Nurse's perceptions of physiotherapists in critical care team: Report of a qualitative study.

BACKGROUND: Interprofessional relationship plays a major role in effective patient care. Specialized units such as critical care require multidisciplinary care where perception about every members role may affect the delivery of patient care. The objective of this study was to find out nurses' perceptions of the role of physiotherapists in the critical care team.
METHODS: Qualitative study by using semi-structured interview was conducted among the qualified nurses working in the Intensive Care Unit of a tertiary care hospital. The interview consisted of 19 questions divided into 3 sections. Interviews were audio recorded and transcribed. In-depth content analysis was carried out to identify major themes in relation to the research question.
RESULTS: Analysis identified five major issues which included role and image of a physiotherapist, effectiveness of treatment, communications, teamwork, and interprofessional relations. Physiotherapists were perceived to be an important member of the critical team with the role of mobilizing the patients. The respondents admitted that there existed limitations in interprofessional relationship.
CONCLUSION: Nurses perceived the role of physiotherapist in the critical care unit as an integral part and agreed on the need for inclusion of therapist multidisciplinary critical care team.

Introduction

Interdisciplinary teamwork is an essential component of holistic care since team members’ skills, experience, and knowledge are pooled together to produce the best outcomes.[1] Each of the members in the Intensive Care Unit (ICU) team plays a unique role according to the patients need. Physiotherapy has been accepted as an integral component of the management of patients who require intensive care and physiotherapists play a unique role as a part of the ICU team.[2] Physiotherapists are elemental team representatives of the clinical healthcare team, and they need to understand other practitioners’ roles and communicate effectively to provide high-quality, coordinated patient care.[3] A nurse on the other hand plays a vital role in critical care unit serves as an important communicator in the ICU team. Every professional perceives differently about their colleagues from other field of health care.[4]

Nurses make up a large component of the healthcare sector and are essential in the interprofessional healthcare team in a hospital setting. This perceived dominant role may influence the power relationship between nurses and physiotherapists. In the current demanding healthcare environment, interprofessional team practice is being promoted as a comprehensive means of providing cost-effective healthcare.[5] Literature suggests that professional specialization has led to a fragmentation between professions, which is likely to result in health care team members being unable to look at problems of patient as a whole team.[6] A small number of studies have highlighted a part of the attitudes and perceptions that may underlie interprofessional relationships and their effect on teamwork and effectiveness of management in critical care.[7] Communication is being identified of particular interest because of the complex sociotechnical tendency of the ICU environment. Interpersonal factors have been reported as the main causes of stress in high-dependency areas whereas poor communication reported as cause of errors.[8]

A study exploring interprofessional perceptions of physiotherapists and midwives, using the nominal group technique and follow-up questionnaires, identified the lack of awareness about each other's discipline.[9] Another study examined the nurse–occupational therapist interface and established that there was little similarity between the work of nurses and therapists, which produced conflicts in patient handling.[10]

There stands a scarcity of literature in the Indian hospital setting for incorporating interdisciplinary practice in the critical care setting and role perception between health care providers of various professions. Further research about collaboration and communication between physiotherapists and nurses in the critical care unit will serve as base to improve the interprofessional relationships. The objective of this study was to examine nurses’ perceptions of role of physiotherapists in the critical care team at a tertiary care teaching hospital in India.

Methods

This study was designed to examine nurses’ perceptions and experiences, rather than to measure specific identified attitudes; semi-structured interview was used as an appropriate method. Critical care nurses with the minimum experience of 6 months were recruited for the interview, after obtaining written informed consent. This study was approved by the Institution Ethics Committee of Father Muller Charitable Institutions.

A purposive, random sample of 33 nurses was obtained. This sample size was chosen to allow in-depth exploration and range of perceptions. As the study was exploratory, it did not aim to secure a strictly representative sample. A written informed consent was obtained from each participant before the commencement of the interview. Investigators personally contacted the nursing supervisor from each unit to identify the total number of nurses working in that critical care team and also to recognize the ones fulfilling the inclusion criteria. Once they were identified, the interviewer individually approached them and fixed up a specific time for interview according to the convenience.

The interview questions were developed based on previous literature and from discussions with various experienced ICU team members. The interview questions focused on the following general issues: Existence of physiotherapist in the ICU, the role they played, and various techniques used by the therapists while providing ICU care. Questions about the interaction and communication between the nurses and therapists within the ICU were also asked. In addition, questions related to multidisciplinary practice and its necessity were also included to know their perceptions. Although a common interview guide was used for all interviews, the precise manner in which questions were raised varied in response to the direction of each interview.

In each case, however, the style of the interview was informal and unstandardized, and a nonjudgmental stance was taken to participants reported perceptions and experience. The interview took place for 15–20 min in a silent room where there was no disturbance. The interviews were tape-recorded and then transcribed manually. Field notes on relevant nonverbal aspects of the interview were also constructed and documented. Data were then analyzed by means of content analysis by two investigators independently.[11]

Themes emerged from the interview transcripts were categorized, and relationships between the resulting categories were identified. Two checks were made on the validity of the analysis. First, coding on a subsample of transcripts was checked by an investigator who was trained in qualitative research and having similar research interests and relevant background knowledge. Through this process, no discrepancies in coding were identified although some additional insights were gained.

Results

Thirty-three nurses (32 females and 1 male) were interviewed from the critical care units. The participants’ experience varied from 6 months to 14 years. Presentations of the results reflect the themes identified from the analysis. These themes, are presented under two main headings: The main issues and the key outcomes identified [Table 1]. A few of the broader issues emerged from the data also presented.

Table 1

Principle issues from analysis

Role and image of a physiotherapist

The issue that emerged most strongly in relation to the physiotherapist's role was that of facilitating ambulation in critical care patients (n = 20). All participants referred to this aspect of physiotherapy, and it was frequently placed within a functional context by reference to a range of functions. Ambulation/assisting the patient to walk and limb physiotherapy (n = 23) were the most commonly perceived roles of physiotherapists. The only nonphysical aspect of the physiotherapist's role mentioned was motivating patients (n = 1). This might represent the actual role adopted by physiotherapists in the critical care team but might also reflect the way in which the other aspects of therapy are probably less visible to the health care professionals.

Effectiveness of treatment

A strong theme that emerged from the data was that how nurses perceived efficacy of physiotherapy in managing range of patients. A majority of the respondents admitted to have seen improvement in outcomes (n = 29). Physiotherapy was described by several nurses as a field of practice which facilitated quicker weaning, accelerated discharge from critical unit and providing independence to patients in spite of being admitted to critical care, for example, when asked whether they had seen improvement in patients with physiotherapy; nurse reported:

“Yes, many number of times. Mostly in case of patients ventilated. The patients actually stood up with the ventilator, and this was very surprising to see.”

“Yes, quite a lot of improvement especially after the patient has walked. We feel that they look happy and then complaint of less pain. And once they walk, they are sent out of the postoperative soon. So, we consider walking as a sign of shift out at times.“

A total number of four nurses reported that they did not notice improvement of following physiotherapy but on the other hand denied of having seen any adverse events posttherapy.

Communication

When enquired about the importance of interprofessional communication, all the nurses (n = 33) felt the necessity to have strong communication skills. One of the respondents reported.

“Patient's minute details will not be missed out if good communication exists.”

The nature of the information exchanged between the professionals was highly valued and seen as a significant contribution to good teamwork although it appeared to be of short duration. However, some of the perceived problems in information sharing, which the nurses valued highly included lack of time: for eg., “Usually we will not discuss because we will be busy with our work, but sometimes we may discuss something like if anything is to be told from physician side.”

Interprofessional communication related to the patient care was found to be limited although there was strong felt need for interprofessional communications.

Interprofessional interaction

All the participants felt there was frequent exchange of important information between the two professionals, especially regarding the “feeding timings,” “sedation,” and any other adverse events that occurred during the time physiotherapists were not around.

In an attempt to explore any underlying conflicts, one of our questions aimed to determine the knowledge of existing disagreements between the professionals. When prompted, a few of the nurses admitted that they had minor conflicts in patient care (n = 12) while a majority of them reported of not having any conflicts. The conflicts if any were resolved by simple face-to-face discussion reported by the respondents.

“Whatever the problem was between the physiotherapist and I was settled within a day as we discussed that issue and it was never repeated again.”

This theorizes that “selfdom” or “ego” is not permitted in critical care as it can have a direct impact on patient's care. Certainly, the majority of the subjects admitted that there should be more interaction between nurses and physiotherapists for appropriate congruency in patient care.

Teamwork/interprofessional relations

Most of the nurses strongly felt the necessity of forming a multidisciplinary team in the critical care setting (n = 31). This was combined with considerations such as “it will save each person's time,” “management will be completely patient centered,” “and confusions will be less.” These statements suggest that teamwork would thus be an accepted way of providing holistic care since team members skills, experience, and knowledge are pooled together to produce the best outcome.

Discussion

The major role of a physiotherapist as perceived by the nurses was facilitating early mobilization. This could be attributed to the fact in the center where this study was carried out practices early mobilization protocol which was designed and tested indigenously.[12] Most of the respondents felt that a physiotherapist could help in case of ventilated patients, thereby reducing the chances of ventilated associated infections and improving patients’ condition and promote quicker recovery.

All the nurses commented on the need to have good communication in the critical care unit. A study of this kind advocated that communication would be a significant step in assisting healthcare delivery to clients and their families to become flawless, efficient, and effective.[9] Hence, there is need for the same to reflect a core competency between health professionals. A majority of nurses felt lack of time as the major reason for lack of communication in the critical care practice.

Disagreements are another criterion which requires to be pondered on when there is any discussion on critical care. Some of the respondents felt that disagreements are bound to take place in a setting where two professions do not work in congruency. Hence, if teamwork is incorporated in every setup, it will be fairly beneficial. The major factor that may influence this is interprofessional learning, and it has shown to have a positive impact on their awareness and understanding of other professional roles, interprofessional issues, and how they valued others roles as well as the support they offer, which in turn helped to reduce barriers and interprofessional conflicts.[13]

Perhaps understandably, as each profession views the issue from its own perspective, the blame for change or adaptation is liable to be shifted to the other profession. This suggests that if change is to be effective, it should be bilateral, with the blame for change shared across the two professions. One way in which this might occur would be through nurses and physiotherapists working concurrently with the patient, accomplishing the goals of both nursing and therapy in the same activities. For example, a change of the patient's position to side lying may simultaneously provide skin pressure care and improve lung ventilation and sputum clearance. It would appear that physiotherapists should consider spending some time sharing with nurses’ sufficient skills to provide continuity of care for patients. Physiotherapists cannot on one hand expect nurses to provide continuity in progression and on the other hand be protective of therapy skills in this area. In any case, physiotherapists should not be unduly worried on this score. Brown and Greenwood suggest that such “flexible cooperation” might enhance the core skills of each profession by promoting the working roles of both.[14] Such role development might lead, in turn, to increased interprofessional respect. Some nurses felt respected by the therapists and felt their nursing input was valued. Nurses also, despite the problems identified, spoke of good or excellent relationships with physiotherapists but admitted that it lacked teamwork because they did not discuss patient goals with each other often, so they did not work together on strategies to achieve those goals. One of the major limitations of this study is the smaller sample size which might not be able derive the perception of entire nurse population. Therefore, a study with larger sample size may be is required.

Conclusion

This preliminary exploratory study revealed that nurses working in the critical care team have positive perception about the physiotherapists. Participants of this study were aware of the role of physiotherapists in critical care, which will be useful in clinical decision making of the therapist. Further studies in this aspect are warranted to generalize the results.

Financial support and sponsorship

Father Muller Charitable Institutions.

Conflicts of interest

There are no conflicts of interest.