Research Report

Physical Therapist Practice in the

Acute Care Setting:
A Qualitative Study

Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023

Pauline M. Masley, Carey-Leah Havrilko, Mark R. Mahnensmith, Molly Aubert,
Diane U. Jette
P.M. Masley, PT, DPT, was a stu-
dent in the Department of Reha-
bilitation and Movement Science,
Background. Physical therapist practice in the acute care setting is not thor-
University of Vermont, Burlington, oughly understood, and it has been argued that skilled care is not required.
Vermont, at the time of the study.

C.-L. Havrilko, PT, DPT, was a stu-

dent in the Department of Reha-
bilitation and Movement Science,
University of Vermont, at the time
of the study.
M.R. Mahnensmith, PT, DPT, was
a student in the Department of
Rehabilitation and Movement Sci-
ence, University of Vermont, at
the time of the study.
M. Aubert, PT, DPT, was a student
in the Department of Rehabilita-
tion and Movement Science, Uni-
versity of Vermont, at the time of
the study.
D.U. Jette, PT, DSc, is Professor
and Chair, Department of Rehabil-
itation and Movement Science,
University of Vermont, Rowell
Building, 106 Carrigan Rd, Burl-
ington, VT 05401 (USA). Address
all correspondence to Dr Jette at:
diane.jette@uvm.edu.
[Masley PM, Havrilko C-L, Mah-
nensmith MR, et al. Physical ther-
apist practice in the acute care set-
ting: a qualitative study. Phys Ther.
2011;91:906 –919.]
© 2011 American Physical Therapy
Association
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 informa-
tion, 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.

Post a Rapid Response to

this article at:
ptjournal.apta.org

906 f Physical Therapy Volume 91 Number 6 June 2011


T
he American Physical Therapy
Association’s annual Rothstein
Debate in 20071 revealed vari-
ous 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 phys-
ical 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 underuti-
lized. Some participants suggested
that ambiguity about the role of
physical therapists in acute care set-
tings might be partially attributed to
shortfalls in education, whereas oth-
ers 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 under-
standing of patient outcomes attrib-
utable to physical therapy manage-
ment in acute care settings. Physical
therapists at the 2007 Rothstein
Debate provided only anecdotal evi-
dence in support of their work, not-
ing that they observed patients get-
ting better and leaving the hospital
every day.
The acute care setting is character-
ized by short patient stays brought
about by 2 decades of changing eco-
nomics in the US health care system.
These changes have demanded
increased efficiency and effective-
ness of patient care and have
resulted in both fewer physical ther-
apy sessions for patients and changes
in the types of goals set for an epi-
sode of care.2 Such changes in prac-
tice have given rise to the question
of whether physical therapy is valu-
able in such a limited time frame.
June 2011
Physical Therapist Practice in the Acute Care Setting
Indeed, in the context of so many
interventions from various health
care providers in the acute care set-
ting, one might ask how much
patient improvement can be attrib-
uted to physical therapy alone.
There appears to be little informa-
tion describing the distinctive
knowledge and skills that physical
therapists use in the care of patients
in the acute care setting. Further-
more, as evidenced by comments at
the 2007 Rothstein Debate, physical
therapists are aware of the percep-
tion 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 reason-
ing and decision making that can be
accomplished only by people who
are educated as physical therapists.
Several recent studies described var-
ious 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 pro-
cesses of both physical therapists
and occupational therapists as
related specifically to patient dis-
charge 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 med-
ical centers in the United States in
2008 indicated that practice cen-
tered 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 readmis-
sion for patients discharged to set-
tings recommended by physical ther-
Volume 91
apists than for patients discharged to
settings not in concert with physical
therapists’ recommendations, sug-
gesting 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
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
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 lim-
ited 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 physi-
cal 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 partici-
pants (physical therapists) in
describing, interpreting, and analyz-
ing various aspects of their clinical
practice. Grounded theory is based
on a method of systematic collection
and analysis of qualitative informa-
Available With
This Article at
ptjournal.apta.org
• Discussion Podcast with Gail
Jensen, Sharon Gorman, and
author Diane Jette. Moderated by
Rebecca Craik.
• Audio Abstracts Podcast
This article was published ahead of
print on April 21, 2011, at
ptjournal.apta.org.
Number 6 Physical Therapy f 907
Physical Therapist Practice in the Acute Care Setting

Table 1. convenience sample based on the

Facility Characteristics principal investigator’s acquaintance
Data for Facility:
with managers at the 3 academic
medical centers and their willingness
Characteristic 1 2 3
to facilitate the study. Data were
Size (no. of licensed beds) 430 675 777
available from 18 of the 20 physical
Average patient length of stay (d) 5.2 4.1 4.5 therapists who initially agreed to
Average daily full-time equivalents (physical therapists participate; 1 therapist was unavail-
and physical therapist assistants) on: able during the data collection
Weekdays 14 19 13 period, and 1 therapist could not
Weekends 4 10 5 be reached. The participants are
described in Table 2.

Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023

tion with the purpose of generating a
theory that explains a social or psy-
chological phenomenon.7 Using the
participants’ perspective, investiga-
tors attempt to explain how people
in a specific setting understand, take
action, manage, and interact in day-
to-day situations. A guiding assump-
tion of grounded theory is that there
is a “basic social psychological pro-
cess” 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 Com-
mittee on Human Subjects at the Uni-
versity of Vermont and their own insti-
tutions, if required. This was a
Procedure
Semistructured interviews were con-
ducted via telephone or in person,
depending on the availability of par-
ticipants 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 com-

Table 2.
Participant Characteristics
Years
Practicing
in Acute Highest
Participant Years Care Professional Certified
No. Institution Sex Practicing Settings Degree Specialization

1 1 Female 2.5 2.5 DPT None

2 1 Female 9 9 DPT Neurology

3 1 Female 5 5 MSPT None

4 1 Female 9 9 DPT Geriatrics

5 1 Female 32 12 DPT Neurology

6 1 Female 6 3 MSPT None

7 1 Female 6.5 6.5 MSPT None

8 1 Female 3 3 MSPT None

9 2 Female 4 4 DPT None

10 2 Female 3 3 DPT None

11 2 Female 4.5 4.5 MSPT None

12 2 Male 2.5 2.5 DPT None

13 2 Male 7 7 DPT Cardiopulmonary

14 3 Female 24 21 BS None

15 3 Female 13 10 DPT None

16 3 Female 22 10 BS None

17 3 Male 29 29 DPT Cardiopulmonary

18 3 Female 13 12 MSPT None

908 f Physical Therapy Volume 91 Number 6 June 2011


piled 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 set-
ting.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 con-
ducted 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 thera-
pists 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 discus-
sion and provide rich descriptions of
the clinical reasoning processes
underlying physical therapists’ deci-
sions and actions, the context or
environment in which they prac-
ticed, and their perceptions of the
roles that they played in their prac-
tice 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) Partici-
pants controlled the flow of informa-
tion so as to limit the extent to
which the interviewer led the discus-
sion. For example, we asked partici-
pants what criteria they used to
decide whether a patient received
physical therapy service. If a partici-
pant said that he or she first deter-
mined whether a patient was medi-
cally stable, then the interviewer
asked the participant to talk more
about what medical stability meant
and how to determine medical sta-
bility. If a participant mentioned that
June 2011
Physical Therapist Practice in the Acute Care Setting
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 con-
stant 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 investiga-
tion. For example, when a new con-
cept 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 iden-
tify ways in which subsequent inter-
views could be improved to provide
additional detail and depth of infor-
mation. 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 par-
ticipant 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 deter-
mined that no new participant
recruitment was required when it
Volume 91
became evident that no new infor-
mation was emerging from inter-
views with the 18 participants.
When the interviews were com-
pleted, we searched the transcripts
for the prime indicators of various
concepts, confirming or disconfirm-
ing our original labels and determin-
ing whether all concepts had been
discovered. Meetings progressed
through an iterative process in
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
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 itera-
tive process of proposal, debate,
refinement and, finally, group con-
sensus. We then reassessed the tran-
scripts to confirm or refute the
themes that were agreed upon. We
also sought to compare themes
within each setting and across set-
tings.11 Next, we selected specific
quotations that supported and best
exemplified the themes. Using the
themes and their hypothesized rela-
tionships, we developed a working
theoretical model to describe the
decision-making process, the role of
physical therapists, and the context
for providing physical therapy ser-
vices in the acute care setting.
After we defined the themes and
developed a working theoretical
model, we summarized the themes
and their meanings with support-
ing quotes and provided this
material to participants for their
review.12(pp275–276) Participants
were invited to confirm, refute, elab-
orate on, or suggest edits for the
themes and the meanings that we
had assigned. This process of mem-
ber 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
Number 6 Physical Therapy f 909
Physical Therapist Practice in the Acute Care Setting
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 feed-
back about the relationships of the
themes and suggested 1 additional
theme that was incorporated into
the model.
Results
Eight themes that described the clin-
ical 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 analy-
sis of medical information, applica-
tion of specialized physical therapy
knowledge, communication to gain
information, and communication to
provide information—suggested the
fundamental core from which clini-
cal 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 appropri-
ateness 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 per-
son’s hematocrit is very low, then
we may want to wait until they get a
blood transfusion” (PT-9). Partici-
pants also used medical information
to formulate an overall image of a
910 f Physical Therapy Volume 91
patient’s presentation and what their
approach to patient care might be
before they met the patient: “You
start making decisions from the min-
ute you start looking at the chart”
(PT-14). Participants expressed the
need to apprise themselves of diag-
nostic test results, imaging reports,
surgical procedures, and other data
that might indicate activity precau-
tions, such as weight-bearing status,
blood pressure, heart rate, and oxy-
gen saturation. They also identified
the need to understand the implica-
tions 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 physi-
cal therapy knowledge. Partici-
pants reported the importance of
their expertise in mobility and move-
ment 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 func-
tion” (PT-4). This specialized knowl-
edge 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 dur-
ing a treatment session. Participants
noted that physical therapists are
concerned with the quality, effi-
ciency, and functionality of move-
ment, 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 partici-
pant noted, “I want to see what that
‘walking around’ means. I want to
see the quality of it” (PT-5).
Number 6
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 special-
ized knowledge about movement
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
and function was what separated
them from nurses or technicians
who might walk up and down a hall-
way 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 dif-
ferences 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’ dis-
tinct 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 informa-
tion. Participants noted that they
perpetually acquired information
about their patients from a number
of sources. Physical therapists rou-
tinely spoke with patients, families,
and team members such as nurses,
physicians, and case managers to col-
lect information regarding patients’
June 2011

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 infor-
mation about a patient’s status and
progress since the previous session
was thought to be essential to effi-
cient 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 set-
ting, as well as discharge planning:
“We want to know about their pre-
vious 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 infor-
mation. In addition to acquiring
information about their patients, par-
ticipants consistently spoke with
patients, families, and team members
to report patients’ status and prog-
ress. 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 recommen-
dations 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 prog-
ress, 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
June 2011
Physical Therapist Practice in the Acute Care Setting
rate, oxygen level—let them know if
I weaned the patent off of oxygen,
anything like that” (PT-7). Partici-
pants believed that it was necessary
to provide nursing staff with infor-
mation to help them understand a
patient’s functional abilities and
allow nurses to continue the mobil-
ity 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 com-
munication 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 val-
ued 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 spe-
cifically, ‘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 par-
ticipant 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 depart-
ment: “Her reflexes were inconsis-
tent from right lower extremity to
left lower extremity. Her coordina-
tion 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
Volume 91
[computed tomography] scan, and
she had multiple sclerosis” (PT-17).
Encompassing Constructs
Three themes— continual dynamic
assessment, professional responsibil-
ity, and complex environment—
encompassed and incorporated the
fundamental core, suggesting the
influence of perceived role and envi-
ronment on clinical reasoning
processes.
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
Continual dynamic assessment.
We conceptualized continual
dynamic assessment as on-the-spot,
reiterative clinical reasoning. Contin-
ual dynamic assessment involved a
within-session, moment-to-moment
process of recurring evaluation,
adaptation of interventions, and
adjustment of goals as a session pro-
ceeded and a patient responded to
an intervention. It required analysis
of medical data, use of specialized
knowledge, and integration of infor-
mation gleaned from reading a med-
ical record and from communication
with the patient and other health
care team members. Participants
noted the need to continually moni-
tor 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, depend-
ing on how a patient was reacting:
“When you’re [with the patient]
you’re always thinking about should
I proceed to the next step, physio-
logically? 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
Number 6 Physical Therapy f 911
Physical Therapist Practice in the Acute Care Setting
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 satura-
tion) 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. Par-
ticipants 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 communica-
tions with others, their clinical rea-
soning, and the decisions they made.
We conceptualized professional
responsibility as exercising profes-
sional expertise to advocate for
patients and contribute to the quality
of patient care. Participants upheld
this responsibility through various
means, including maintaining stan-
dards of practice, educating others
about their practice, providing edu-
cation to other health care profes-
sionals 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 pro-
fessional competence and our pro-
fessionalism, and part of that is main-
taining 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 litera-
ture in my assessment statements
912 f Physical Therapy Volume 91
supporting my prognostic indicators
or my discharge plans as often as I
can.”
As part of their professional respon-
sibility, 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 sin-
gle 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 cer-
tain 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: “Basi-
cally 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 responsibil-
ity included making decisions about
which patients should receive phys-
ical therapy services and how best to
provide that care. We heard partici-
pants express concern about some-
times improper utilization of physi-
cal therapy in the hospital: “I feel like
we can be inappropriately used as a
walking service” (PT-2). Another par-
ticipant 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
Number 6
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 resi-
dents think our role is purely just
walking, as opposed to doing true
assessments of gait, of balance, of
mental status, of safety” (PT-10). Par-
ticipants believed that these situa-
tions were opportunities to uphold
their professional responsibility by
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
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 com-
ponent of professional responsibility
as advocating for patients’ best inter-
ests, 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 contrib-
uting to the safety of health care
team members through education
about mobilizing patients. As noted
by one participant, “After we evalu-
ate 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 contin-
ued, “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. Partici-
pants described the acute care set-
ting as a complex environment char-
acterized by a fast pace, multiple
interactions, ubiquitous high-tech
equipment, and the precarious
June 2011

nature of patients’ health and physi-
ological states. The environment
influenced all aspects of physical
therapy care in the acute care setting
as well as the roles and responsibili-
ties of the physical therapists work-
ing in it. The environment required
the understanding of medical infor-
mation and the application of spe-
cialized knowledge and dictated the
need for continual and rapid assess-
ments: “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 recogniz-
ing worsening of mental status as
potential recurrence of hemorrhag-
ing in the brain, recognizing abnor-
mal neurological findings that physi-
cians 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 antici-
pate the patient’s progress much
quicker” (PT-7). With regard to
deciding the most effective interven-
tions 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
June 2011
Physical Therapist Practice in the Acute Care Setting
stuff” (PT-5). At the same time, par-
ticipants remarked that, unlike phys-
ical therapy in other settings, physi-
cal 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 decondi-
tioning” (PT-5).
Participants noted that providing
patient care in this complex environ-
ment 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 through-
out 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). Addi-
tionally, communication was viewed
as being critical to the safety of
patients in an environment in which
patients’ physiological status could
rapidly change. Participants per-
ceived the level and diversity of com-
munication 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 ful-
filling their professional role and
responsibilities and using continual
dynamic assessment while integrat-
ing the information collected from
the medical record, from the patient
examination, and from communica-
tion 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
Volume 91
patients want . . . and trying to com-
bine 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 examina-
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
tions, intensity of exercise, or dura-
tion of session and between-session
decisions about frequency of treat-
ment. As an example, one partici-
pant 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 mak-
ing 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 med-
ications, then I’m probably not going
to see them, . . . . I would be cau-
tious of a patient [who] was requir-
ing 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 deci-
sion 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 set-
ting: “I see us as sort of being the
Number 6 Physical Therapy f 913
Physical Therapist Practice in the Acute Care Setting
Figure.
Theoretical model.
triage system for all of the other ther-
apies 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 diagno-
sis, 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
914 f Physical Therapy Volume 91
leans on us to make a decision
whether a patient can go home or go
to rehab to get their process mov-
ing” (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 ele-
ments necessary for clinical reason-
ing and its reiterative quality, the
environment in which clinical rea-
soning was accomplished, the
results of the clinical reasoning pro-
cess, and physical therapists’ per-
spective on their role in the acute
Number 6
care setting. The theoretical model
shown in the Figure represents the
themes and their relationships and
interactions. The complex practice
environment interacted with partici-
pants’ sense of professional respon-
sibility and shaped their clinical rea-
soning processes and their decisions
regarding patient care. As evidenced
by the descriptions of our partici-
pants and as noted by Edwards and
Jones,13 the process of clinical rea-
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
soning 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.
Although an episode of care in the
acute setting has a well-defined
beginning and end, our model sug-
gests 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 clin-
ical reasoning and decision making
and a willingness to change a plan
instantaneously during a single treat-
ment session as well as across the
episode of care. The process contin-
ued until the ultimate patient out-
come in the acute care setting: dis-
charge to the next, appropriate level
of care. Similarly, Smith et al,6 in
describing decision making by car-
diorespiratory physical therapists in
the acute care setting, and Edwards
et al,14 in describing the clinical rea-
soning of orthopedic and neurologic
physical therapists in private prac-
tice and physical therapists in home
health care settings, found that the
processes were multifaceted, com-
plex, 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) applica-
tion of specialized physical therapy
knowledge, (3) communication to
gain information, and (4) commu-
June 2011

nication 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 ther-
apist to attend to certain data from
monitoring equipment as he or she
analyzed the patient’s safety and abil-
ity to move from a supine position
to a sitting position. Changes in the
monitored physiological data during
the intervention might then deter-
mine the parameters of the treat-
ment session and what was com-
municated 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, treat-
ment precautions and contraindica-
tions, pharmaceutical benefits,
adverse effects and interactions, and
normal versus abnormal physiologi-
cal responses to movement both
before and during treatment ses-
sions. 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 reason-
ing, there did not appear to be as
strong an emphasis on the need to
June 2011
Physical Therapist Practice in the Acute Care Setting
collect and quickly interpret medical
information for decision making in
other physical therapist practice set-
tings as in acute care settings.14 –16
In the clinical reasoning process
described by our participants, medi-
cal knowledge and specialized phys-
ical therapy knowledge interacted in
several ways. For example, partici-
pants considered how movement
might compromise medical stability
or how medical conditions or medi-
cations might affect patients’ physi-
ological responses to movement or
compound safety issues. The physi-
cal therapists understood, antici-
pated, 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 knowl-
edge and skills to evaluate safety and
independence in functional mobil-
ity. This approach represented diag-
nostic reasoning in that it included
gathering and interpreting of infor-
mation 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. Simi-
larly, Smith et al6 described how
cardiorespiratory physical therapists
used the response to an interven-
tion to improve their understand-
ing of a patient’s condition. Watch-
ing patients move has also been
shown to be an important source of
information for physical therapists’
decision making in other care set-
tings16,17 but may focus on impair-
ments 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, pneumo-
Volume 91
nia, 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 ther-
apists in acute care settings had goals
and interventions related to func-
tion, regardless of the type of diag-
nosis.4 Similarly, participants in an
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
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 pur-
pose. Their communications formed
elements of both diagnostic and nar-
rative clinical reasoning.13,14 In the
context of the acute care setting, nar-
rative, or patient-centered, reasoning
appears to take the form of under-
standing the impact of patients’
needs and wants, culture, and the
social-economic environment on dis-
charge 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 his-
tory, 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 communi-
cate with the number and variety of
other health care providers regard-
ing each patient in other settings as
Number 6 Physical Therapy f 915
Physical Therapist Practice in the Acute Care Setting
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 rec-
ommendations. This result may rep-
resent an evolving and improving
role for physical therapists in acute
care settings, because at least one
earlier study indicated difficult inter-
actions 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 occur-
ring during continual dynamic
assessment was largely diagnostic
reasoning.13 That is, during sessions
physical therapists observed and ana-
lyzed patients’ subjective reports of
how they were feeling and the func-
tion 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 aban-
doned 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 phys-
ical therapists revised decisions
throughout all aspect of the episode
of care and incorporated information
about changes in patients’ condi-
tions into decisions about interven-
tions. The constant and repeated
assessment of the “whole patient”
916 f Physical Therapy Volume 91
transpired to maintain the patient’s
safety while working toward improv-
ing function and independence and
securing the most appropriate dis-
charge 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 assess-
ment. This theme reflected the pro-
fession’s core values of accountabil-
ity, excellence, and professional
duty.21 Accountability was mani-
fested in participants accepting their
diverse roles in the acute care set-
ting, including educating other
health care team members about
their role, determining whether
patients require their care, and work-
ing with nurses to enhance their
safety. It appears that in the acute
care setting, the role of physical ther-
apy can be misunderstood. Partici-
pants described having to explain
their scope of practice to other pro-
viders 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 edu-
cating 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 main-
taining 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 func-
tion as a “walking service.” The
theme of professional responsibility
also had elements of the core value
Number 6
of excellence. Participants noted
their obligation to uphold profes-
sional standards by consistently
using current knowledge and theory
in their care of patients and by cre-
ating written, evidence-based stan-
dards of care for physical therapy
staff to reference. Excellence also
was demonstrated by participants
noting the need for ongoing profes-
sional development. Finally, the
theme of professional responsibility
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
reflected the core value of profes-
sional duty. Participants were com-
mitted to their ultimate role of advo-
cating for the best interests of
patients and providing effective
physical therapy services.
Professional responsibility in acute
care physical therapy was docu-
mented by Lopopolo in 1999.18 Par-
ticipants in her study described the
role of physical therapists in acute
care settings as including highly inte-
grated clinical reasoning and high
levels of communication and collab-
oration 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 prac-
tice seemed to reflect a feature of
expert physical therapists reported
by Jensen et al,17 that is, patient
advocacy accomplished through
constant communications with oth-
ers involved in patient care.
Complex environment. The
complex environment created the
overall context within which physi-
cal 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 inter-
fering or distracting activity occur-
ring near the physical therapist-
patient interaction. The acute care
setting also is an intellectually com-
plex environment, requiring physi-
June 2011

cal 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 fea-
tures 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 associ-
ated with a decision. These features
are unlikely to dominate other inpa-
tient or outpatient rehabilitation set-
tings and have not been reported in
studies of physical therapists in out-
patient and home health care
settings.14,15
Decision making for patient care.
In our model, decision making for
patient care was the result of reiter-
ative clinical reasoning and took
place within the context of physical
therapists’ professional responsibili-
ties in a complex environment. On
the micro level, the decision-making
process used in the acute care set-
ting could be likened to knowing-in-
action, as described by Schön.20 That
is, participants demonstrated flexi-
bility in their decision making; deci-
sions were based on tacit knowledge
and intuition and resulted in instan-
taneous actions. In turn, patients’
responses to those actions influ-
enced subsequent decisions. Smith
et al6 reported similar features of
decision making by physical thera-
pists in the acute care setting.
Macro-level decision making com-
prised consideration of the whole
patient in designing and implement-
ing an optimal plan of care for the
episode of care and recommending a
discharge setting. Patient care at the
macro level included instrumental
June 2011
Physical Therapist Practice in the Acute Care Setting
approaches (selecting and interpret-
ing examinations and interventions)
and communicative approaches
(addressing the unique perspective
of patients, such as fears and expec-
tations).13 Decisions relied on par-
ticipants’ 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 refer-
ral. Their initial impressions were
subject to change, but the anticipa-
tion of a rapid discharge constantly
influenced the decision-making pro-
cesses. Previous studies also cited
the important role of physical thera-
pists in discharge planning and dis-
charge recommendations in the
acute care setting.4,5,18
Implications for Practice in the
Acute Care Setting
Recent research supports the propo-
sition that physical therapists’ deci-
sion making in the acute care setting
has long-term positive effects on
patients.5 The results of our study
support the important role of phys-
ical therapists in the acute care
setting. Their knowledge, clinical
reasoning skills, decision-making
capabilities, and professional respon-
sibilities indicate that physical thera-
pists in the acute care setting pro-
vide 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 set-
tings.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 fea-
tures include the constant applica-
Volume 91
tion of medical information and the
integration of that information with
specialized physical therapy knowl-
edge; 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 vari-
ous discharge settings; and a
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
crowded, complex, fast-paced envi-
ronment. However, the major con-
cerns of physical therapists in the
acute care setting, like physical ther-
apists in other settings, are patient
safety and functional mobility. We
believe that this information may be
helpful to those who educate profes-
sional (entry-level) physical therapist
students in preparing them for prac-
tice 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 meth-
ods may not be representative of
those in other medical centers or
geographic areas. We also did not
observe participants in their prac-
tices, relying solely on their per-
ceptions of the content and con-
text of their practices. In addition,
researcher bias may have influenced
the development of our themes and
model. When we asked our partici-
pants to review our findings, how-
ever, 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 dif-
ferent parts of the United States and
around the world. Additional areas of
Number 6 Physical Therapy f 917
Physical Therapist Practice in the Acute Care Setting
research that could be explored
include a comparison of clinical rea-
soning processes and decision mak-
ing 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 phys-
ical therapists, the clinical reasoning
processes used by physical thera-
pists, 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 mobil-
ity and to engage in rapid and con-
tinual assessment of patients and
their responses to movement. The
practice environment was highly
complex, involving patients who
were medically unstable and were
undergoing technological monitor-
ing 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 environ-
ment in which they worked. A con-
tribution was the recommendation
of the appropriate discharge setting
918 f Physical Therapy Volume 91
for each patient. The findings sup-
port an important and specialized
role for physical therapists in the
acute care setting.
All authors provided writing and data anal-
ysis. Dr Jette provided concept/idea/research
design and institutional liaisons. Dr Masley,
Dr Havrilko, Dr Mahnensmith, and Dr Aubert
provided data collection.
This article was submitted September 2, 2010,
and was accepted February 18, 2011.
DOI: 10.2522/ptj.20100296
References
1 American Physical Therapy Association.
Rothstein Debate weighs PTs in acute care.
PT 2007: Highlights. http://www.apta.org/
PTinMotion/2007/9/PT2007/. Accessed
March 29, 2011.
2 Holt P, Winograd CH. Prospective pay-
ment and the utilization of physical ther-
apy service in the hospitalized elderly.
Am J Public Health. 1990;80:1491–1494.
3 Jette DU, Grover L, Keck CP. A qualitative
study of clinical decision making in recom-
mending discharge placement from the
acute care setting. Phys Ther. 2003;83:
224 –236.
4 Jette DU, Brown R, Collette N, et al. Phys-
ical therapists’ management of patients in
the acute care setting: an observational
study. Phys Ther. 2009;89:1–24.
5 Smith BA, Fields CJ, Fernandez N. Physical
therapists make accurate and appropriate
discharge recommendations for patients
who are acutely ill. Phys Ther. 2010;90:
693–703.
6 Smith M, Higgs J, Ellis E. Characteristics
and processes of physiotherapy clinical
decision making: a study of acute care car-
diorespiratory physiotherapy. Physiother
Res Int. 2008;13:209 –222.
7 Chenitz WC, Swanson JM. From Practice
to Grounded Theory. Menlo Park, CA:
Addison-Wesley Publishing Co Inc; 1986.
8 Hutchinson SA, Wilson HS. Grounded the-
ory: the method. In: Munhall PL, Oiler
Boyd C, eds. Nursing Research: A Quali-
tative Perspective. 2nd ed. New York, NY:
National League for Nursing Press; 1993:
209 –243.
Number 6
9 Glaser BG. Basics of Grounded Theory
Analysis. Mill Valley, CA: Sociology Press;
1992.
10 Munhall PL. Revisioning Phenomenology:
Nursing and Health Sciences Research.
New York, NY: National League for Nurs-
ing Press; 1994.
11 Boeije H. A purposeful approach to the
constant comparative method in the anal-
ysis of qualitative interviews. Qual Quant.
2002;36:391– 409.
12 Miles MB, Huberman AM. Qualitative
Data Analysis. Thousand Oaks, CA: Sage
Publications Ltd; 1994.
13 Edwards I, Jones MA. Clinical reasoning
and expert practice. In: Jensen GM, Gwyer
Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023
J, Hack LM, Shepard KF, eds. Expertise in
Physical Therapy Practice. 2nd ed. St
Louis, MO: Saunders Elsevier; 2007:209.
14 Edwards I, Jones M, Carr J, et al. Clinical
reasoning strategies in physical therapy.
Phys Ther. 2004;84:312–330.
15 May S, Greasley A, Reeve S, Withers S.
Expert therapists use specific clinical rea-
soning processes in the assessment and
management of patients with shoulder
pain: a qualitative study. Aust J Phys-
iother. 2008;54:261–266.
16 Wainwright SF, McGinnis PQ. Factors that
influence the clinical decision-making of
rehabilitation professionals in long-term
care settings. J Allied Health. 2009;38:
143–151.
17 Jensen GM, Gwyer J, Shepard KF, Hack
LM. Expert practice in physical therapy.
Phys Ther. 2000;80:28 – 43.
18 Lopopolo RB. Hospital restructuring and
the changing nature of the physical thera-
pist’s role. Phys Ther. 1999;79:171–185.
19 Curtis KA, Martin T. Perceptions of acute
care physical therapy practice: issues for
physical therapist preparation. Phys Ther.
1993;73:581–594.
20 Schön D. Educating the Reflective Practi-
tioner. San Francisco, CA: Jossey-Bass;
1987.
21 American Physical Therapy Association.
Professionalism in physical therapy: core
values. Available at: http://www.apta.
org/uploadedFiles/APTAorg/About_Us/
Policies/BOD/Judicial/Professionalismin
PT.pdf. Accessed March 29, 2011.
June 2011
 Physical Therapist Practice in the Acute Care Setting

Appendix.
Potential Interview Questions

What are the criteria used by physicians or nurses when they decide to refer patients for physical therapy? Are they
implicit or explicit? How do the criteria vary by the type of service or unit the patient is on?
When a patient is referred for physical therapy, what are the criteria you use to decide whether the patient receives
physical therapy services?
How do you decide whether or not a patient receives ongoing intervention?
What are the decisions you have to make before, during, and after patient treatment sessions?
Talk about the kinds of information and thoughts that go through your head as you care for patients.

Downloaded from https://academic.oup.com/ptj/article/91/6/906/2735037 by guest on 12 March 2023

What factors influence your decision to . . .?
How critical do you think your decision is to the [progress, safety, motivation, etc.] of the patient?
How often do you have to make decisions about . . .?
How is the decision to . . . influenced by input from other health care professionals?
How are the types of decisions you make different from those physical therapists make in other areas of practice?
How would patients’ care differ if physical therapists were not there?
What is the perception of physical therapists in acute care settings?

Invited Commentary Cynthia Coffin-Zadai

Masley and colleagues are to be
applauded for pursuing this impor-
tant qualitative line of practice anal-
ysis that identifies and begins to
answer the question of what physi-
cal therapists specifically contribute
to the management of patients in the
acute hospital environment.1 One
essential value derived from probing
the content and outcome of the
physical therapist’s contribution is
the creation of a detailed description
of acute care practice that can lead
to valid quantitative study. Specifi-
cally determining which patients
benefit most from physical therapist
management allows us to eliminate
unnecessary care and deliver tar-
geted care more efficiently. An addi-
tional and equally important out-
come will be our ability to better
define the professional skill set phys-
ical therapists require to provide the
identified services.
This study has described the acute
care practice environment as fast
paced, time sensitive, complex, and
interactive. That setting-specific
description helps identify the envi-
ronmental changes that have
occurred as the length of stay has
shortened in response to dwindling
reimbursement. According to the
Centers for Disease Control and Pre-
vention’s National Center for Health
Statistics, the number of hospital
days of care for patients of all ages
was 226 million in 1970 compared
with only 166 million in 2006.2 Sim-
ilarly, the average length of stay was
7.8 days in 1970 and 4.8 days in
2006. Today’s hospital environment
is one where patients are admitted
for procedures, invasive medical
management, and surgical interven-
tions while longer-term healing,
recovery, and rehabilitation occur
elsewhere.
As a result, questions have been
raised regarding the relevance of
physical therapist intervention and
management, commonly associated
with the more lengthy rehabilitation
phase of care, being delivered in
such a fast-paced setting.3 The
responses of the physical therapists
interviewed in the study by Masley
and colleagues suggest something
else is occurring.1 The themes of this
article and previous studies regard-
ing the role of the physical therapist
seem to demonstrate that physical
therapists have evolved to becoming
valued professional consultants who
provide a unique, essential perspec-
tive, rendering them integral contrib-
utors to the acute care team.4 – 6
Today’s physical therapists special-
ize in evaluating and managing the
patient’s functional mobility needs
and, within that scope, serve as both
consultants and effective transitional
care providers.

June 2011 Volume 91 Number 6 Physical Therapy f 919