Physical therapists practice in a multitude of different settings. Each setting poses new challenges and creates opportunities for professional growth and development. Regardless of the setting, physical therapists maintain consistent roles of consultation, education, critical inquiry, and administration, as defined by the Guide to Physical Therapy Practice.1 Once a therapist develops the skills, behaviors, and competence necessary to master a specific setting, it can be difficult to continue the drive towards becoming an expert and lifelong learner. Many therapists get into the routine of patient care and miss opportunities for professional growth. As I found myself in this particular predicament, I found an opportunity to change practice settings, and the opportunities for professional growth have been exponential.
Physical Therapist Roles Defined
The Guide to Physical Therapist Practice defines the roles of a physical therapist as patient management, consultation, education, critical inquiry, and administration. In all practice settings, physical therapists manage patients and clients in the ways that the settings demand. Physical therapists are consultants when they apply their skills and specialized knowledge to identify problems, recommend solutions, and produce outcomes. Consultation can occur directly as in the client/therapist relationship, or indirectly as in being a second opinion, or reference to a business. Physical therapists fulfill their role as educators when they share information in order to increase knowledge, create skills and instill competence in their audience. This can occur in an academic setting or informally. Critical inquiry occurs when physical therapists apply the scientific method to analyze new ideas, and research to apply it to specific patients. Administration involves planning, directing, and managing resources. Each setting demands each of these roles differently.1
My six years of clinical experience has been largely in acute care, both in a large university teaching hospital, as well as a small community hospital. Recently, I have started working in home health. The roles, though constant by definition, are variable by setting.
Large University, Teaching Hospital
In a large university teaching hospital, the primary role a physical therapist assumes is education. In this environment, a physical therapist teaches resident physicians, nurses, and student interns from all medical disciplines the physical therapy role, as well as the limitations to the services provided. As educators, the physical therapist leads by example, providing in-service trainings, grand rounds, and shadowing opportunities to colleagues. Additionally, PTs in acute care educate patients and their families about the disease and rehabilitation process. This role becomes increasingly important as large teaching hospitals admit patients with more complex medical conditions which can overwhelm patients and their families. The secondary role that PTs assume in acute care at a large teaching hospital is administration. The hectic and learning environment of the large educational medical center leads resident physicians to order physical therapy services based on assumed protocols instead of identifying the medical need, and determining the potential benefit for skilled services. Every patient does not need physical therapy services, and therefore, overutilization of physical therapy consultation necessitates the efficient and effective management of resources including patient prioritization, utilization of ancillary support staff, therapeutic equipment, time management, and usage of therapy space.2,3
In smaller community hospitals, the primary role that physical therapists serve is that of consultant. Physicians and hospitalists in community hospitals have generally already gone through a residency, and therefore, should have an understanding of what services physical therapists provide. Therefore the focus shifts towards patient consultation-evaluation and treatment. Additionally, physical therapists in smaller community hospitals act as consultants to nursing staff to assist with safe mobility of patients. They recommend which lift, technique, chair, toilet aides, and positions would be best for their patients and safest for the professional to prevent workplace injury. Secondarily, physical therapists in community hospitals, serve as administrators similarly to those in larger hospitals, with the exception being the difference in available resources.
As a novice home health clinician, I have quickly discovered that home health therapists primarily serve as administrators. Home health physical therapists are responsible for not only rehabilitating their patients, but also for coordinating durable medical equipment, managing caregiver stress, managing patient medications, maintaining constant communication with nurses, physicians, nursing assistants, and other therapy staff and the actual process of rehabilitation. Home health therapists also must manage their time for documentation, travel, mileage= and time spent in the patient's home. They also must be certain that they have all necessary supplies for all of their patients prior to leaving the office. In this setting, physical therapists are also case managers in the global manner that they provide care, referring to other disciplines as indicated, and managing all aspects of patient's care. Secondarily, home health therapists act as consultants. Specialized programs run by home health agencies in community centers or assisted living facilities are consultative services to the specific agencies and community at large.
Geriatric patients have special needs
Regardless of the practice, setting geriatric patients have specific needs which physical therapists must address and incorporate into their approach to establish and maintain the client-therapist relationship. Physical therapists must screen for musculoskeletal, cognitive, cardiovascular, neuromuscular, integumentary, and psychosocial impairments. Individual considerations impact all of the bodily systems.4 For example, an elderly man who recently lost his wife, may be more prone to depression, wounds, and falls due to grief, inadequate nutritional intake, and weakness. Many geriatric patients take multiple medications, and can be at risk for increased side effects, confusion, and toxicity due to the decreased absorption and metabolism of the medications.5 Both the presence and absence of supportive caregivers can impact carryover of therapeutic interventions. Additionally, the presence of unsupportive caregivers can also hinder the rehabilitation process. A physical therapist should consider the health of the caregiver and incorporate interventions which are feasible for the caregiver to carry out.6
When considering the four roles of physical therapy, geriatric patients require education. The education should be specific to the individual patient's needs. Physical therapists should make modifications to facilitate learning including handouts with large text for patients with vision problems, written logs to track therapy progress in patients with memory problems, simple instructions to minimize the risk of confusion, and maximize caregiver involvement as much as possible to help with carryover of tasks.7
Physical therapists have four roles that shift depending on the practice setting. As a professional, part of lifelong learning involves self assessment, and evaluation. Physical therapists can identify their skills, behaviors, and strengths and apply these roles to different practice settings to determine the setting in which they would be best suited to practice. This process can help keep strong clinicians in the profession, while also using their best qualities in appropriate settings.
1. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association, 2003.
2. Lopopolo, RB. Hospital restructuring and the changing nature of the physical therapist's role. Physical Therapy. Feb 1999; 79: 171-185.
3. Lopopolo, RB. The relationship of role-related variables to job satisfaction and commitment to the organization in a restructured hospital environment. Physical Therapy. October 2002; 82: 984-999.
4. Bottomley JM, Lewis CB. Geriatric Rehabilitation: A Clinical Approach. 2nd ed. Upper Saddle River, NJ: Prentice Hall, 2003.
5. Roach S., Lochhaas T. Pharmacology for Health Professionals. Philadelphia: Lippincott Williams & Wilkins, 2005.
6. Bottomley JM, Lewis CB. Geriatric Rehabilitation: A Clinical Approach. 2nd ed. Upper Saddle River, NJ: Prentice Hall, 2003
Jill Gerringer is a home health physical therapist with LifePath Home Health, a subdivision of Hospice of Alamance-Caswell, in Burlington, NC. She is completing her transitional DPT at University of New England in Portland, ME, and will graduate May 2011. She graduated from Thomas Jefferson University in 2004 with her Master's of Science in Physical Therapy, and has practiced in a hospital setting for the majority of her career.