Patients’ and healthcare professionals’ experiences and perceptions of physiotherapy services in the emergency department: a qualitative systematic review

Background

In the last decade, emergency department (ED) attendances and admissions to acute care have increased significantly. The physiotherapist skill set is not just restricted to the expert treatment of musculoskeletal (MSK) conditions [1] but it plays roles in managing complexity, such as assessing, treating and managing patients with a wide range of clinical presentations including falls and neurological and respiratory conditions. Some physiotherapists who have undertaken advanced practice training may also be able to suture, plaster and prescribe, for example, allowing these practitioners to autonomously treat minor injuries and enabling them to provide a “one-stop-shop” approach to care. Consequently, physiotherapists are being appointed to EDs, urgent care centres and minor injury units worldwide allowing doctors to see patients who require more immediate input [2–4]. An ED physiotherapist has been defined as a ‘clinician dedicated to working as a member of the ED team to manage patients either autonomously or in conjunction with other attending medical or nursing staff’ [5]. This shifts EDs from ‘traditional’ teams comprising of doctors and nurses where physiotherapy was previously a ‘referred to’ service [6].

Internationally, literature examining ED physiotherapy has considered the impact services have on waiting times, safety, costs and access [1, 7, 8] and their effectiveness in treating MSK conditions and achieving patient satisfaction [9, 10]. Quantitative research dominates as confirmed by Kilner’s systematic review SR [2]. Although some qualitative research has considered in-depth views of patients’ and healthcare professionals’ experiences and perceptions of ED physiotherapy services currently, there is no agreed consensus on the role or value of ED-based physiotherapists. The aim of this SR was to retrieve, critically appraise and synthesise the evidence from studies relating to the perceptions and experiences of patients and emergency department practitioners.

Search strategy

Quality of studies

None of the studies in this review were excluded following the appraisal process; however, there was variation in their quality. All were checked to see whether they had obtained approval from a relevant Research Ethics Committee (this checkpoint is also part of the CASP criteria). Six studies confirmed they were granted approval; one study failed to explicitly document this [11]. This does question the trustworthiness of the research [22], and by omitting this, it is difficult to determine whether there were any conflicts of interest. The majority of the studies did document the procedures undertaken to ensure ethical issues were considered, such as confidentially and informed consent [6, 12–14]. However, not all acknowledged ethical considerations, which does limit applicability. Trustworthiness was considered [6, 13, 15], for example, data collection methods were piloted before commencing the final study to ensure that the chosen participant questions were appropriate to elicit full in-depth responses. Kilner and Sheppard’s study lacked a truly qualitative feel due to its reliance upon an internet-based survey [6]. Harding et al.’s study was described as an observational study but only interviews were reported, no observations [14]. Small sample sizes were a problem in the case of Lefman and Sheppard’s [12] and Morris et al.’s [16] who only identify three staff participants.

Two studies in this SR [12, 14] and several in a previous SR [23] reported undertaking triangulation which aids the credibility of their findings [24]. One study reported undertaking multiple-analyst triangulation, where four researchers were involved [14]. Sheppard et al. also commendably acknowledged that the researcher undertook writing a reflexive diary [15]. This process can enhance research triangulation further and improve the overall rigour of qualitative findings [25]. However, this researcher appeared to be the only data analyst. A final consideration, which can enhance the integrity of qualitative findings, is member checking [26]. Two studies [11, 12] undertook this process.

Geographical location

Six of seven studies in this review were undertaken in Australia [6, 12–16], and therefore, the application of these findings to other international physiotherapy ED posts is limited. The experiences and perceptions of ED physiotherapy services are likely to vary from country to country and even from department to department within the same country due to demographic differences and influencers [27]. Furthermore, the same researchers dominate this subject field. Anaf has authored two of the studies in this review [13, 15] and Sheppard four [6, 12, 13, 15], biasing the findings further.

Themes

Patients across all studies perceived physiotherapists to be clinical specialists. There was variation in their experiences and perceptions. Physiotherapists were viewed as specialists in rehabilitation post injury [13]. Not all patients were explicit that these skills were a ‘specialisation’ of a physiotherapist in the ED, instead some patients perceived these skills to be those they would expect to find from any ED clinician [13].

There was a general consensus that ED physiotherapists are specialists in acute MSK assessment and management. Patients viewed physiotherapists as experts in MSK management [13–16], and some were happy to see a physiotherapist instead of a doctor [14]. Other patients referred to physiotherapist’s MSK specialism by explaining their experiences of treatment with a physiotherapist; for example, they talked about physiotherapists as practical professionals, providing hands-on treatment, exercises and functional assessments [13, 15].

All healthcare professionals in Lefmann and Sheppard’s study [12] valued the ability of ED physiotherapists to undertake a thorough MSK assessment and offer a specialist service for patients. Doctors also perceived this, saying “they are the experts” [11, p6]. Physiotherapists and doctors agreed that ED physiotherapists require enhanced MSK knowledge and appropriate skill to work in the ED [6, 11]. Advanced nurses perceived that ED physiotherapists had MSK expertise and even perceived their skill to be more advanced than that of ED doctors [16]. Doctors acknowledged that an MSK physiotherapy intervention combined with medical input allowed for an accurate diagnosis and thorough treatment strategy that was beyond ‘the norm’ of their ED [11]. Nurses and doctors felt that having MSK expertise improved quality of care and satisfaction for patients in the ED [11, 16].

Beyond the MSK expertise, all studies identified that patients viewed the ED physiotherapist as having a broad spectrum of clinical skills. Patients perceived physiotherapists to be very thorough clinicians [14–16] and felt that their assessments were thoroughly covering wide aspects of care, including social history, environment, and functional status [15]. Patients also viewed ED physiotherapists as being able to problem-solve and recognised their contribution in treating and managing pain, respiratory conditions and effectively treating the elderly [13, 15]. Patients had confidence in the clinical ability of ED physiotherapists [13] and were aware of their scope of practice; they were also satisfied that physiotherapists knew when to refer on [14].

Although physiotherapists themselves reported that, as well as being skilled in MSK conditions, they also had generic clinical skills [12], doctors and nurses in the same study did not, however, share this view, only discussing the MSK contribution physiotherapists brought to the ED ([12]. In a different study, physiotherapists agreed, reporting that their skill was ‘generic’ and that they also had additional training in occupational therapy and social work; however, this was the only study to mention specific cross-professional skill [6]. Physiotherapists perceived their care in the ED to be holistic [12]. Both doctors and physiotherapists acknowledged that physiotherapists were able to appropriately treat vestibular disorders, providing an alternative option for patients in the ED and accelerating patient care [11, 12]. Physiotherapists and doctors also perceived ED physiotherapists as having appropriate skills to treat elderly patients in the ED, undertake mobility and safety assessments [6, 11, 12] and wound care [11]—this was the only study that discusses this—although physiotherapists did express they would like to be trained in suturing [6]. Doctors and physiotherapists reported that ED physiotherapists had advanced or ‘extended scope’ skills in X-rays [6, 16] and plastering; however, there was no consensus amongst physiotherapists as to whether these skills were considered as ‘extended scope’ [6].

A valued aspect of the ED-based physiotherapist was their ability to inform, educate and advise. Patients perceived ED physiotherapists as being professional with enhanced communication skills [13–16] and that they were also empathetic, supportive and encouraging which aided patient confidence in coping with their injury [13, 14]. Patients reported receiving education and management strategies about how to manage their condition [13–16]. Patients recounted receiving advice on movement, safety and mobility aids and perceived physiotherapists to be valuable in developing their confidence to self-manage [15].

Healthcare professionals perceived that physiotherapy ED services were beneficial, but perceptions around how they achieved this varied. Physiotherapists felt they offered timely and efficient MSK assessment and treatment in the ED and were key in discharge planning and onward referral to ensure timely community or hospital care [6, 12]. Doctors and nurses agreed, saying that immediate physiotherapy input benefited onward continuity of care and recovery [11, 16]. Physiotherapy ED presence positively influenced the speed of ED care for others as the MDT was freed to see other cases [11]. This was especially beneficial from a nursing perspective when the ED was busy [12, 16]. However, some doctors in Lebec et al.’s study [11] believed that additional ED MDT members slowed patient turnover although they acknowledged that the time spent was crucial to patient care. Some doctors reported only understanding the benefits of an ED physiotherapy service after they had worked with ED physiotherapists [11]. Doctors were the only professional group that expressed that physiotherapists in the ED had unique personal characteristics, reporting that they enjoyed working alongside them. Physiotherapists and doctors expressed a requirement for physiotherapists to be educated to a specific clinical level to work in the ED environment [6, 12]. The physiotherapy ED service holds benefits for both staff and patients, and some doctors and nurses suggested that the hours of service should be extended [16].

The evidence base from patients was less clear as to the value of physiotherapists in ED. Some patients reported that they were unaware that their consultation had been with a physiotherapist, presuming instead the physiotherapist was a doctor [16]. Patients also reported that they had not expected to be treated by a physiotherapist in the ED [13, 15]. Patients who had previously experienced ED physiotherapy care expected to see a physiotherapist [15] particularly for an MSK issue [14].

There were variations in the level of patient satisfaction. Some patients suggested that the physiotherapy service was the best aspect of their ED experience [15] and others simply described a positive experience [14] or reported that it was adequate [15]. Positive satisfaction was expressed in relation to the organisation and speed of ED physiotherapy care [14, 16] and of follow-up care [13–15]. Some patients were not satisfied with seeing a physiotherapist in the ED and expressed that they would have preferred to have seen a doctor or a nurse [14]; however, other patients described their experience as “thorough” and “better than expected” [14].

There were varying views amongst healthcare professionals as to whether physiotherapists were working autonomously, but still as part of the ED MDT, or in complete isolation. Doctors viewed physiotherapists as part of the MDT, and acknowledged that they wished to work alongside physiotherapists to aid their own learning and were even happy for physiotherapists to question their own MSK diagnoses and for them to undertake the initial assessment [11, 12]. Doctors did express, however, that this was only once they trusted the physiotherapist’s clinical expertise [11, 12]. Physiotherapists reported that it was challenging to simultaneously try and enhance their clinical autonomy in the ED, while also trying to be accepted into the wider ED team. To overcome this, physiotherapists acknowledged that it was key to build strong relationships with medical colleagues and demonstrate clinical competence to aid trust [12]. Physiotherapists also felt they were always having to prove themselves in the ED and sought additional support beyond the ED environment from their wider physiotherapy network to avoid feeling professionally isolated [6, 12].

There was no conclusion as to whether an ED physiotherapy service provided an opportunity or professional challenge. Healthcare professionals acknowledged that ED physiotherapy remains an “unrecognised” aspect of ED care due to the poor understanding about what physiotherapists can offer patients and their clinical expertise [11, 12]. Doctors and nurses expressed caution over physiotherapists taking on advanced roles in the ED [12]. Nurses articulated concern that physiotherapists may be asked to treat some of their caseload [12]. However, some doctors perceived this new ED profession as healthy competition between the MDT [12]. Physiotherapists generally felt confident in their clinical ability but recognised there could be resistance to their presence from ED colleagues and perceived this as a reluctance to change and embrace new roles in an environment that has always been medically dominated [12]. Physiotherapists had divided views over whether their ED role should be seen as an opportunity to extend their scope of practice and professional boundaries, or whether they should simply work within their own remit and respect the expertise of other professionals [6].

Limitations

The studies included had methodological limitations, limiting the credibility of this review. Many of the studies that undertook interviews had very small sample sizes, and the majority only undertook their research in one ED for a limited timeframe, making it challenging for the findings to be applicable to larger populations [38]. Future studies need to consider including a larger variation of population groups across more ED sites, this would build on the themes generated in this review and enhance understanding of patient and healthcare professionals’ experiences and perceptions of ED physiotherapy services. This review also included a prospective observational study which collected a variety of data [16], as it was the only study to provide data for both population groups although the qualitative data provided was minimal. The research is dominated by Australia and by two researchers in particular so transferability to other healthcare systems is limited. Separate, independent quality appraisal and data extraction of each article included, with subsequent discussion to achieve consensus, reduced the potential for bias to occur.