patients.”49(p810) Acute care physical therapists remain in this setting because of the opportunity for multidisciplinary teamwork, which is seen to be rewarding.36
Environmental factors that cannot be controlled by physical therapists may frequently cause negative emotions. Operational demands, such as increases in workload and documentation, staff shortages, and limited support staff availability, may lead to feelings of stress and being overwhelmed. Hospital regulations, funding limits, and the culture within a health care team also act as boundaries limiting physical therapists' decisions. Physical therapists may have to compromise and modify treatment plans to account for the realities of the external environment (ie, staff/equipment availability, organizational/procedural priorities). This possibility suggests that physical therapists are acutely aware of the barriers that limit their clinical decision making.50 However job dissatisfaction may result when physical therapists feel constrained from maintaining desired standards of care. Lopopolo51 found that where environmental changes reduce professional autonomy, physical therapists may become discontented and less committed to their job and organization. The review findings were supported by previous studies, where health care professionals acknowledged difficulties working in acute hospitals due to the presence of overarching rules, defined cultures, lack of funding, and staff shortages.3,36 In particular, the lack of professional autonomy for physical therapists is clearly a significant issue that warrants further investigation.19,22,52
Investigating the understanding of the physical therapy role by other health professionals in acute care (ie, medical and nursing) may be important in understanding role credibility and acceptance53 and the concomitant autonomy (or lack thereof) that physical therapists experience in acute care. The lack of awareness of the scope of physical therapy may be affected by it being amalgamated into the generic “allied health” sector, particularly where physical therapists are managed by staff who are not directly aligned with the profession.36 It is possible that increased awareness of the critical role of physical therapy within the health care team may lead to mutual respect, better interdisciplinary communication and teamwork, increased understanding by patients and their families regarding the importance of physical therapy, and ultimately better patient care. Future studies should focus on clarifying health professionals' perceptions of the physical therapy role to further address enablers and barriers to improving its acceptance.
Physical therapists' experiences in acute care also were influenced by their years of clinical experience. Novice physical therapists felt less confident about their decision making compared with their more experienced counterparts and have a less defined sense of professional identity as they struggle to determine or discern their own role within the team, as well as the roles of other professionals. The accompanying self-doubt leads to an increased dependence on more experienced peers to agree with their decisions about treatment. As novice physical therapists have fewer past clinical experiences to assist them in approaching multifaceted decisions, they tend to rely on “textbook” approaches and standard workplace procedures. In contrast, more experienced therapists tend to be more creative in “manipulating” and making use of their environment to treat patients with complex conditions. These differences affect novice therapists' capabilities to cope in acute care. The transition from novice to experienced practice lies partly in the motivation of the clinician to learn and to undertake reflective practice. Reflective practice, which is the ability for a practitioner to notice how he or she is acting or thinking and then intentionally alter how he or she subsequently acts,54 is a part of health professional practice and professional practice development.55 It seems reasonable to suggest that, in general, novice physical therapists require more reflective practice than their experienced colleagues, yet may lack the skills to do so. Additionally, reflective practice, like all forms of self-evaluation, takes time,56 which was in very short supply in some clinical settings. Potential strategies to mitigate the negative effects of this transition in the profession include scheduling short but regular time away from the clinical environment, with directed opportunities for novice physical therapists to set and review learning goals, thereby encouraging and scaffolding reflective practice. Another possibility is to clearly outline expectations for specific tasks, which may assist novice therapists in understanding the job roles required of them, thereby removing the fear of the unknown. Recent examples of documents outlining such expectations include vocational checklists for specific interventions57 and the development of minimum clinical standards of practice to facilitate training and practice expectations.22
Implications
Supervisors and hospital managerial staff may use these findings to improve the desirability of acute care positions, reduce burnout, and attract and retain staff. Although there may be aspects of the environment that are difficult for physical therapists to manipulate (ie, overarching regulatory or insurance requirements), external advocacy by professional bodies for physical therapists working in acute care is essential, along with internal advocacy by physical therapy leaders in acute care hospitals. Continued development of the evidence base to demonstrate the effectiveness and cost-effectiveness of the role also is essential, particularly in the context of patient outcomes and organizational priorities, such as length of stay and other quality indicators, in acute care hospitals.58 Employment of additional support staff, such as allied health assistants, may help support the physical therapy workforce in managing workload demands and staff shortages.59,60 Innovative solutions, such as new models of care61,62 and other interventions to understand and address culture change, may be important to consider,50 especially as funding and workload pressures are likely to continue to increase in the future.3,59,63 Physical therapist managers and staff also may need to take more responsibility for internal workload management, such as introducing better triage, prioritization, and referral tools37,64,65 and minimizing documentation requirements and unnecessary meetings, to allow physical therapists more time for direct patient care. Increased engagement with the health care team also is important—for example, negotiating with medical and nursing staff to ensure that pain and other medications and other care interventions are delivered in a timely fashion to facilitate physical therapy intervention. Requiring these types of skills as part of practice standards may positively influence their development.22
Managers must understand the positive influence of strong and collegial interprofessional relationships43 and social support28 on staff experiences, particularly as many physical therapy departments may be physically and professionally siloed in acute care. Strategies to encourage integration of physical therapists within their ward environment and team, such as attending journal club meetings, ward meetings, and social events, may be beneficial. Development of physical therapists as individuals also appears to be important. Strategies such as providing training programs to help staff cope with stress or to develop and improve communication and negotiation skills may be beneficial,52 along with access to professional development and research.66
Clinical and professional supervision are recent innovations to physical therapy departments,29,67 although until their efficacy has been clearly established,68 caution should be exercised in widespread implementation. Early monitoring for burnout and intervention also may be important in retaining staff. For novice physical therapists, a buddy or formal mentoring program, along with clearer expectations of job roles and performance standards, could be implemented to better support them in their transition to experienced clinical practitioner.57 However, for effective use, care must be taken to ensure that novice physical therapists understand that senior mentors are a source of support, rather than assessors of performance.69 This review did not identify any substantive comparisons in experiences between novice and senior or expert physical therapists, and such comparisons may be valuable in understanding retention and staff development in acute care. Moreover, the scope of the review did not allow for investigation of interventions designed to support or improve the experiences of physical therapists in acute care; therefore, the potential strategies suggested above require robust evaluation of their effectiveness prior to recommending widespread implementation.
Better definition of the scope of practice and role of physical therapy across the spectrum of practice in acute care, such as recently developed in critical care,22 may assist in clarifying the role for both physical therapists and other multidisciplinary team members. Such role definition and clarification may help minimize conflicts over scope of practice. Further development of extended scope or advanced practice roles may clarify roles and provide a platform for advocacy and continued development of professional credibility, which may aid professional autonomy.22,53,70 However, preserving scope and autonomy may increasingly be difficult as emphasis shifts to transdisciplinary roles71 in the setting of constrained funding and resources.3,29,43
Future studies could explore perspectives and understanding of the acute physical therapy role of other health care professionals working in this setting and the experiences of physical therapists working in other clinical settings. Comparisons could be made with the findings of this review to determine distinctive characteristics associated with each multidisciplinary team member or physical therapy setting (for example, musculoskeletal inpatients versus the intensive care unit). Interprofessional and interdisciplinary training and education72 may be a useful method of developing interprofessional cultural competence73 in the acute care setting to assist in developing such understanding. Perceptions of undergraduate students' experiences working in acute care also could be explored, particularly in countries such as Australia, where most clinical placements occur in the acute care setting.74 Similarities and differences between student and novice physical therapist experiences could be compared to explore how beliefs and attitudes about acute care develop. Future interventional studies testing strategies such as those suggested previously to improve the experiences of physical therapists working in acute care also should be conducted.
Limitations
Qualitative synthesis uses interpretative methods to analyze findings, which makes it necessarily subjective; therefore, reproducibility of findings cannot be ensured.75 Moreover, the process of grouping common themes from different studies may decontextualize the findings.76 Hence, data extraction tables include participant and setting characteristics so that readers themselves may interpret the context. In addition, a second reviewer verified themes to improve the validity of findings.
The total sample size of physical therapists represented by the included studies was small at 81 participants. Although, from a qualitative research perspective, this may be a sufficient sample, given that the total estimated full-time staffing in tertiary acute hospitals in Australia alone is at least 1,500,77 care should be taken in considering the implications of the qualitative synthesis for local environments. Five of the 8 studies reported data saturation, a condition whereby further data collection would not alter the analysis. However, achieving data saturation within a qualitative synthesis of qualitative findings is not as readily ascertained, as this implies that “no new findings would emerge in subsequent results sections.”78 Although there was a significant overlap of themes from the included studies, there was a sense that further studies in alternative contexts might yield additional perspectives.
The review findings may not be transferable to all health systems. Physical therapist practice varies among different countries, as each is suited to “meet the needs of a specific country's citizens” and its political environment.79 For example, physical therapy referral in critical care in the United States is frequently physician-initiated in comparison with automatic routine referral for all patients, which exists in many intensive care units in Australia.21 The term “acute care” also encompasses many wards that differ significantly in terms of operations and regulations. For example, the average length of stay reported in acute care for 15 different countries varies between 4.5 and 12.0 days.80 However, in the United States, Australia, and Canada, the average length of stay of patients in the emergency department is less than 10 hours.81–84 Thus, this review's findings may not be transferable across all wards.
In conclusion, this systematic review identified 4 key themes associated with physical therapists' experiences of working in the acute hospital setting: environmental factors, communication, the physical therapist as a person, and professional identity. Environmental factors in the acute care setting can affect the decision making, reasoning, and emotions of physical therapists. Physical therapists must be able to communicate effectively with their patients and work colleagues. Furthermore, physical therapists feel that they need to identify their role to other health professionals to minimize unnecessary or artificial constraints to be able to treat all patients who may benefit. Investigations of the perspectives, understanding, and experiences of the physical therapy role should be considered in future studies.
Appendix 1.
Search Termsa
a Terms in each column were combined with OR. *=truncation; adjn=terms are near each other by n number.
Appendix 2.
Example of Search Strategy (MEDLINE via Ovid, 1946 to May 2014)
Appendix 3.
Quality Assessment Toola
a Adapted from Walsh and Downe,41 2006. Y=yes, N=no, NA=not applicable.
Footnotes
All authors approved the final manuscript. Ms Lau was involved in study design; performed the searches, screening, data extraction, analysis, and interpretation; and completed the initial draft of the manuscript. Dr Skinner (guarantor) was involved in study conception and design, screening, data extraction, and interpretation and reviewed the manuscript for intellectually important content. Ms Lo was involved in study design, screening, data extraction, and interpretation and reviewed the manuscript for intellectually important content. Dr Bearman was involved in study conception and design, screening, data extraction, analysis and interpretation, and reviewed the manuscript for intellectually important content.
The study received in-kind support from the departments of physical therapy at Monash University and The University of Melbourne and from the HealthPEER Department of Monash University. No formal funding was received.
- Received May 4, 2015.
- Accepted March 10, 2016.
- © 2016 American Physical Therapy Association
References
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