Abstract
Background Physical therapist practice in the acute care setting is not thoroughly understood, and it has been argued that skilled care is not required.
Objectives The objective of this study was to describe the role of physical therapists, the clinical reasoning processes used by physical therapists, and the context for providing physical therapy services in the acute care setting.
Design A convenience sample of 18 physical therapists working in 3 academic medical centers in the United States was included in this qualitative study with grounded-theory methods.
Methods Semistructured interviews were conducted. Transcripts were coded, and a constant comparative process of analysis was used to determine common themes. A theoretical model was derived.
Results Eight themes were identified: collection and analysis of medical information, application of specialized physical therapy knowledge, communication to gain information, communication to provide information, continual dynamic assessment, professional responsibility, complex environment, and decision making for patient care. Among the limitations of this study were that the sample and method limited the generalizability of the findings, the participants were not observed in their practices, and researchers' preconceived views may have influenced the interpretation and derivation of themes.
Conclusions Physical therapists in the acute care setting used clinical reasoning that required the ability to integrate medical information with physical therapy knowledge. Clinical reasoning required continual dynamic assessment of patients in a crowded, complex, fast-paced environment and resulted in rapid decision making. Constant communication with many people was critical to the process. The major concerns for physical therapists in the acute care setting, like physical therapists in other settings, were patients' mobility and safety. The goals were an optimal plan of care and an appropriate discharge setting for each patient. The therapists' roles reflected professional core values applied in ways unique to the acute care setting.
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| acute physical therapy care |
The American Physical Therapy Association's annual Rothstein Debate in 20071 revealed various thoughts and opinions regarding the role of physical therapists in acute care settings. Although many participants engaged in the debate believed that it was clear why physical therapists should provide care in hospitals, many noted that the role of physical therapists in acute care settings was not clearly understood by others and that physical therapy might be overutilized or underutilized. Some participants suggested that ambiguity about the role of physical therapists in acute care settings might be partially attributed to shortfalls in education, whereas others discussed the possibility that physical therapists were simply not being asked to practice at a high skill level in those settings. What emerged from this debate was a sense of the need to better define and describe the role of physical therapists in acute care settings, to educate patients and other health care professionals about the scope of practice, and to advance the understanding of patient outcomes attributable to physical therapy management in acute care settings. Physical therapists at the 2007 Rothstein Debate provided only anecdotal evidence in support of their work, noting that they observed patients getting better and leaving the hospital every day.
The acute care setting is characterized by short patient stays brought about by 2 decades of changing economics in the US health care system. These changes have demanded increased efficiency and effectiveness of patient care and have resulted in both fewer physical therapy sessions for patients and changes in the types of goals set for an episode of care.2 Such changes in practice have given rise to the question of whether physical therapy is valuable in such a limited time frame. Indeed, in the context of so many interventions from various health care providers in the acute care setting, one might ask how much patient improvement can be attributed to physical therapy alone. There appears to be little information describing the distinctive knowledge and skills that physical therapists use in the care of patients in the acute care setting. Furthermore, as evidenced by comments at the 2007 Rothstein Debate, physical therapists are aware of the perception that patient care in the acute care setting does not require skilled, professional physical therapy personnel.1
Skilled services imply a need for complex and sophisticated reasoning and decision making that can be accomplished only by people who are educated as physical therapists. Several recent studies described various aspects of physical therapy practice in the acute care setting that suggested this high level of problem solving. In 2003, Jette et al3 described the decision-making processes of both physical therapists and occupational therapists as related specifically to patient discharge recommendations in the acute care setting. In that study, the process of decision making appeared to require high-level thinking to draw conclusions by analyzing and synthesizing findings related to patients' activity and participation restrictions, needs and wants, life context, and ability to participate in therapy. A more recent study describing the content of physical therapy services in 3 academic medical centers in the United States in 2008 indicated that practice centered on identifying and managing limitations in function, on educating patients, and on discharge planning.4 A study published in 2010 reported a lower incidence of hospital readmission for patients discharged to settings recommended by physical therapists than for patients discharged to settings not in concert with physical therapists' recommendations, suggesting the importance of physical therapists' input in outcomes for patients.5 However, these studies did not explore the clinical reasoning processes that physical therapists used in managing their patients' overall care during acute care stays. Additionally, the role of physical therapists and the context of their practice were not investigated. A recent study described the broad characteristics of physical therapists' clinical decision making in the acute care setting,6 but that study was limited to physical therapists providing cardiorespiratory care in Australia. The purpose of the qualitative study reported here was to expand the breadth of understanding of the role of physical therapists, the clinical reasoning processes used by physical therapists, and the context for providing physical therapy services in the acute care setting.
Method
Design
Qualitative research methods with a grounded-theory approach were used. This design engaged participants (physical therapists) in describing, interpreting, and analyzing various aspects of their clinical practice. Grounded theory is based on a method of systematic collection and analysis of qualitative information with the purpose of generating a theory that explains a social or psychological phenomenon.7 Using the participants' perspective, investigators attempt to explain how people in a specific setting understand, take action, manage, and interact in day-to-day situations. A guiding assumption of grounded theory is that there is a “basic social psychological process” that members of a group use in resolving a specific problem.8
Participants
A purposive sample of 20 physical therapists practicing in the acute care setting at 3 academic medical centers in the northeastern United States agreed to participate in this study. The facilities are described in Table 1. Participants signed informed consent forms approved by the Committee on Human Subjects at the University of Vermont and their own institutions, if required. This was a convenience sample based on the principal investigator's acquaintance with managers at the 3 academic medical centers and their willingness to facilitate the study. Data were available from 18 of the 20 physical therapists who initially agreed to participate; 1 therapist was unavailable during the data collection period, and 1 therapist could not be reached. The participants are described inTable 2.
Table 1.
Facility Characteristics
Table 2.
Participant Characteristics
Procedure
Semistructured interviews were conducted via telephone or in person, depending on the availability of participants and researchers. One interview was conducted with each participant. Each interview was recorded with a digital voice recorder and transcribed verbatim by the investigators. Before the data collection period, we compiled a list of potential questions to ask the participants (Appendix). The questions were derived from information in the literature that suggested the types of decisions made by physical therapists and their roles in the acute care setting.3–6 However, consistent with grounded theory and to limit our biases, we completed a relatively superficial literature review.9(p32) During the analysis of data, we conducted a more thorough literature review in an attempt to find and explain links between the existing literature and the themes emerging from our work.9(p32) The questions also were derived from anecdotal information from physical therapists who worked in the acute care setting and who described their approaches to patient care and the changes that they had seen in their practice settings in recent years.
The process of questioning was designed to facilitate deep discussion and provide rich descriptions of the clinical reasoning processes underlying physical therapists' decisions and actions, the context or environment in which they practiced, and their perceptions of the roles that they played in their practice settings. That is, questions were designed to elicit more than simple “yes” or “no” responses, and follow-up questions were asked to solicit details to enhance the initial answer to a question.10(p94) Participants controlled the flow of information so as to limit the extent to which the interviewer led the discussion. For example, we asked participants what criteria they used to decide whether a patient received physical therapy service. If a participant said that he or she first determined whether a patient was medically stable, then the interviewer asked the participant to talk more about what medical stability meant and how to determine medical stability. If a participant mentioned that his or her management of patients' mobility was different from that of nurses, a follow-up question might be, “Tell me a bit more about those differences.” The order of questions and the specific wording varied on the basis of the dialogue during the interview and follow-up questions. The interviews lasted, on average, 1 hour.
Analysis
As the interviews proceeded, a constant comparative process was used: we read transcripts, labeled text, and met weekly to analyze and discuss interview content and strategies, adjust questions, and determine emerging concepts and themes.8,11 Through this process, we refined the interview questions to better address the overall purpose of the investigation. For example, when a new concept was mentioned by a participant, we discussed whether the concept required more explicit exploration with subsequent participants. In addition, we read each transcript and critiqued the interview to identify ways in which subsequent interviews could be improved to provide additional detail and depth of information. The constant comparative process ensured the saturation of data. This process involved reading each transcript as it was produced and discussing the connections among statements made by the participant during the interview and the similarities and differences between the information provided during the interview and the information obtained from previous transcripts. At each reading, we identified words, phrases, and concepts that were reiterated as well as newly expressed ideas. This process led us to decide what, if any, additional information we wanted to obtain from subsequent interviews and how to phrase questions to solicit the desired information.11 We determined that no new participant recruitment was required when it became evident that no new information was emerging from interviews with the 18 participants.
When the interviews were completed, we searched the transcripts for the prime indicators of various concepts, confirming or disconfirming our original labels and determining whether all concepts had been discovered. Meetings progressed through an iterative process in which themes were proposed; debated to determine overlaps, gaps, clarity, and relationships with one another; and then revised. Once the general themes were agreed upon, their specific titles and definitions were determined through an iterative process of proposal, debate, refinement and, finally, group consensus. We then reassessed the transcripts to confirm or refute the themes that were agreed upon. We also sought to compare themes within each setting and across settings.11Next, we selected specific quotations that supported and best exemplified the themes. Using the themes and their hypothesized relationships, we developed a working theoretical model to describe the decision-making process, the role of physical therapists, and the context for providing physical therapy services in the acute care setting.
After we defined the themes and developed a working theoretical model, we summarized the themes and their meanings with supporting quotes and provided this material to participants for their review.12(pp275–276) Participants were invited to confirm, refute, elaborate on, or suggest edits for the themes and the meanings that we had assigned. This process of member checking was conducted to ensure that none of the participants' responses was misinterpreted or omitted and, most importantly, that our interpretations were viewed as being accurate. Sixteen participants responded, and their feedback largely confirmed the themes that we had identified. Three provided suggestions for further refinement of the theme definitions, and these were incorporated. Finally, an expert qualitative researcher who was not one of the investigators was asked to review the participant transcripts, themes, and the model.12(pp281–282) She provided feedback about the relationships of the themes and suggested 1 additional theme that was incorporated into the model.
Results
Eight themes that described the clinical reasoning processes used by physical therapists, their role, and the context for providing physical therapy services in the acute care setting were identified.
Core Constructs
Four themes—collection and analysis of medical information, application of specialized physical therapy knowledge, communication to gain information, and communication to provide information—suggested the fundamental core from which clinical reasoning proceeded during each encounter with a patient as well as over the entire episode of care.
Collection and analysis of medical information.
Participants stated the need to collect and reflect on medical information as an important first step in analyzing the appropriateness of therapy for a patient. Their approach to securing this information was characterized by statements such as the following: “I look at the chart to determine if I think that they are medically stable for PT [physical therapy]” [stated by participant 7 (PT-7)] and “If a person's hematocrit is very low, then we may want to wait until they get a blood transfusion” (PT-9). Participants also used medical information to formulate an overall image of a patient's presentation and what their approach to patient care might be before they met the patient: “You start making decisions from the minute you start looking at the chart” (PT-14). Participants expressed the need to apprise themselves of diagnostic test results, imaging reports, surgical procedures, and other data that might indicate activity precautions, such as weight-bearing status, blood pressure, heart rate, and oxygen saturation. They also identified the need to understand the implications of these data for their selection of interventions as well as the patient's ability to participate. One participant stated, “I look through those lab values looking for any trends and sort of start building a picture of what this person looks like” (PT-13). Another said, “If we get somebody for chest PT, I usually look at whether they have lab tests that would indicate that they have an infection” (PT-5).
Application of specialized physical therapy knowledge.
Participants reported the importance of their expertise in mobility and movement dysfunction in the care of patients: “We're the experts in mobility and safety from a mobility standpoint. So, we're consulted in order to give our opinion on a patient's ability to move and function” (PT-4). This specialized knowledge is used to create a plan of care and to inform prognosis. Participants also described physical therapy–specific knowledge about a patient's movement gained and applied during a treatment session. Participants noted that physical therapists are concerned with the quality, efficiency, and functionality of movement, not just the ability to move. For example, when informed by a nurse that a patient had gotten out of bed and “walked around,” a participant noted, “I want to see what that ‘walking around' means. I want to see the quality of it” (PT-5).
Participants believed that their knowledge and skills in this area were unique and essential to the role that they played in the acute care setting, noting physical therapists may be the only providers asking questions such as, “…can they move in bed, and do they do safe transitional movements? Do they need an assistive device?” (PT-17). Participants noted that their specialized knowledge about movement and function was what separated them from nurses or technicians who might walk up and down a hallway with a patient for the sake of getting the patient out of bed. One participant described this difference as follows: “A nurse might just look at a patient and see them walking, but a PT [physical therapist] might look at a patient and see subtle differences in their gait and step length and stride and be able to assess that in connection with their safety and baseline” (PT-2). Another participant described physical therapists' distinct role in facilitating patients' independent mobility: “I think that the nurses…tend to do more for the patient than the patient may actually need, whereas we go in with the mind-set of letting the patient do as much as they can on their own” (PT-4). Participants believed that their specialized knowledge and focus on safe, effective, and independent functional mobility were what made physical therapists' role in the acute care setting unique. Put succinctly by one participant, “I don't think anyone has the training we have as far as movement dysfunction” (PT-2).
Communication to gain information.
Participants noted that they perpetually acquired information about their patients from a number of sources. Physical therapists routinely spoke with patients, families, and team members such as nurses, physicians, and case managers to collect information regarding patients' status and progress: “I may go up and verify with the nurse what the patient is actually doing. I may call the resident and…I'll talk to the patient” (PT-14). Speaking with nurses and physicians to gain information about a patient's status and progress since the previous session was thought to be essential to efficient and effective care.
Gaining information from patients and family members regarding the living situation and the amount of assistance a patient would have at home influenced the interventions selected during the course of the patient's stay in the acute care setting, as well as discharge planning: “We want to know about their previous level of function. We want to know their home environment and how their home setup is. We want to know their equipment needs” (PT-12). Similarly, another participant stated, “I need to know from the family, ‘How much support are you capable of providing?'” (PT-11).
Communication to provide information.
In addition to acquiring information about their patients, participants consistently spoke with patients, families, and team members to report patients' status and progress. Participants agreed that it was important to keep the patient and the patient's family informed of progress being made in therapy, short-term and long-term goals, and the physical therapist's recommendations for placement after acute care: “I'll say to them, ‘Based on how you performed today, I think you'll be able to go home from here' or ‘I think you'll need to go to rehab'” (PT-7). Participants expressed the need to provide nursing staff with information about a patient's progress, especially if anything significant changed: “I would also check in with the nurses to let them know how the patient performed and alert them to any changes in blood pressure, heart rate, oxygen level—let them know if I weaned the patent off of oxygen, anything like that” (PT-7). Participants believed that it was necessary to provide nursing staff with information to help them understand a patient's functional abilities and allow nurses to continue the mobility plan that the physical therapist had recommended: “[I] let them know how a patient did with us so that they can carry it over or [tell them] how they can help the patient back to bed” (PT-16).
Participants reported the need to speak with physicians and other members of the health care team. As one participant noted, “It takes communication because maybe the medical doctors think someone will be able to go home but then they don't progress as well….” (PT-12). Another participant said, “I'll also check in with the case manager, so that they can start planning” (PT-7). In general, the participants believed that their communication was valued and respected and that they were consulted and asked for their opinions about patients' status and needs. As noted by one participant, “[Some physicians] will call you specifically, ‘You were a great help with this last patient. What do you think about…?'” (PT-18). Participants also indicated that communication with physicians was required if anything was unclear or if “red flags” appeared during therapy. One participant described a situation in which he was asked to provide a quick safety screen before a 40-year-old patient who had fallen was sent home from the emergency department: “Her reflexes were inconsistent from right lower extremity to left lower extremity. Her coordination was off; her proprioception was off…taking one step forward, she completely lost her balance. I gave the doctor all this data. I said she needs a neuro consult. She had a CT [computed tomography] scan, and she had multiple sclerosis” (PT-17).
Encompassing Constructs
Three themes—continual dynamic assessment, professional responsibility, and complex environment—encompassed and incorporated the fundamental core, suggesting the influence of perceived role and environment on clinical reasoning processes.
Continual dynamic assessment.
We conceptualized continual dynamic assessment as on-the-spot, reiterative clinical reasoning. Continual dynamic assessment involved a within-session, moment-to-moment process of recurring evaluation, adaptation of interventions, and adjustment of goals as a session proceeded and a patient responded to an intervention. It required analysis of medical data, use of specialized knowledge, and integration of information gleaned from reading a medical record and from communication with the patient and other health care team members. Participants noted the need to continually monitor their patients and assess their physiological responses throughout each treatment session regardless of the severity of their conditions. As one participant explained, “I look at heart rate response to exercise,…blood pressure response,…oxygen saturation,…balance, and RPE [rate of perceived exertion]” (PT-11). Participants explained that they needed to be ready to make quick decisions about alterations in their care at any given time, depending on how a patient was reacting: “When you're [with the patient] you're always thinking about should I proceed to the next step, physiologically? Where to stop, when to stop, or how can I proceed safely?” (PT-5). Participants also described a similar session-to-session process of recurring evaluation to determine goals as well as types and intensities of interventions, asking the question, “Do I need to modify what I'm doing?” (PT-14). One participant gave an example of this process when revisiting one of her patients: “Her sats (oxyhemoglobin saturation) were only 92%, and so I thought that was a little bit odd.…So that made me think, ‘I'm going to make sure I check her breath sounds'” (PT-2).
Professional responsibility.
Participants described to us a strong sense of professional responsibility to their patients, coworkers, and institutions and to the profession as a whole. This sense of responsibility defined their roles and influenced the way in which they collected and used information, their communications with others, their clinical reasoning, and the decisions they made. We conceptualized professional responsibility as exercising professional expertise to advocate for patients and contribute to the quality of patient care. Participants upheld this responsibility through various means, including maintaining standards of practice, educating others about their practice, providing education to other health care professionals to enhance their safety, and advocating for the best patient care and outcomes.
Participants viewed maintaining competence as a way in which to promote professional responsibility: “Our job requires us to maintain professional competence and our professionalism, and part of that is maintaining our knowledge” (PT-13). Participants also noted the obligation to use evidence in practice to uphold standards and provide the best care for their patients: “I think everything should be evidence based. That's the only proof that we have that certain things are effective” (PT-3). The same participant went on to say, “I try to cite evidence from the literature in my assessment statements supporting my prognostic indicators or my discharge plans as often as I can.”
As part of their professional responsibility, participants noted the need to contribute to high-quality care. For example, participants described developing standards of care for patients: “We have a patient care standard for pretty much every single thing that we do…updated with [supporting] literature” (PT-4). Participants also described physical therapists' roles in providing care through clinical pathways for some types of conditions. In other cases, participants noted following physician-driven protocols for certain types of conditions. It was not clear whether physical therapists had input into these protocols.
Participants also demonstrated an awareness of their accountability for good outcomes for patients: “Basically you don't [want to] end up with somebody who's disabled because we didn't move them when we could have” (PT-5). High-quality care also meant ensuring that skilled and appropriate physical therapy care was delivered. This responsibility included making decisions about which patients should receive physical therapy services and how best to provide that care. 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” (PT-2). Another participant noted, “Sometimes we get more consults than are necessary because people kind of see us as, you know, ‘you call, we haul'” (PT-5).
Participants indicated that the scope of practice for physical therapists was not understood by health care team members, possibly because of the discrepancy between what it looked like they were doing with patients and what their treatment sessions actually involved: “I think that sometimes other health care professionals underestimate what we do because I think we make it look easy” (PT-5). “Interns and residents think our role is purely just walking, as opposed to doing true assessments of gait, of balance, of mental status, of safety” (PT-10). Participants believed that these situations were opportunities to uphold their professional responsibility by educating others about the role of physical therapists and how and when to utilize their services: “What we should be doing if we get an inappropriate referral is trying to track down the resident…and helping to educate them” (PT-15).
Participants discussed another component of professional responsibility as advocating for patients' best interests, even if their professional recommendations differed from those of physicians: “If you feel strongly about it and you feel it's important for your patient, you'll advocate for it regardless of the response that you're worried about getting” (PT-18).
Physical therapists' responsibilities were also noted to include contributing to the safety of health care team members through education about mobilizing patients. As noted by one participant, “After we evaluate their mobility, we're going to make recommendations for the nurses on how we think it's safe for them to be mobilizing the patient” (PT-2). The same participant continued, “That's kind of our job to make sure that the patient is safe and that the nurses are safe helping them mobilize.”
Complex environment.
Participants described the acute care setting as a complex environment characterized by a fast pace, multiple interactions, ubiquitous high-tech equipment, and the precarious nature of patients' health and physiological states. The environment influenced all aspects of physical therapy care in the acute care setting as well as the roles and responsibilities of the physical therapists working in it. The environment required the understanding of medical information and the application of specialized knowledge and dictated the need for continual and rapid assessments: “In this environment some of the decisions are life and death. You could make a clinical decision that literally could kill somebody. So, you have to understand the equipment, the bolts, the drains, the lines, the science behind things” (PT-16). Some examples of situations in which participants needed to make critical decisions included recognizing worsening of mental status as potential recurrence of hemorrhaging in the brain, recognizing abnormal neurological findings that physicians had not noted, understanding the need to defer treatment when blood pressure was unstable, and knowing precautions for avoiding negative effects on surgical procedures.
Participants noted that decisions about patient care were made much more quickly and that the total time frame in which they cared for an individual patient was much shorter than in other practice settings: “I need to be able to make decisions much quicker and be able to anticipate the patient's progress much quicker” (PT-7). With regard to deciding the most effective interventions for a patient, one participant stated, “You have such a short time with patients that it's really, ‘OK, what are the big bangs for today?'” (PT-18). We also heard participants say that they were working within a crowded and physically complex space to deliver care for patients: “It's moving them safely with all the lines and the tubes and the monitors and making sure we don't dislodge stuff” (PT-5). At the same time, participants remarked that, unlike physical therapy in other settings, physical therapy in the acute care setting must have a multisystem focus. That is, participants' concerns were never limited to 1 body part or system but revolved around patients' overall function and physiological state: “We're trying to prevent…range of motion issues…skin breakdowns…pneumonias…severe deconditioning” (PT-5).
Participants noted that providing patient care in this complex environment required they have not only effective communication skills but also an ability to adapt those skills to interact with a large number and a wide variety of people throughout the day: “So, [I do] a lot of communication with other health care providers…we work with the team…MDs and the nurses…and care coordinators” (PT-12). Additionally, communication was viewed as being critical to the safety of patients in an environment in which patients' physiological status could rapidly change. Participants perceived the level and diversity of communication as being much different from what occurs in other practice settings.
Result of Clinical Reasoning: Decision Making for Patient Care
Decision making for patient care involved formulating and executing an optimal plan of care on a moment-to-moment, within-session basis as well as over the entire episode of care. Our participants described fulfilling their professional role and responsibilities and using continual dynamic assessment while integrating the information collected from the medical record, from the patient examination, and from communication with various parties to develop the best plan of care: “There's a lot of thinking [about] what the doctors want, the nurses want, and the patients want…and trying to combine all that into what the therapist needs to be able to do” (PT-8).
Decision making appeared to take 2 forms. One form we labeled as micro-level decision making. We defined this type of decision making as a minute-to-minute and day-to-day process. Micro-level decisions included within-session decisions regarding the content of examinations, intensity of exercise, or duration of session and between-session decisions about frequency of treatment. As an example, one participant said she might, “[ask a patient about] lightheadedness, any increase in pain, any shortness of breath, [then] retak[e] vital signs, assessing his sitting balance while he's there. If he's ok, then we move on; if he's not, then we can always lie back down” (PT-8). Another participant discussed this type of decision making as it related to considering the impact of patients' medications after cardiac surgery on her management decisions: “If they're requiring blood pressure support with pressor medications, then I'm probably not going to see them,…. I would be cautious of a patient [who] was requiring medication to control chest pain. [These situations] would indicate that they're not hemodynamically stable and they might require further medical or surgical intervention” (PT-11).
We labeled a second form of decision making as macro level. We viewed this form of decision making as a process related to longer-term goal setting and discharge planning. At the macro level, the major focus of participants' decision making was determining goals that supported discharge plans and moved patients toward leaving the hospital. Macro-level decision making was based on the “big picture” and went beyond patients' stays in the acute care setting: “I see us as sort of being the triage system for all of the other therapies that they may need when they leave. We're going to plan out [the patient's] rehab process from our first initial meeting with him until the planned discharge day” (PT-13). Participants indicated a broad range of factors considered in macro-level decisions: “It depends on the diagnosis, it depends on discharge plan, also what their status is at the time of the evaluation and what their status was prior to coming in” (PT-16). Finally, participants emphasized the importance of macro-level decision making, particularly in relation to recommendations for discharge planning: “Most of the medical team leans on us to make a decision whether a patient can go home or go to rehab to get their process moving” (PT-4). “We're widely respected as far as our input…they want us to make an assessment to say where does this patient need to go” (PT-17).
Discussion
Theoretical Model
Eight themes described core elements necessary for clinical reasoning and its reiterative quality, the environment in which clinical reasoning was accomplished, the results of the clinical reasoning process, and physical therapists' perspective on their role in the acute care setting. The theoretical model shown in the Figure represents the themes and their relationships and interactions. The complex practice environment interacted with participants' sense of professional responsibility and shaped their clinical reasoning processes and their decisions regarding patient care. As evidenced by the descriptions of our participants and as noted by Edwards and Jones,13the process of clinical reasoning was influenced by the larger social context, that is, shaped by the environment and the perspectives and values of the physical therapists working in the environment.
Figure.
Theoretical model.
Although an episode of care in the acute setting has a well-defined beginning and end, our model suggests that participants did not view their care of a patient as a linear, stepwise process leading from admission to discharge. The process required continuous, repetitive clinical reasoning and decision making and a willingness to change a plan instantaneously during a single treatment session as well as across the episode of care. The process continued until the ultimate patient outcome in the acute care setting: discharge to the next, appropriate level of care. Similarly, Smith et al,6 in describing decision making by cardiorespiratory physical therapists in the acute care setting, and Edwards et al,14 in describing the clinical reasoning of orthopedic and neurologic physical therapists in private practice and physical therapists in home health care settings, found that the processes were multifaceted, complex, and cyclical in nature.
Core constructs.
We found 4 themes at the core of the clinical reasoning process in the acute care setting: (1) collection and analysis of medical information, (2) application of specialized physical therapy knowledge, (3) communication to gain information, and (4) communication to provide information. These were the crucial elements of each treatment session and the entire episode of care, and each potentially influenced the others. For example, obtaining information about a patient's medical status from a nurse might lead the physical therapist to attend to certain data from monitoring equipment as he or she analyzed the patient's safety and ability to move from a supine position to a sitting position. Changes in the monitored physiological data during the intervention might then determine the parameters of the treatment session and what was communicated back to the nurse or physician.
Because, by its nature, the acute care setting is one in which patients who are medically unstable are treated, the physical therapists in our study needed to use knowledge about pathophysiology, symptoms and findings related to red flags, treatment precautions and contraindications, pharmaceutical benefits, adverse effects and interactions, and normal versus abnormal physiological responses to movement both before and during treatment sessions. The physical therapists in our study also needed to know the appropriate information to collect to derive an analytically sound plan of care. The physical therapists monitored, quickly interpreted, and responded to various types of data to ensure the safety of their patients. Perhaps not surprisingly, Smith et al6 described similar attributes related to decision making in acute care cardiorespiratory physical therapy, such as the consideration of large amounts of data and the immediacy of decisions. Although Edwards et al14 found that physical therapists in private practice and home health care settings considered tissue pathology in their diagnostic reasoning, there did not appear to be as strong an emphasis on the need to collect and quickly interpret medical information for decision making in other physical therapist practice settings as in acute care settings.14–16
In the clinical reasoning process described by our participants, medical knowledge and specialized physical therapy knowledge interacted in several ways. For example, participants considered how movement might compromise medical stability or how medical conditions or medications might affect patients' physiological responses to movement or compound safety issues. The physical therapists understood, anticipated, and planned for these various possibilities. Once the medical status of a patient was understood and anticipatory preparations were made, the physical therapists in our study used their specialized knowledge and skills to evaluate safety and independence in functional mobility. This approach represented diagnostic reasoning in that it included gathering and interpreting of information to determine the type or extent of a problem.13,14
Most of the information used in this part of the clinical reasoning process was derived from watching patients move and assessing the quality of the movement and the physiological response to the movement. Similarly, Smith et al6 described how cardiorespiratory physical therapists used the response to an intervention to improve their understanding of a patient's condition. Watching patients move has also been shown to be an important source of information for physical therapists' decision making in other care settings16,17 but may focus on impairments in a specific body structure or region.15 The physical therapists in our study were interested in getting patients moving for many reasons, including those that likely are less common in other settings, such as preventing deconditioning, pneumonia, and pressure ulcers related to bed rest. Our participants reported focusing on total body function or broad concerns about health, safety, and mobility; this result confirms the findings of a previous quantitative study indicating that more than 80% of the patients seen by physical therapists in acute care settings had goals and interventions related to function, regardless of the type of diagnosis.4 Similarly, participants in an earlier study examining the changing roles of physical therapists after hospital restructuring noted an increased focus on the functional needs of patients.18
The physical therapists in our study integrated medical information and specialized knowledge in originating bidirectional communications. That is, they formulated questions to gain relevant information from patients and members of the health care team and provided information to them. Participants seemed to view their communications in these 2 forms, each with distinct content and purpose. Their communications formed elements of both diagnostic and narrative clinical reasoning.13,14 In the context of the acute care setting, narrative, or patient-centered, reasoning appears to take the form of understanding the impact of patients' needs and wants, culture, and the social-economic environment on discharge recommendations.3
The physical therapists in our study interacted with physicians, nurses, case managers, and others on more than a daily basis. In other settings, communication with patients both to gain information about their history, goals, and social support as well as to educate them about treatment interventions and options may be similar or identical, but it is unlikely that physical therapists communicate with the number and variety of other health care providers regarding each patient in other settings as they do in the acute care setting. In a study of factors affecting physical therapists' decision making in the long-term-care setting, participants reported consistent interactions with nurses and other rehabilitation colleagues, but other health care professionals were not mentioned in this context.16 Our participants expressed an overall feeling of acceptance by physicians and respect for their opinions and recommendations. This result may represent an evolving and improving role for physical therapists in acute care settings, because at least one earlier study indicated difficult interactions with physicians and the need for physical therapists to develop better communication skills.19
Continual dynamic assessment.
Continual dynamic assessment reflected the highly changeable nature of the physiological status of the patient in the acute care setting. The type of clinical reasoning occurring during continual dynamic assessment was largely diagnostic reasoning.13 That is, during sessions physical therapists observed and analyzed patients' subjective reports of how they were feeling and the function of nearly every body system on a rapid and constant basis, all within the context of the data collected from patients' charts and the other providers on the team. Alternatives or adjustments to interventions and their potential consequences were considered, implemented, or abandoned even as a treatment session progressed. Continual dynamic assessment mirrored the process of reflection in action as described by Schön.20 Similarly, Smith et al6 reported that cardiorespiratory physical therapists revised decisions throughout all aspect of the episode of care and incorporated information about changes in patients' conditions into decisions about interventions. The constant and repeated assessment of the “whole patient” transpired to maintain the patient's safety while working toward improving function and independence and securing the most appropriate discharge setting.
Professional responsibility.
The theme of professional responsibility suggested the framework in which the physical therapists applied core elements of clinical reasoning and engaged in continual dynamic assessment. This theme reflected the profession's core values of accountability, excellence, and professional duty.21Accountability was manifested in participants accepting their diverse roles in the acute care setting, including educating other health care team members about their role, determining whether patients require their care, and working with nurses to enhance their safety. It appears that in the acute care setting, the role of physical therapy can be misunderstood. Participants described having to explain their scope of practice to other providers and having to be proactive in gaining access to patients whom they believed would benefit from their services. We also found that physical therapists believed that it was their responsibility to add to the quality improvement process of the institution to ensure that patients were receiving what they needed during their stays. Fulfilling this responsibility took the form of educating new residents and nurses about when and why to consult a physical therapist and educating nursing staff on how to carry out a patient's mobility plan while maintaining their own safety.
Accountability was demonstrated through participants ensuring that skilled care was necessary rather than, as noted by one participant, allowing physical therapists to function as a “walking service.” The theme of professional responsibility also had elements of the core value of excellence. 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. Excellence also was demonstrated by participants noting the need for ongoing professional development. Finally, the theme of professional responsibility reflected the core value of professional duty. Participants were committed to their ultimate role of advocating for the best interests of patients and providing effective physical therapy services.
Professional responsibility in acute care physical therapy was documented by Lopopolo in 1999.18Participants in her study described the role of physical therapists in acute care settings as including highly integrated clinical reasoning and high levels of communication and collaboration with other health care team members, converging on the needs of patients. Additionally, although the majority of the participants in our study had less than 10 years of experience, on the whole their practice seemed to reflect a feature of expert physical therapists reported by Jensen et al,17that is, patient advocacy accomplished through constant communications with others involved in patient care.
Complex environment.
The complex environment created the overall context within which physical therapists practiced in acute care settings. This theme represents the varied, fast-paced nature of the acute care setting, in which a physically complicated environment is made more difficult by the amount of interfering or distracting activity occurring near the physical therapist-patient interaction. The acute care setting also is an intellectually complex environment, requiring physical therapists to monitor and analyze several different sources of data at once in an often crowded and noisy environment while keeping patient safety paramount. The complexity is compounded by the number of daily interactions with other health care providers. Although not explicitly describing the environment, Smith et al6 reported some of the same features in decision making in the acute care setting as our participants, including criticalness, the changing and evolving status of the patient, urgency, the number of variables, the relevance of all of the available data, and the perceived risks associated with a decision. These features are unlikely to dominate other inpatient or outpatient rehabilitation settings and have not been reported in studies of physical therapists in outpatient and home health care settings.14,15
Decision making for patient care.
In our model, decision making for patient care was the result of reiterative clinical reasoning and took place within the context of physical therapists' professional responsibilities in a complex environment. On the micro level, the decision-making process used in the acute care setting could be likened to knowing-in-action, as described by Schön.20 That is, participants demonstrated flexibility in their decision making; decisions were based on tacit knowledge and intuition and resulted in instantaneous actions. In turn, patients' responses to those actions influenced subsequent decisions. Smith et al6 reported similar features of decision making by physical therapists in the acute care setting.
Macro-level decision making comprised consideration of the whole patient in designing and implementing an optimal plan of care for the episode of care and recommending a discharge setting. Patient care at the macro level included instrumental approaches (selecting and interpreting examinations and interventions) and communicative approaches (addressing the unique perspective of patients, such as fears and expectations).13 Decisions relied on participants' medical and specialized knowledge as well as information about a patient's personal goals and social-emotional status. Participants reported that with a typically short length of stay for their patients, macro-level decision making related to discharge began at the first moment they followed up on a referral. Their initial impressions were subject to change, but the anticipation of a rapid discharge constantly influenced the decision-making processes. Previous studies also cited the important role of physical therapists in discharge planning and discharge recommendations in the acute care setting.4,5,18
Implications for Practice in the Acute Care Setting
Recent research supports the proposition that physical therapists' decision making in the acute care setting has long-term positive effects on patients.5 The results of our study support the important role of physical therapists in the acute care setting. Their knowledge, clinical reasoning skills, decision-making capabilities, and professional responsibilities indicate that physical therapists in the acute care setting provide skilled care that others do not. Our study attempts to articulate the clinical reasoning processes that appear to be simple and second nature to physical therapists in the acute care setting. Foundationally, these processes appear to be similar to those reported in the literature for other physical therapy practice settings.6,13–15,17 Clinical reasoning in the acute care setting, however, appears to have features that are somewhat different from those found in other settings. These features include the constant application of medical information and the integration of that information with specialized physical therapy knowledge; continual dynamic assessment resulting in rapid decision making; a focus on the whole patient and the impact of all physiological systems on the patient's physical function; constant communication with many different people; the application of knowledge of characteristics of various discharge settings; and a crowded, complex, fast-paced environment. However, the major concerns of physical therapists in the acute care setting, like physical therapists in other settings, are patient safety and functional mobility. We believe that this information may be helpful to those who educate professional (entry-level) physical therapist students in preparing them for practice in the acute care environment.
Limitations
The results of our study are not broadly generalizable. We used a convenience sample of participants from 1 geographic area and only 3 different medical centers. Although we found commonalities across the 3 medical centers, the views of our participants and their practice methods may not be representative of those in other medical centers or geographic areas. We also did not observe participants in their practices, relying solely on their perceptions of the content and context of their practices. In addition, researcher bias may have influenced the development of our themes and model. When we asked our participants to review our findings, however, they largely confirmed them.
Future Research
Our model needs to be validated with different groups of physical therapists in the acute care setting because models of practice and roles of physical therapists may vary in different parts of the United States and around the world. Additional areas of research that could be explored include a comparison of clinical reasoning processes and decision making across physical therapy settings. Future research could also include an investigation of why physical therapists choose different settings in which to practice, illuminating key skills and personality traits that may be more suited to one type of practice environment than another and helping students and novices evaluate their career options.
Conclusion
Here we described the role of physical therapists, the clinical reasoning processes used by physical therapists, and the context for providing physical therapy services in the acute care setting. The results revealed that physical therapists used sophisticated clinical reasoning processes that required the ability to integrate medical information with specialized knowledge about mobility and to engage in rapid and continual assessment of patients and their responses to movement. The practice environment was highly complex, involving patients who were medically unstable and were undergoing technological monitoring as well as diverse and frequent interactions with many health care providers. The results demonstrated that physical therapists in the acute care setting aspired to provide the best care for individual patients while assuming some accountability for the overall quality of the environment in which they worked. A contribution was the recommendation of the appropriate discharge setting for each patient. The findings support an important and specialized role for physical therapists in the acute care setting.
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