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Research Reports |
PA Miller, PT, MHSc, is Assistant Clinical Professor, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada. She was Profession Leader, Physiotherapy, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada, at the time of the study. Address all correspondence to Ms Miller at 5 Undercliffe Ave, Hamilton, Ontario, Canada L8P 3G9 (pmiller{at}mcmaster.ca)
P Solomon, PT, PhD, is Associate Professor and Assistant Dean, Physiotherapy Programme, School of Rehabilitation Science, McMaster University
Submitted July 31, 2000;
Accepted November 12, 2001
 | Abstract |
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Key Words: Hospital restructuring • Organizational restructuring • Professional practice • Professional roles • Program management
| Introduction |
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A move away from traditional hierarchical management models to what is called "program management" (PM) has accompanied the restructuring efforts.6 In PM, there is a shift from the traditional differentiation by function (eg, nursing and physical therapy departments) to an organization where the emphasis is supposed to be on programs that address the needs of specific patient populations. Decision making is supposed to be decentralized to program managers and frontline staff, which could include physicians, nurses, physical therapists, and other team members. Program managers often have full accountability for the fiscal and human resources of the program. The organizational design varies greatly, and many health care facilities develop a modified or partial program model with varying levels of integration of the clinical and functional services.6
When a department is eliminated with the move to PM, its staff are deployed to programs. There is less emphasis on the individual professional disciplines as staff are allocated to multidisciplinary teams, usually with the exception of physicians. There has been little systematic study of the influence of organizational restructuring or PM on the professional practice of health care professionals. Baker7 identified a number of implications for professional and managerial roles in health care that result from a move to PM. He suggested that, although the move to PM can result in opportunities that allow for greater involvement in decision making and planning, there may also be a loss of the professional unity that is typically provided by the department structure, a lower visibility of professional standards, and the increased potential for difficulties when profession-specific performance issues arise. Trujillo et al8 described the influence of the health care delivery restructuring on the practice of rehabilitation professionals. They noted that staff have less time for direct clinical work because they assume additional administrative duties. In addition, new staff are often expected to carry full caseloads quickly without having a mentoring system in place. They proposed a number of strategies to help staff cope with the changes, including streamlining documentation and enhancing team function.
Aas9 suggested that the decentralization that accompanies organizational restructuring may lead to improved job satisfaction for those health care personnel who have greater participation in decision making and greater autonomy in their work. However, there are potential negative consequences such as the deterioration of competence resulting from isolation from colleagues in the same profession and the decreased loyalty of health care professionals to their superiors because of their loyalty to their own profession. Globerman et al10 reported the results of a telephone survey undertaken to explore the effect of organizational restructuring on the care delivery and practice of social workers. Social workers in leadership positions identified concerns about their loss of control over standards of practice, continuing education budgets, hiring, and performance appraisals. Respondents were concerned about the program staff's lack of understanding of the social work role and the decreased opportunities for professional collegiality. The authors reported various strategies that had been undertaken (eg, establishment of professional committees, undertaking activities to enhance intraprofessional communication) to support the practice of the social workers in the various hospitals.
Two research reports11,12 examined the effect of hospital restructuring on the role of the physical therapist. Lopopolo11 developed a conceptual model of the effect of hospital restructuring on the role of physical therapists using a qualitative case study methodology. She gathered data from observation of the physical therapists at work to gain insight into communication processes and the operation of the department. A review of documentation at the time of the restructuring provided information about the how the changes in the physical therapy department related to the organizational changes. Further information was gathered through 3 semistructured interviews of key informants (physical therapy director, nurse coordinator, and 2 physical therapists). Professional role changes were noted in activities related to the provision of patient care and professional interaction. Physical therapists noted the need for flexibility, a greater focus on patient discharge, increased sharing of information among team members, and the importance of a "home base" to aid intraprofessional communication and to foster a sense of professional identity.
In a subsequent study, Lopopolo12 used the Delphi technique to explore the role behavior changes of physical therapists. Participants included physical therapy department directors or clinical managers who were working in acute care hospitals across the United States. The results indicate that the current practice of physical therapists in acute care hospitals includes an increased focus on the functional needs of the patient, an increase in administrative duties assumed by the physical therapist, and an increase in the integration of the physical therapist into the patient care team. The physical therapists also identified the value of maintaining a professional approach to one's work and the necessity of using a wide range of mechanisms to maintain a sense of professional community (eg, staff meetings, intraprofessional communication, educational activities). These research findings validated many of the observational reports described by the authors noted earlier.7,8,10
Many physical therapists work in hospitals where organizational restructuring has occurred.12,13 In many cases, the traditional physical therapy department structure no longer exists. What are the personal and professional implications of the move to PM? Is patient care affected? The purpose of this study was to use qualitative methods to examine how a recent move to PM influenced the professional practice of physical therapists in a large teaching hospital from the perspective of frontline staff. Information from practicing physical therapists about changes in their professional practice that result from this organizational restructuring has not been previously reported.
The merger of 2 two-site Canadian hospitals occurred in November 1996, and a new organization was established. Both former hospitals were in the process of implementing PM for at least a year before the merger. A partial program design6 was adopted by the new organization in which several departments remained in existence (eg, pharmacy, laboratory medicine, education services). Physicians were aligned with a program or programs, and they were expected to function as part of the multidisciplinary team. One physician assumed the role of medical director of the program, collaborating on administrative issues with the program director. However, the majority of departments, including physical therapy, were disbanded, and the staff were deployed to programs. The hospital reorganization created a large, urban teaching facility that provides acute care services at 3 sites and rehabilitation and chronic care services at a fourth site. With the merger, programs were established that spanned as many as 3 sites.
At the time of the study (January to March 1998), the physical therapy staff had been deployed to 15 of the 17 clinical programs in the hospital. The move to PM involved the loss of 2 full-time directors of physical therapy, 1 full-time director of rehabilitation (who directed physical therapy, occupational therapy, speech-language therapy, and recreation therapy staff), 1 part-time assistant director of physical therapy, 3 part-time student education coordinators, and 3 part-time physical therapy researchers across the 4 sites. The 15 senior physical therapists who carried a clinical caseload and who also had protected time for administrative duties such as mentoring new staff and promoting clinical excellence were reclassified as staff physical therapists. Only 1 leadership position in physical therapy was retained by a physical therapist who had the designation of "clinical specialist" in the musculoskeletal area. Her part-time position included clinical responsibilities and discipline-specific mentoring and teaching activities.
Following the merger, the staff established a professional practice committee that met monthly. The committee consisted of 10 staff members representing both physical therapists and physical therapist assistants from across the 4 sites. One part-time profession leader who was a member of that committee was responsible for the promotion and maintenance of professional standards across the hospital. The profession leader was selected by the physical therapists just before the merger. She was 1 of 23 profession leaders who comprised the hospital's Professional Advisory Committee that was created to address professional practice issues that crossed both programs and disciplines.
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Subjects
All part-time and full-time physical therapists in the hospital (N=80) were sent a letter inviting them to volunteer to participate in a focus group or interview that would examine the influence of PM on their professional practice. Thirty-seven physical therapists responded to the invitation. Twenty-five physical therapists participated in the focus groups. Eight volunteers did not participate in focus groups or interviews because of scheduling difficulties. Focus groups were divided according to site. There were a total of 5 focus groups (FGs)—2 groups from the rehabilitation and chronic services site (FG1 and FG2) and 1 group from each of the 3 acute care sites (FG3, FG4, and FG5). Each focus group represented a sample of convenience because it included only those therapists who were able attend sessions scheduled at predesignated times. Focus groups contained 3 to 7 participants. Four physical therapists, chosen to represent broad areas of clinical practice and a range in duration of employment in the organization, participated in the structured interview (I1-4). All physical therapists provided informed consent before participation.
The participants were 27 women and 2 men. Twenty-six of the participants were employed full-time. They reported a mean length of practice of 10.2 years (SD=7.9, range=1–30 years) and a mean length of employment at the hospital of 6.5 years (SD=5.0, range=3 months–17 years). The majority of the physical therapists (65.5%) worked in 1 clinical program, 9 physical therapists (31%) worked in 2 programs, and 1 physical therapist (3.5%) worked in 3 programs. The majority of therapists (93%) stated that there were other therapists working in their program at their site.
Data Analysis
All transcribed tapes were entered into the Ethnograph software package.*14 The analysis utilized an open-coding technique as described by Strauss and Corbin.15 The analysis began with a line-by-line analysis of each transcript to identify and code specific events related to the therapists' experiences within the PM environment. The transcripts were reviewed by 2 analysts (PAM and PS) who reached a consensus on all the coding categories. Following the initial coding, the concepts were registered on the computerized version of the transcript. All concepts were then examined and grouped together to form categories or themes. In order to be identified as a theme, the concept must have been present in both focus groups and interviews. The analysts met and reviewed the final coding, discussed any discrepancies and made modifications to reach a final consensus on the identified themes. Representative quotes from each theme were identified from the transcripts. To solicit feedback and comments on the findings, the results of the study were subsequently presented to a group of physical therapists composed of participants from the study and other physical therapists employed at the hospital.
A number of verification procedures were used to enhance the credibility of the data.16 Using information from focus groups and interviews provided corroborating evidence from different sources on the themes. Similarly, because 2 investigators were involved in the analysis, different perspectives were incorporated into the analysis process. In addition, the results were reviewed by the participants so that they could provide feedback on the interpretation of our findings (a process known as "member checks"16), thereby supporting the credibility of the results.
| Results |
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Sense of Loss
Many physical therapists spoke of a sense of loss. This theme is related to the loss of professional identity that comes from a sense of being part of a cohesive group. Without a profession-specific department, therapists missed the sense of collegiality, informal friendships, and interactions with role models. The physical therapists acknowledged the important role that their colleagues had played in their working life. The sense of loss appeared to be exacerbated because the therapists no longer had a department head and did not feel that they had adequate professional representation.
All of us have lost that sense of identity as a corporate profession. (FG1)We don't have the same communication between each other and the same professional development with each other. Even for emotional support after a bad day or rough patient, a tough situation with a nurse, we could come down and get support from each other on the same level and that's really important to us. (FG3)
But I find with the new people coming in, they are sort of floating around, and they're sometimes the only PT [physical therapist] that works in their area. They really don't know what's what, and it's hard for them. So I see that and think, "Oh, my gosh, where's the department when you need it?" (I1)
Low Morale
This theme reflected a sense of negativity and of "giving up." Participants spoke of a lack of enjoyment and job satisfaction. Although some therapists spoke about the possibility of leaving their positions, others had already taken action.
Lately, I'm not enjoying coming to work. Frustration, future upcoming stresses...[they] just make it not as much fun as it used to be. (FG3)Program management is one of the reasons I'm leaving. I don't have incentive to stay here. (FG4)
And they're expecting those things [professional activities (eg, educational in-services and mentoring)] still to happen when it used to have managers or seniors or whatever to do that. Now they're saying, you guys still have to do it, but nobody is going to get any recognition or any money or anything to do it, or time or whatever. So it's like, "Well, if I used to do it and used to get compensated for it, why would I do it now?" (FG2)
Positive Coping
In contrast to those physical therapists who expressed feelings of low morale and a sense of loss, a group of people, as one theme indicated, accepted the changes, viewed developments positively, and were able to articulate specific attitudes and strategies that we labeled positive coping.
Experience it, deal with [it], grow with [it]. Accept that it's not always going to be pleasant. Try to keep your balance, keep some humor.... (FG5)I think you have to be able to cope with a lot of people demanding a lot of things from you and not being able to meet them. And you have to be able to say, "I'm doing the best that I can, and I can't meet everybody's needs all the time." So it becomes...like we say, "We're really thick-skinned." Knowing what your limitations are but still trying to do your best. (FG2)
I think program management has made us all work better as a team, to make decisions as a program and not just as individual disciplines. I think we've had to learn from each other, and that's been good. (FG5)
Loss of Professional Development Opportunities
With the move to PM, physical therapists were accountable to the program managers, whose focus was the cost-effective provision of patient care. Access to funds for professional development was limited, because many programs did not include education funds in their operating budget. Therapists also found that there was less support for their involvement in academic activities in the local university's physical therapy program. The value of professional development activities seemed to be in question when it appeared to be carried out using dollars that had been allocated for patient care. Other, less formal professional development activities such as in-services had also been curtailed. Furthermore, the elimination of the senior therapist and education coordinator positions significantly limited opportunities for orientation and mentoring of new staff.
At the moment, if you want to develop your education or if you want to develop research or if you want to develop anything, you are the one that has to make that change and initiate it.... [In] the [programs] that I work on, there's not that education or research person or anything like that. If you want to do it, you find a way to do it. (I1)You learn from asking questions, from watching somebody else who has perfected their techniques. That's how you learn. And if you're in a program where there's only maybe one other therapist or you're the only one, there's virtually no opportunity to do that within your work. (FG1)
It's hard for everyone in the climate today, but for the new grads, it's really difficult because you have to be an expert in your program. There's no room for learning anymore. So you'd better get up to snuff, and that's that. (FG2)
Need to Assume Multiple Roles
In the PM model, therapists had assumed responsibilities related to the management of program operations in addition to patient care. For many physical therapists, this necessitated the development of new skills. Some therapists who assumed administrative responsibilities felt uncomfortable because they did not feel prepared for these new responsibilities.
I think that you need more skills than you used to need in a department model because now you have to be an advocate for yourself, for the profession, for the client. You have to have the administrative skills. You have to have much better communication skills, although I always said you have to work collaboratively in a team model. This is a bigger and looser team, so your skills have to be a lot better. (I2)I think that other team members that are not allied health have difficulty seeing that we're not just clinicians but we are directors and we are negotiators and we are everything, and that takes up a lot of our day just doing that. It's not just PT [physical therapy] work. You're teaching students, you're doing everything that a director used to do. We have to figure out your own leave, find your own coverage. There's no backup for anything. (FG4)
What we don't have is managerial training and expertise. We're good in our profession, but that doesn't mean that we're a good case manager, it doesn't mean that we're a good chairperson of our team, or it doesn't mean that we can raise those issues about performance of somebody—even if it's our job. Just because you're a good nurse or a good therapist or doctor doesn't mean that you have those other skills. (FG1)
Professional Advantages
Some physical therapists noted that, with the increased interdisciplinary work, there appeared to be an greater recognition of their role and skills as physical therapists. In contrast to those who worried about the need to develop new skills, some therapists welcomed the opportunity to expand their scope of responsibilities beyond patient care.
I think that we've been on more interdisciplinary committees, with others—allied health and nursing staff and administration. So people get to see our problem-solving skills, they get to really value that. I think that they even have more insight into what we do clinically. I don't know why that is, because we were always on the wards before, but there seems to be a bigger awareness of our role and our skills. (FG3)I think [program management] is promoting the profession...it's putting yourself front and center in getting your needs known, meshing with other professionals, working cohesively as a group. (FG4)
I think we're always fighting for our role as a PT [physical therapist] or for the role of physical therapy.... So it's always the feeling that you have to be stronger as a professional within physical therapy because there is so much coming at you and you have to defend that so much. If you said, "Is my identity as a PT stronger or weaker?" I'd say stronger because I'm fighting for it all the time. Not weaker because people are trying to impose on it, but stronger internally because I'm making sure that those lines are there. (FG2)
Impact on Patient Care
With the introduction of PM, therapists noted that there were direct implications on the way in which they were able to provide physical therapy services. Although some therapists spoke of positive benefits, the majority of the implications were considered negative. Because therapists were required to participate in administrative activities, there was a concern about the reduction in time available for patient care. Some therapists felt that they were challenged to be more creative in dealing with patient care because they had less opportunity to seek assistance from physical therapist colleagues.
I do think it's affected the standards of practice in that they're not being monitored in the same way. And so I think, as a professional, that it has impacted [practice] in a negative way. (FG5)I think I find I am more responsible for the care of the patient. You can't just run to whomever and say, "I need help with this patient." You have to search within your team or within yourself. It might force you to be a little bit more creative, which is not a bad thing, but, I don't know. (I3)
We have to be part of all the team decisions and have to take on more responsibility in administrative types of things, like ordering equipment and making decisions about how we're going to do things. And that in the end [it] takes away from your time with patients. (FG5)
I think that that there are a lot of advantages in patient care and working with patients as a team and collaborating. You can set up plans for patients, have goals, and set up more team protocols. (I4)
| Discussion |
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The physical therapists conveyed a sense of low morale and loss that had not been reported in other studies. This low morale is not unexpected when an organization undergoes significant restructuring. The power shift that occurs with the change of authority from departmental manager to program director can lead to conflict and resentment.7 Because this study examined the effect of the restructuring process on the professional working life of the frontline physical therapist, it is not surprising that affective responses were reported when physical therapists described their personal experiences. Other studies have focused more specifically on the role of the physical therapist11,12 or examined the perceptions of managers,10 where the impact on the therapists' morale may not be as evident.
The physical therapists struggling with the organizational changes associated with the shift to PM also had to cope with the loss of valued informal collegial networks. There appeared to be a need for social contact with colleagues within the work environment. Informal socializing is valued by health care professionals.10,11 The complexity of intraprofessional communication following organization change has been reported,8,13 and a number of strategies have been described to maintain a sense of community and professional identity among the physical therapists.11,12 These strategies include regular professional meetings and maintaining a physical space for these meetings. This study was undertaken shortly after the organizational restructuring and adoption of PM had occurred; therefore, professional strategies to support communication and collegiality among therapists may not have been fully instituted. This timing could also account for the negative tone of some of our findings. Furthermore, it is possible that therapists who choose to work in large tertiary care centers do so because of a desire for contact and exposure to peers. If so, it follows that these therapists would experience a greater sense of loss and isolation when they were deployed to programs.
Informal socializing among colleagues also helps create an environment that fosters mentoring. Mentorship and ongoing feedback are important for the organizational socialization of new employees.18 Smith18 described the process of organizational socialization as a continuous, interactive process between the organization and the employee, in which the employee becomes an integrated member of the organization. The process of organizational socialization in our opinion is relevant to any employee, whether an experienced therapist or a new graduate. Smith identified the need for a mentor to assist with organizational socialization by role modeling, coaching to improve clinical competency, and sharing information about the professional and organizational culture.
A call for mentorship programs is not new to the profession. Bohannon19 described the importance of mentorship for physical therapists, which we believe is as important today as it was in 1985. Although these opportunities are often the responsibility of senior therapists and may occur informally in a departmental structure, we believe there is a need to consider strategies that support the establishment of formal mentoring programs when there are decentralized organizational structures. The perceived lack of support for professional development activities noted by the participants suggests the need for the establishment of a professional mentorship program to support professional socialization.
Professional socialization is the process by which an individual learns the values, attitudes, and beliefs of the profession.20 We contend that the process of professional socialization is increasingly important in the current health care environment, because the emphasis on multidisciplinary and interdisciplinary practice serves to decrease professional autonomy and the distinctiveness of the professions.21 Although professional education provides the fundamental platform for professional socialization, early interactions with physical therapists and other health care professionals, in our opinion, can reinforce the socialization process. In the absence of formal mechanisms, which can often be removed with the introduction of PM, we believe physical therapists will need to proactively seek out opportunities for professional socialization. In our opinion, mentoring programs also have an important role in promoting the professional values and culture important to the socialization process.
The range in years of professional experience of the participants may explain, in part, why the therapists conveyed mixed feelings about assuming multiple roles and responsibilities. Freda,22 in a study examining rewarding aspects of occupational therapists' jobs, discovered that beginning clinicians found patient care responsibilities to be the most rewarding. Management responsibilities were not perceived as rewarding until the therapists had worked at least 7 to 10 years.
There are several limitations to our study. The organizational restructuring that occurred in this hospital was complex, consisting of an amalgamation of 2 institutions spanning 4 sites and a concurrent shift to PM. It is possible that other, simpler restructuring processes involving only the move to PM may have less impact on the professional working life of the staff. By creating programs that spanned more than 1 site, the merger compounded the challenge to the staff to understand and establish new relationships and roles within a new program. Challenges to communication among staff resulted because the 2 former sites used 2 different systems for electronic communication. The impact of the merger that accompanied the move to PM and its specific impact on affect, professional practice, or patient care activities cannot be ignored, and the results of this study must be considered in light of all the additional organizational restructuring activities that had taken place.
This study was undertaken several years ago when a large institution in Canada was undergoing both merger and restructuring activities. As in all qualitative research, the reader needs to determine the extent to which the findings can be transferred to his or her setting. The sample was one of convenience, and the possibility exists that the therapists who volunteered and were able to participate were those who had been affected most adversely by the changes. The negative tone of some of our findings may reflect this situation. Given the limited amount of literature in this area, however, we feel that our study has furthered the understanding of the challenges perceived by physical therapists whose facility shifts to PM. We present the perceptions of physical therapists who had, in the preceding 18 months, experienced significant restructuring of both their organization and their professional network. Because the results indicate only a "snapshot" at one point in time, further inquiry is needed regarding the longitudinal effects of these changes.
Because there were no recent graduates in the sample (all participants had more than 1 year of work experience), the impact of organizational restructuring on the practice of new graduates is unclear. New graduates might be better able to adapt because they would not have been exposed to the traditional departmental structure and, therefore, would not perceive deficiencies in the system. We believe education programs for therapists have increased their emphasis on management, consultation, and communication skills, and this may better prepare new graduates.23 They, however, are the therapists most in need of structures that support professional and organizational socialization, and, therefore, they may be adversely affected by present organizational structures. Further research is currently under way to examine the needs of new graduates in acute care teaching hospitals with different organizational structures.
Our findings reinforce the impression that today's physical therapists require a broad range of competencies to be effective practitioners. In addition to clinical skills, they need to have the skills to be effective team members—an understanding of the physical therapist's expanded role, superior communication skills, the ability to implement strategies that support self-governance, and an interest and ability to determine professional direction and growth.13 Swinamer24 suggests that clinicians working in acute care facilities that have undergone restructuring are working in conditions similar to those of independent practitioners in the private sector. We argue that professional associations and educational institutions need to provide continuing education to allow for skill development outside of the traditional areas of clinical expertise. Physical therapists also have to recognize that these skills are important. They need to identify their learning needs in these areas and take advantage of professional development opportunities.25
Our findings identify several areas that need to be addressed by the profession. We believe a mentoring program can be viewed as an integral component of every work environment because it can benefit both the junior staff and the mentor and indirectly benefit the employer and the profession. Furthermore, mentorship in our opinion is critical for successful professional and organizational socialization of physical therapists. Staff and physical therapist administrators may need to use creative strategies to ensure that mentoring programs are available in a PM environment. Furthermore, clinicians, educators, and professional associations should continue the debate about the competencies required for professional (entry-level) practice, recognizing the ever-changing and broad scope of work environments. Future researchers should evaluate how to most effectively support physical therapists who experience organizational restructuring and, more importantly, how to aid the positive coping that we observed in some of the participants.
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| Footnotes |
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Ethical approval for qualitative research involving hospital staff was not required by the Research Ethics Board, Hamilton Health Sciences Corporation.
This material was adapted from a presentation given at the Canadian Physiotherapy Association Congress; Calgary, Alberta, Canada; July 1, 2001.
This research was supported by a grant from the Hamilton Civic Hospitals Foundation, Hamilton, Ontario, Canada.
* Qualis Research Associates, PO Box 3356, Salt Lake City, UT 84110. 
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