Factors Determining the Current Use of Physiotherapy Assistants: Views on their future role in the South and West UK Region

Physiotherapy assistants form approximately 20% of the work force within physiotherapy departments and account for a large proportion of the delivery of physiotherapy care. There is great interest in developing the scope of practice of physiotherapy assistants and evidence that this is under way. Little is known about the factors determining use of physiotherapy assistants and their views on their future role. The purpose of this study was to investigate how the role of physiotherapy assistants was changing, identify the factors that affect the development of the physiotherapy assistants' role and determine the views of physiotherapy assistants and physiotherapists on the future work of physiotherapy assistants. Semi-structured interviews were carried out with a stratified random sample of 18 physiotherapy assistants from the South and West Region and separately, with their 18 physiotherapy supervisors. The physiotherapy assistants worked in a range of settings – elderly care, paediatrics, outpatients and primary care. Analysis of the interviews showed that there was variation in scope of activities of physiotherapy assistants and in the level of supervision. Supervision was reduced primarily in particular specialty areas, such as elderly and primary care. Changes were primarily locally determined. A change or shortage of qualified staff was regarded as being instrumental in the development of practice. Training, levels of responsibility and supervision, and the development of generic workers were issues of concern for this changing workforce.     

Role of physiotherapy auxiliary personnel in Nova Scotia: a descriptive survey

This study was designed to gather information and opinion on the impact and role of auxiliary personnel in physiotherapy, in Nova Scotia (NS). The physiotherapist/auxiliary ratio and present and future levels of education, supervision, and activities of auxiliary personnel were investigated. All NS physiotherapists registered with the Nova Scotia College of Physiotherapists (NSCP) were surveyed by mailed questionnaire; one follow-up was sent. Two questionnaires were developed. Potential levels of the terms assistant and technician were defined to facilitate interpretation of the opinion statements. Questionnaire A was mailed to all registered physiotherapists (n = 279, response rate 83%). Questionnaire B was mailed with Questionnaire A to directors and clinic owners (n = 73, 79% response rate). Results showed a physiotherapist/auxiliary personnel ratio (excluding clerical) of 3.75:1. The majority of personnel were trained in-house. There was a trend toward less frequent supervision with more extensively trained auxiliary personnel. More respondents considered that formally trained assistants would best serve the profession of physiotherapy in the future. To conclude, this study adds to the body of knowledge of the Canadian Physiotherapy Association and the NSCP. It should assist the NS Department of Health and Fitness in analyzing needs for training of auxiliary personnel in Physiotherapy, and provide data for future studies.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction. Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims: To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods. 20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results. Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion. Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions. Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

Clinical chemical indexes and severity of coronary atherosclerosis

The present study measured triglycerides (TG), total cholesterol (TC), HDLcholesterol (HDL-C), LDL and LDL/HDL-C, TC/HDL-C and HDL-C/TC. 100 ratios in 261 men and women undergoing coronary arteriography.

The results show that TG, TC, HDL-C and LDL levels are not related to the severity of coronary artery disease (CAD).

The LDL/HDL-C, TC/HDL-C and HDL/TC.100 ratios are statistically related to the severity of CAD.

The LDL/HDL-C ratio appeared to be the most sensitive index for reflecting CAD of mild severity with a predictive value of 83.3% at 76.6% specificity and at 77.7% sensitivity (cut-off: 3.20).

Average values of LDL and HDL-C alone are not reliable indices of mild severity CAD.     

Comparison of Four Methods of Allocation for Clinical Trials with Small Sample Sizes

Although not without critics, randomised controlled trials are the most powerful method of attributing cause-effect relationships between phenomena. Physiotherapy is not immune from the need to demonstrate its effect using this methodology.

Central to the success of trials is the method of allocation used within randomised controlled trials in physiotherapy, which through necessity are small in terms of sample size.

In this study four methods of allocation are used on 48 stroke patients and the results compared. Three of the methods (simple randomisation, minimisation and alternate allocation) showed some form of imbalance. Two of the methods demonstrated potential problems in terms of selection bias (block randomisation and alternate allocation). All forms of randomisation (minimisation, block randomisation and simple randomisation) were capable of adjustment in order to overcome the problems of imbalance and selection bias, whereas problems with alternation did not appear to be redeemable.

The authors strongly suggest that alternate allocation (alternation) is never used in clinical trials.

These findings are pertinent, not only to researchers in stroke, but also to those involved in the design and execution of any randomised trials in physiotherapy and the allied professions.

The conclusions reached in this study should also help readers of randomised controlled studies in assessing the suitability of allocation procedures.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction.?Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims:?To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods.?20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results.?Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion.?Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions.?Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

Job experiences of personal assistants employed in a consumer-directed personal assistance services programs.

The demand for personal assistants for persons with disabilities is outpacing the supply. The objective of this pilot project was to describe the training and supervision needs of personal assistants, the nature of the assistant-consumer relationship, and the job satisfaction associated with being employed as a personal assistant. Telephone interviews were conducted with 24 personal assistants. All of the participants reported being competent and well trained in their work and 79% of the participants reported being very satisfied with their work as a personal assistant. All also reported they had an opportunity to accomplish something worthwhile in their jobs. Participants reported high levels of satisfaction with their relationship with their employers and with their jobs in general, despite dissatisfaction with low wages. Further research is needed to identify strategies for increasing the supply of personal assistants, who are pivotal to helping consumers maintain their independence.     

Is patient responsibility for managing musculoskeletal disorders related to self-reported better outcome of physiotherapy treatment?

Musculoskeletal disorders are prevalent and a major burden on individuals and society. Information on relationships of patient involvement and responsibility to outcome is limited. This study aimed to explore relationships between self-reported outcome of physiotherapy treatment and attitudes toward responsibility for musculoskeletal disorders. A cross-sectional postal survey design was used. Patients (n=615) from an outpatient physiotherapy clinic, who had finished their physiotherapy treatment within the last 6 months were sent a questionnaire that included the Attitudes regarding Responsibility for Musculoskeletal disorders instrument (ARM), self-reported outcome of treatment and sociodemographic data. A total of 279 (45%) completed forms were returned. Multiple logistic regression analysis was used. The patients' scores on the four dimensions of ARM (“responsibility self active,” “responsibility out of my hands,” “responsibility employer,” and “responsibility medical professionals”), controlled for age, sex, education, and physical activity as well as for number of treatments, main treatment, and physiotherapist, were associated with the patients' self-reported treatment outcome. Patients who attributed responsibility more to themselves were more likely (OR 2.37 and over) to report considerable improvement as the outcome of physiotherapy treatment. Because this study was conducted at only one physiotherapy outpatient clinic and had a cross-sectional design, the results should be replicated in other settings. Because patients' attitudes regarding responsibility for musculoskeletal disorders can possibly affect the outcome of physiotherapy treatment, it might be useful to decide whether to systematically try to influence the person's attitude toward responsibility for the management of the disorder or to match treatment to attitude.     

Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand

BackgroundIn Australia and New Zealand, there are currently no recommendations to guide staffing levels for intensive care unit (ICU) physiotherapy services, and there is limited information about the current services provided.ObjectivesThe objective of this study was to document the profile of intensive care physiotherapy services currently offered in Australia and New Zealand.MethodsA binational survey was distributed to physiotherapists. The survey sought information on staffing and service profiles for weekday, weekend, and after-hour services including on-call and evening shifts.ResultsEighty-six sites completed the survey, with responses primarily from Level 3 (47/86, 55%) and public ICUs (74/86, 86%). For weekday services, the ratio of full-time equivalent physiotherapy staff allocated per bed was similar between all intensive care levels (0.11 [0.08–0.15], p = 0.421). Thirty respondents (35%) were satisfied with their staffing and reported higher levels of physiotherapy staff per bed (0.15 [0.1–0.2], p < 0.001). Most sites reported lower levels of staffing for weekend services (76/86, 88%), and many physiotherapists indicated that they were not satisfied with this service (55/86, 64%). Most Level 2, Level 3, and paediatric ICUs had a designated senior physiotherapist, with similar levels of senior physiotherapy staff allocated per bed between all ICU levels (0.05 [0.03–0.08], p = 0.844). Few sites reported dedicated staff attributed to intensive care education, research, tracheostomy service, or outreach roles. On-call physiotherapy services were available in 49 of 86 (57%) hospitals surveyed; however, utilisation of the service by ICUs was mainly reported to be less than once per month (19/49, 39%).ConclusionsPhysiotherapy staffing ratios were similar across different ICU levels. While weekend services are available for most ICUs, staffing levels are reduced. Higher staffing ratios were associated with higher levels of satisfaction to complete professional roles and responsibilities.     

Outcome Measures Used in Therapy Departments in Scotland

Occupational and physiotherapy departments in Scotland were surveyed to establish the extent to which outcome measures, and especially standardised measures, were used. A two-phase investigation was carried out; respondents indicating use in the first questionnaire survey were the subject of a second survey designed to provide more detailed information on measures. A total of 247 questionnaires were mailed to senior therapists (108 physiotherapists and 139 occupational therapists). A 74% response rate was achieved and a significantly higher proportion of physiotherapists than occupational therapists responded.

The questionnaires indicated that outcome measures were used in 72 departments, representing 39.1% of all departments responding to the first questionnaire. Wide variation was found between geographical areas of Scotland regarding both response rate and use of outcome measures. When the 72 departments were contacted for further details, 86% responded. Of the 62 therapists who responded, 46 confirmed that measures were in use (others reported measures were at the planning stage or use had been discontinued).

The majority of outcome measures had been introduced in the 1990s and standardised measures were used in 17 departments. Patients' views on outcome, while sought in approximately half of all departments, were seldom collected systematically in a structured format. The majority of respondents regarded outcome measurement favourably, and more positive than negative views were expressed. Outcome data were used in departments for a wide range of purposes.     

无陪护医院医疗护理员培训体验的质性研究*

目的: 了解医疗护理员接受培训的体验,为构建培训层级管理体系提供参考。方法: 采用质性研究中的现象学研究方法,选取无陪护医院完成培训的11名医疗护理员进行深度访谈,应用Claizzi七步分析法对资料进行分析、整理、归纳出主题。结果: 从被访人的内心感受、亲身经历提炼出2个主题6个方面内容。主题1为认知与情感的双重体验,包括4个方面,分别为职业认同感和自我肯定、学习的潜能与乐趣、护理安全意识提升、知识与技能的获取。主题2为培训项目整体印象,包括2个方面,分别为培训内容实用性强、期待培训形式更加多样化。结论: 护理员培训是提升医疗护理员队伍整体素质的必要手段,是无陪护医院落实护理服务,满足患者健康护理需求的保障。     

Do Physiotherapy Records Meet Professional Standards?: Commitment to good practice and improved patient care through audit within the Birmingham Heartlands Adult Cystic Fibrosis Centre

Audit was performed to assess physiotherapy documentation within the adult cystic fibrosis unit at Birmingham Heartlands Hospital, against nationally accepted standards compiled by the Chartered Society of Physiotherapy (1993) and the Association of Chartered Physiotherapists in Respiratory Care (1994). Through their involvement with clinical audit, healthcare professionals derive benefits for themselves, by increasing their knowledge and understanding of effective practice, thus enhancing the effectiveness of the care they deliver.

Audit was initially completed between December 1998 and January 1999 using the medical notes of all 43 adult cystic fibrosis patients admitted to the hospital. Physiotherapy documentation was assessed using a proforma designed by the authors. Results of audit concluded that the ‘gold standard’ of 100% completion rate was not met for all criteria of documentation. Recommendations were implemented before re-auditing. These included improving professional standards awareness via a programme of in-service training for all staff, development of local standards, and piloting the development of a new pre-printed assessment sheet. The audit loop was completed by re-auditing six months after initial audit to reassess the effect of recommendations.

Documentation was re-audited for all 43 patients admitted between July and August 1999.

Results showed that for registration details, 11 out of 12 sections scored 93% or greater completion rates in audit 2 compared with 5 out of 12 in audit 1. There was improvement in completion within 9 out of 12 (75%) of categories (2%-53% range of improvement).

All categories of subjective assessment scored 84% or above completion rate in audit 2 compared to 5 out of 7 categories in audit 1. Improvement was noted in 4 out of 7 categories (range of improvement 7%-21%) in audit 2.

The objective assessment showed 11 out of 14 sections scored 90% or above in audit 2 compared to 8 out of 14 in audit 1. Improvement in 11 out of 14 categories (78%) demonstrated a range of improvement from 2% to 61% in audit 2. For any test not completed or requested it is recommended that this be documented.

It was recommended that all areas of assessment should be completed within 24 hours of referral.

All 43 physiotherapy records displayed a treatment plan, and 95% of patients' notes demonstrated ongoing evaluation in audit 2 compared to 93% in audit 1. Of all entries made, 99% in audit 2 were signed compared with 95% in audit 1. 97% were dated in audit 1 and 99% in audit 2. A discharge summary was completed in 77% of all notes in audits 1 and 2.

Regular in-service training for all on-call staff will continue to ensure awareness of documentation standards. Re-audit in 12 months will evaluate implementations after audit 2 – the use of a new pre-printed assessment form and development of a CF physiotherapy care pathway. The aim is to achieve the ‘gold standard’ of 100% completion rate for documentation, ensuring ongoing commitment to provision of improved patient care through audit.     

Self Chest Clapping: Patients'' Views and the Effects on Oxygen Saturation

The literature suggests that self chest clapping (SCC) does not enhance rate of sputum clearance if combined with the active cycle of breathing techniques (ACBT), but many patients find SCC beneficial and continue to use it. Previous studies have examined the effects of assisted chest clapping on oxygen saturation (SaO₂), but what would be the effects of SCC on SaO₂? It was important to establish any possible detrimental effects from its use and to explore the views of patients using it as part of their treatment.

The SaO₂ was measured in 20 clinically stable patients with cystic fibrosis during their physiotherapy (the ACBT with SCC in a gravity assisted position) and all patients completed a short anonymous questionnaire to obtain their views on SCC. Patient characteristics of lung function, arterial blood gases, response to bronchodilator therapy, 24-hour sputum weight and exercise ability were recorded, within 48 hours of participation within the study, to identify a possible relationship between these and a change in SaO₂.

In the group as a whole there was a statistically significant mean fall in SaO₂ with SCC (p = 0.026). However, this fall was never greater than 4.4%. In some patients a fall in SaO₂ was recorded with SCC, but in others there was an increase. There was no correlation between the variables measured and a fall in SaO₂ with SCC. The patients using SCC had strong views and beliefs about why they did so.     

Cost effective interprofessional training: An evaluation of a training unit in Denmark

In 2004, the first Danish undergraduate interprofessional training unit (ITU) was established at the Regional Hospital Holstebro, inspired by experiences from Sweden. In this unit, medical, nursing, occupational therapy and physiotherapy students are given responsibility, under supervision by trained and motivated personnel, for rehabilitation and care of patients in a subunit of an orthopaedic department. The aim of this study was to see whether the ITU was cost effective in treating patients compared with a conventional orthopaedic ward. One-hundred and thirty-four patients admitted for primary hip or knee replacement surgery were included in the study. All costs were recorded in the ITU and in the conventional ward. Follow-up was done by a quality of life questionnaire three months after the operation. Comparison was done by univariable and multivariable testing of costs and effect. In both, the ITU was more cost effective than the conventional ward. No difference was found in complications and patient-reported quality of life. In conclusion, clinical training can be given to students in an ITU without reducing productivity in a hospital environment if pedagogic principles, clinical tutors and patient logistics all adapt to the challenge of the teaching environment.     

District nurses’ experience of supervising nursing students in primary health care: A pre- and post-implementation questionnaire study

Nursing students go through clinical supervision in primary health care settings but district nurses’ (DNs) circumstances when supervising them are only briefly described in the literature. The aim of this study was to investigate DNs experience of supervising nursing students before and after the implementation of a new supervision model. Ninety-eight (74%) DNs answered a questionnaire before and 84 (65%) after implementation of the new supervision model. The study showed that DNs in most cases felt that conditions for supervision in the workplace were adequate. But about 70% lacked training for the supervisory role and 20% had no specialist district nurse training. They also experienced difficulty in keeping up-to-date with changes in nurse education programmes, in receiving support from the university and from their clinic managers, and in setting aside time for supervision. Improvements after the implementation of a new model chiefly concerned organisation; more DNs stated that one person had primary responsibility for students’ clinical practice, that information packages for supervisors and students were available at the health care centres, and that conditions were in place for increasing the number of students they supervised. DNs also stated that supervisors and students benefited from supervision by more than one supervisor. To conclude, implementation of a new supervision model resulted in some improvements.     

Perceptions of staff and family responsibility to provide hospitalized older adults with basic activities care and emotional support

Many older adults need help with Activities of Daily Living (ADL) and emotional support during hospitalization. Hospital staff is officially responsible for care, but most older adults are accompanied by family members who provide at least some of the support. In this study, we asked physicians, nurses, nursing assistants, and relatives about hospital staff versus family responsibility for providing ADL care and emotional support, and about actual levels of help provision by the hospital staff in Israel.  Staff members (except physicians) tended to see staff as more responsible for ADL care than family, while emotional support was a shared responsibility. Nursing assistants were the most likely to report that staff provided high levels of support, and all participants reported that staff provided more ADL care than emotional support. It is important for family members and hospital staff to have open discussions of their expectations and responsibilities when older adults are hospitalized.     

Automated measurement of urinary proteins

We have investigated the automation of the trichloroacetic acid turbidometric method for the estimation of urinary proteins using a standard centrifugal analyser.

Conditions of temperature, trichloroacetic acid concentration, sample and reagent volumes have been examined. The method requires 10 μl of urine sample and results have been shown to be linear to 2.0 g per litre with undiluted specimens; higher levels of protein require dilution of the urine samples to obtain greater accuracy.

The coefficient of variation at a level of 0.5 g per litre is 3.5% and at 1.0 g per litre is 1.3%; recoveries ranged from 98.9 to 108%.

The estimation of urinary protein in 29 samples may be carried out in 5 min.     

Rural speech-language pathologists’ perceptions of working with allied health assistants

Abstract

Workforce shortages are forecast for speech-language pathology in Australia, and will have a more significant impact on rural and remote areas than on metropolitan areas. Allied health (AH) disciplines such as physiotherapy and occupational therapy address the problem of workforce shortages and growing clinical demand by employing allied health assistants (AHAs) to provide clinical and administrative support to AH professionals. Currently, speech-language pathologists (SLPs) don't work with discipline-specific allied health assistants in all states of Australia (e.g., New South Wales). This paper aims to provide insight into the perceptions of SLPs in one Australian state (NSW) regarding working with AHAs. Semi-structured interviews were conducted with eight rural SLPs. Qualitative analysis indicated that participants perceived they had deficits in skills and knowledge required to work with AHAs and identified further training needs. Participants perceived the SLP role to be misunderstood and were concerned about poor consultation regarding the introduction of AHAs into the profession. Ambivalence was evident in overall perceptions of working with AHAs, and tasks performed. While previous research identified benefits of working with AHAs, results from this study suggest that significant professional, economic, and organizational issues need addressing before such a change should be implemented in speech-language pathology.     

Serum amyloid A protein in patients with non-insulin-dependent diabetes mellitus

We determined the serum amyloid A protein (SAA) levels in patients with non-insulin-dependent diabetes mellitus (NIDDM), and investigated the possible association between SAA and the complications of NIDDM.

The concentrations of SAA were measured in the plasma of 105 patients with NIDDM (52 men and 53 women, age mean ± SD, 61 ± 13 years) and 91 healthy subjects (37 men and 54 women, aged 57 ± 11 years). SAA concentrations were assayed by enzyme-linked immunosorbent assay.

SAA concentrations in the patients with NIDDM were significantly higher than those in healthy subjects (2.1 ± 1.3 vs. 1.2 ± 0.5 mg/L). There were no obvious relationships between SAA lebels and duration of diabetes, type of therapy, or control of blood sugar in the patients with NIDDM. However, SAA levels in patients with NIDDM increased significantly, with increase of urinary albumin excretion (p = 0.027). The increase of SAA in the patients with NIDDM did not influence the serum concentrations of lipid or lipoprotein.

The SAA concentration in NIDDM was unrelated to the type of treatment, but seemed to be related to the development of diabetic nephropathy.