Defining Key Elements for Effective Physical Therapist–Physical Therapist Assistant Working Relationships: A Qualitative Study : Journal of Physical Therapy Education

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RESEARCH REPORT

Defining Key Elements for Effective Physical Therapist–Physical Therapist Assistant Working Relationships: A Qualitative Study

Hayward, Lorna PT, EdD, MPH; Sellheim, Debra O. PT, PhD; Scholl, Jessica PTA, MA; Joyce, Christopher PT, PhD, SCS

Author Information
Journal of Physical Therapy Education 35(1):p 19-26, March 2021. | DOI: 10.1097/JTE.0000000000000172

Abstract

Introduction. 

Education of doctor of physical therapist (DPT) and physical therapist assistant (PTA) students about their roles and responsibilities for working collaboratively is required for entry-level clinical practice. Research maintains that DPTs graduate with inadequate knowledge regarding the roles, scope of work, utilization and supervision of PTAs. Study objectives were to uncover the characteristics that comprise an effective physical therapist (PT) - PTA working relationship from 3 perspectives; and identify pedagogy that might inform the relationship development.

Methods. 

Using purposive sampling, we recruited PT and PTA clinician recipients of the APTA Outstanding PT-PTA team award; and DPT students and PTA students from 3 academic institutions. Qualitative case study with a phenomenological approach. Interview questions explored participant perceptions and experiences regarding: effective PT-PTA relationships; barriers and gaps in DPT and PTA educational preparation for intra-professional teaming; and educational strategies for addressing deficiencies in students' knowledge and skills.

Results. 

Thirty-two semi-structured interviews were conducted. Four with PT and 5 with PTA Outstanding PT-PTA award recipients. Fifteen interviews were conducted with DPT students, eight were conducted with PTA students. Data resulted in 4 themes; communication, trust and respect, environment, and bonding. The themes described the PT-PTA relationship and included a triad (PT-PTA-patient) with the patient centrally located.

Discussion and Conclusion. 

Respondents indicated that DPT and PTA programs should create curriculum that develops both cognitive and affective clinical skills pertaining to the PT-PTA relationship. Academic and clinical practice settings play an integral role in creating pedagogy and environments conducive to effective PT-PTA teaming. Role clarification may optimize health care performance, patient satisfaction, cost of care and reduce problems related to miscommunication.

INTRODUCTION

The 21st century demand for physical therapy services remains fueled by the number of aging baby boomers utilizing medical services and increased access to health insurance due to the affordable care act.1 More than 50 years ago, the increased demand for physical therapy services required a practice change that included development and utilization of physical therapist assistants (PTAs).2 The roles and responsibilities of the physical therapist (PT) and PTA have evolved dramatically since the 1960s.3

The current context of medicine has forced changes, including the evolution of the first professional degree for PTs to a clinical doctorate, a growth in the number of PTAs, and an expansion of the different settings in which PTAs can work. These professional transformations have underscored the necessity to revisit and redefine the nuances of the PT–PTA relationship to maximize their role in clinical care.3

The purposes of this research were to explore, uncover, and define the qualitative characteristics that comprise an effective PT–PTA relationship from 3 perspectives: 1) PT–PTA clinical teams who have received the outstanding PT–PTA team award from the American Physical Therapy Association (APTA); 2) doctor of physical therapist (DPT); and 3) PTA students at 4 distinct educational programs. In addition, we explored suggestions for curricular strategies to abet the development of desired characteristics in DPT and PTA students. The research questions were 1) From the perspective of exemplary PT/PTA teams, what elements define the effective PT–PTA relationship? 2) From the perspective of DPT/PTA students and teams, what educational approaches may foster these elements in DPT and PTA students? 3) What are DPT/PTA students' reciprocal knowledge of scope of work, roles, responsibilities, and direction and supervision appropriateness? 4) What are DPT/PTA students' perception of effective working relationships between PTs and PTAs?

LITERATURE REVIEW

Education of DPT and PTA students about their roles and responsibilities for working as a team is required for entry-level clinical practice.4,5 This objective is supported by the triple aim of optimizing the patient experience, improving population health, and reducing costs, which are all dependent upon achieving the fourth aim of improving the efficiency, productivity, and work relationship between health care providers.6 Many PT students graduate with inadequate education and knowledge regarding the roles, scope of work, utilization, and supervision of PTAs.7,8 Based on the 2016–2017 APTA membership data, which does not reflect all working PTA/PTs nationwide, the majority (89.5%) of PTA APTA members work with PTs in the following settings: 32% private outpatient practice, 17% hospital-based outpatient, 16% skilled nursing facilities, 9% academia, 8% acute care, and 7.5% in home care.3 Doctor of physical therapy students must be educated appropriately to supervise and direct the PTA in various clinical settings in a manner that promotes work satisfaction for both parties and optimizes the patient's health care experience.9

An effective DPT–PTA relationship, although an abstract concept, for the purpose of this work is defined through an integration of professional and ethical documents for both provider types.4,5,10-13 Published resources exist to assist practitioners' understanding of the DPT–PTA team approach.14,15 Other critical resources include knowledge of PTA education/scope of work.14,16 Even with these published resources, confusion among DPTs and PTAs with respect to division of labor, scope of work, and level of supervision, documented as early as 1971, persists to current day and may result in either under or overutilization of PTAs.8,16,17 Professional attitudes developed by DPTs and PTAs toward each other originate during the professional education phase and continue to evolve during clinical experiences. Few studies have examined educational models designed for optimization of the roles of each profession and for effective intraprofessional collaboration.7,17 Additional efforts are needed to explore the best methods for educating DPT and PTA students to maximize the roles of each provider.18,19 Clarification and reciprocal knowledge of each role may assist with optimizing health care performance, patient satisfaction, and cost of care and reducing problems related to miscommunication.

Improper direction and supervision of PTAs affects quality outcomes and service use17 and increases disciplinary incidents.20 The need for DPTs and PTAs to collaboratively, effectively, and efficiently deliver patient care that is safe, ethical, and effective is imperative. A fractured relationship between the DPTs and PTAs has a negative impact on treatment quality outcomes and appropriate service usage. Conflict often exists between individuals possessing different status within the same profession15 but improves with intraprofessional learning opportunities that address communication, specifically.19,21

No information exists regarding the specific qualities required for the development of effective relationships between PT–PTAs. General elements that comprise a successful relationship, such as effective communication, flexibility, trust, and positive attitudes are hard to define and measure yet critical to successful provider collaboration. These skills are leveraged to help manage situations where roles may be uncertain or in conflict, such as when a PTA has more practical experience in a clinical setting than a newly graduated PT. A need exists to qualitatively define the elements of an effective relationship. Understanding these qualitative nuances can guide the design of educational approaches that facilitates the development of these skills and role definition in DPT and PTA students.19,21

METHODS

Subjects

Purposive sampling22 was used to recruit participants for one-on-one, semistructured interviews. The first cohort was PT and PTA clinicians who received the APTA Outstanding PT–PTA team award between 2006 and 2019. Recipients of this award have a minimum of 3 years of experience working together and a process for communication, determination of roles, and a system of supervision that contributes to the delivery of high-quality patient care.23 We selected PT–PTA team award recipients because we viewed them as the gold standard for behaviors and actions that exemplify successful teaming and the delivery of patient-centered care. Our goal was to recruit a sample of 10 clinicians (5 PTs and 5 PTAs). For the DPT and PTA student cohorts, 4 programs (2 DPT and 2 PTA) were conveniently selected based on expressed willingness to allow the researchers to recruit participants. Participating DPT institutions had a graduate program that was 3 years in length. One program was located in the North Central and the other in the New England region of the United States. The goal was to recruit 2–3 students each from the first, second, and third year of study for a total of 12–14 (6–8 from each institution). All student participants had volunteer, paid work, or clinical education experience working with PTAs. For participating PTA programs, one was located in New England and the second in the North Central United States. Each program awards a 2-year associate degree. We attempted to recruit 2 subjects each from the first and second years of study for a total of 8 participants (4 from each institution). All students had volunteer, clinical education, or paid experience working with PTs in a clinical setting.

Research Design

This qualitative research study employed a multiple case study method with a phenomenological approach.24 A phenomenological approach describes the essence of a phenomenon (PT-PTA relationship) by identifying the common elements reported by those who have experienced it.25 The study had 3 educational institutions, which ensured a wider geographic distribution of participants and allowed for cross-case comparisons. The Institutional Review Boards at Northeastern University, St. Catherine University, and Bay State College reviewed and approved the study. All study participants were provided written informed consent prior to data collection.

Instrumentation

Interview questions and probes were designed by the researchers to explore the participants' perceptions and experiences regarding what elements define effective and productive PT–PTA relationships. All 4 researchers had background in qualitative research (i.e., at least a class in qualitative research) with 2 researchers having extensive backgrounds in qualitative research (previous studies/publications, etc.). The experienced researchers provided guidance for the team on the question development. Additionally, the research team had both PT and PTA input into the questions. One researcher is a PTA and has taught in both PTA and PT programs; 2 other researchers have taught in both PT and PTA programs and created cocurricular learning activities with DPT and PTA students. We utilized these years of experience with PT and PTA students and curricula to shape the research questions. Thus, the interview questions were informed by researchers’ experience in PT and PTA education and clinical practice. Outstanding PT–PTA teams were asked a total of 13 questions about the elements and characteristics that contribute to an effective PT–PTA team and suggestions for what might be taught to DPT–PTA students (Appendix A, Supplemental Digital Content 1, https://links.lww.com/JOPTE/A104). Student participants were asked 10 questions about their observations of PT–PTA team interactions in the clinic and for suggestions for education about the PT–PTA relationship (Appendix B, Supplemental Digital Content 2, https://links.lww.com/JOPTE/A105). For the recruitment of outstanding PT–PTA teams, the researchers located the names of award winners from the APTA website. They generated a list of work emails/phone numbers and sent an email recruitment script to all prospective participants. Those interested in participating were asked to respond to the researcher via email or phone. If no response was provided after 1 week, one of the researchers followed up with another email or phone call. For student recruitment, the researchers, at each participating program, sent an email script to prospective participants. Those interested in participating contacted the researcher at their respective university via email or phone. All participants engaged in a 30- to 45-minute, individual semistructured interview with one of the researchers. Fourteen interviews were conducted in person on campus in a neutral location, and 18 were conducted remotely over the phone. Telephone interviews are considered a viable alternative to face-to-face interviews in qualitative research and allowed for a wider geographic distribution of participants.26-28 If an interview was conducted locally, upon arrival, participants were oriented to the project, asked to sign a written consent form, and complete the demographic intake. When an interview was conducted remotely, the consent form and demographic intake were emailed ahead of the interview. All interviews were audio recorded and transcribed by an outside paid transcriptionist, and participants had an opportunity to review and revise completed transcripts. Demographic information was collected on institution, geographic location, role (DPT student, PTA student, PT provider, PTA provider), sex, clinical experiences to date (location and setting), and hours worked/week. As a thank you, participants were offered a $25 gift card.

Data Analysis

Data were analyzed using a descriptive, qualitative, thematic content analysis with a general inductive approach.29 Qualitative coding and case comparative methods were used to uncover themes within the interview data. During content analysis, the raw data from the interview transcripts were independently reviewed and coded by each of the 4 authors. Next, the 4 researchers met virtually to discuss and debate the predominant patterns and codes they developed. Then, one author drafted an initial framework that grouped data with similar meaning.29 The resulting patterns were collapsed into major categories that best summarized the data at a higher level.22,29 Discussion and consideration by the authors led to identification of 4 core themes for the data into which most categories and patterns fit. The authors took a number of steps to ensure trustworthiness in the qualitative data. Triangulation was used to maintain consistency and trustworthiness.30 Denzin30 describes 3 forms of triangulation: investigator triangulation where multiple researchers participate in the study; data triangulation, which involves repeated data collection over time, space, and persons; and methodological triangulation, which uses multiple methods for data collection. This study made use of the first 2 forms of triangulation. Four authors, with diverse geographic locations, inclusive of both PT and PTAs, were engaged in the data analysis for this project, serving as a strategy of interpretative rigor in which developing patterns, codes, and themes within the data could be discussed and debated.31 Multiple cohorts (persons/participants) were used at different points in their career (time) and in different settings (space). Data sources included interview transcripts collected over a period of 3 months. The semistructured nature of the interviews enabled the researchers to clarify comments and questions that arose during an interview. The structure of the coding and analysis process also served as an additional strategy to ensure procedural rigor. The number of participants was initially determined based on available funding. However, throughout the data collection and analysis process, data saturation was achieved within our sample. Data saturation was achieved in that all authors agreed that the codes were comprehensive and no new patterns emerged.

RESULTS

Demographics

Thirty-two interviews were conducted in total. Four were PTs, and 5 were PTAs who received the outstanding team PT–PTA award. Although we attempted to contact both members of the teams; sometimes only 1 member of the team responded or was able to be located; in some cases, individual members volunteered irrespective of whether the team partner participated. Of these 9 PT–PTA professionals, 7 different years of awardees were represented. One team (PT–PTA) were awardees from the same year. Fifteen were DPT students, 7 from a North Central and 8 from a New England University. Eight were PTA students, 4 from a North Central University and 4 from a New England College. Demographics are located in Tables 1 and 2.

Table 1. - Demographic Characteristics of Outstanding Physical Therapist (PT)–Physical Therapist Assistant (PTA) Team Award Recipients
Characteristic PT (n = 4) PTA (n = 5)
Age, year
 30–39 25%
 40–49 40%
 50–59 50% 20%
 60–69 40%
 No response 25%
Sex
 Female 50% 60%
 Male 25% 40%
 No response 25%
Race
 White (not of Hispanic origin) 50% 100%
 Hispanic/Latino 25%
 No response 25%
Highest degree held
 Associate's degree
 Bachelor's degree 100%
 Master's degree 50%
 Professional doctorate 50%
Years worked as a PT-PTA team
 5–9 y 50% 20%
 10–14 y 25% 20%
 15–19 y 25% 60%
Geographic region
 East North Central 25% 20%
 South Atlantic 50% 60%
 West North Central 25%
 West South Central 20%

Table 2. - Demographic Characteristics of Doctor of Physical Therapist (DPT) and Physical Therapist Assistant (PTA) Students
Characteristic DPT Students (n = 15) PTA Students (n = 8)
Age, year
 20–29 93% 63%
 30–39 7% 25%
 40–49 13%
Sex
 Female 67% 87%
 Male 33% 13%
Race
 White (not of Hispanic origin) 80% 75%
 Hispanic/Latino 25%
 Asian 7%
 Black/African American 7%
 Sri Lankan 7%
Highest degree held
 Associate's degree
 Bachelor's degree 73% 75%
 Master's degree
 No degree awarded yet 27% 25%
Relevant previous experience
 Clinical education 87% 50%
 Observation hours 100% 100%
 Work as rehab aide/tech 47% 25%
 Other healthcare-related experience 38%

Interviews–Physical Therapist–Physical Therapist Assistant

Four themes emerged from analysis of the interviews that identified important elements in building a PT–PTA team: 1) communication; 2) trust and respect; 3) environment; and 4) bonding. Encompassing all themes was a triad composed of the PT, PTA, and the patient with the patient centrally located in the relationship. These themes represent the prerequisite elements identified as critical for effective teams committed to outstanding patient care in physical therapy and are visually depicted in Figure 1. Each theme is presented below and exemplified with participant quotes.

F1
Figure 1.:
Elements identified as critical for effective PT-PTA teams. DPT = doctor of physical therapist; PT-PTA = physical therapist-physical therapist assistant.

Communication

Communication was identified consistently by all participants as critical for effective PT–PTA teaming. Data related to communication clustered around 2 major subthemes: form and function. Form pertained to the qualities of effective communication, such as open, honest, frequent, reciprocal, and written/verbal. Function described how communication was used to delineate roles and deliver consistent and optimal patient-centered care. The following quotes are examples.

Form: Collaborative, honest, and open

[H]onest communication—as a PTA you have to be willing to communicate honestly with them [PT] about your feelings related to patient treatment …. I've worked with many PTs and some of were open to working with a PTA and others were not. If I had that respect, I was respectful in my communication and it helped to foster a good, collaborative relationship. [PTA team]

Practicing communicating, openly. Communication through events as they arise rather than allowing tension to build …. [DPT year 1 student]

Form: Written/verbal

We communicate at least on a daily basis. And if we can't make a face-to-face because we're so busy, we'll write each other emails and leave each other notes about what's going on and where we need help or what we need to follow-up with during the next treatment session. [PT team]

[V]erbal and written communication between the PT and the PTA regarding anything from patient status that day to what treatments worked well. Open and honest communication between the two [PT/PTA] is really crucial in having a really fluid treatment and progression for the patient. [DPT year 3 student]

Function: Role definition

Open communication is really important, so that you can make sure the two of you are on the same terms as far as the patient's plan of care and make sure you can effectively communicate any changes in patient status, patient concerns and if you are working towards to the same goal. [DPT year 3 student]

Communication is first … with a lot of the PTAs and PTs that I worked with, obviously they had to talk about their case load and who was going to be responsible for what patients. [PTA year 1 student]

Function: Treatment of the patient

Communication … what are the main focuses of today's session, what are the short-term goals, long term goals, and then also the goals that the patient has in mind. [PTA year 1 student]

[P]atient centered care … us doing what's best for the patient … you need to communicate with all team members, whether it's the physician, if they are involved, or the PT or another PTA. [PT team]

Trust and Respect

Trust and respect were interchangeable and critical for an effective PT–PTA relationship that was patient centered. Trust partitioned into 2 main areas: trust of each individual therapist and trust each other to do their job. Respect concerned knowledge and roles. As these clinicians and students noted,

Trust and Respect: Individual therapist

I trusted her [PTA] for what she knew and she trusted me for what I knew. We would have a dialogue in terms of why something was happening or not, either within the plan or with the patient. [PT team]

One thing that worked for us was mutual respect and trust. He [PT] is hard working and that helps with developing respect for him. Working with someone who is as interested as you to continue growing and learning …. [PTA team]

Trust and Respect: Do your job

[They] trusted her [PTA] with a lot of their patients. They wanted her [PTA] to be part of a team and work as a unit of 3: PT-PTA-Patient. So no one was stepping on each other's toes. [DPT year 2 student]

[A]n element of trust in the relationship … when it comes to patient rapport … feeling comfortable that they [PTA] has a wide scope of knowledge, and trusting in their abilities and their ways of handling the plans that the PTs come up with. [PTA year 2 student]

Respect: Knowledge and roles

[T]o have a good right hand person [PTA] that I can really work with … there has to be 2-way respect between the 2 of us which is earned. [PT team]

I respect the knowledge that they have [PT], in the role that they have in treating the patient. I hope that they respect me in the knowledge that I have in regards to treating the patient …. I don't challenge the fact that they have much greater depth of understanding of diagnosis and what's best for the patient and I respect that. In return, when I give them [PT] information on what I'm seeing during the treatment and how [the patient] is responding that they respect me and my information that I'm providing to them [PT]. [PTA team]

Environment

Participants noted that the work environment facilitated the success of PT–PTA relationships, which ultimately affected the quality of patient care. Having an organizational structure that is conducive to collaboration was key for our participants. Particularly, our practicing therapists noted the importance of protected time in their schedule to discuss patients, learn from each other, and provide supervision. Qualities used to describe good working environments were collaborative, patient centered, and fun. As these participants stated,

So I think that the therapists really need to be on board with the idea that they're just going to have to have some downtime to do some training [with the PTAs], and not only at the beginning of their employment, but, you know, periodically as the months go on, you need to take time to spend another hour here, another hour there, talking through treatment techniques and new ideas. [Team PT]

When you can collaborate, you bring 2 minds together that are solving the problem and trying to help the patient 2 are better than one and the patient benefits. [PTA team]

It was a fun clinic, they were all professional, they were fun to be around and enjoy each other's company. All the PTs and the PTAs seemed to work in harmony and get along. It was a well oiled machine. [PTA year 2 student]

Bonding

The participants identified elements related to bonding and harmonious relationships between PTs and PTAs. Getting to know people as individuals was helpful for bonding. This point is illustrated below.

I think it's important to do something outside of the clinic together once a month … all the women in my clinic … we all go together and get a pedicure after work. [PT team]

Be close and support each other, in a way that doesn't compromise the work relationship, but you're able to go to each other and talk about any issue, anything. [PTA year 1 student]

In fact, bonding was referred to by one clinician like being in a marriage.

I always look at a PT-PTA relationship, especially in certain settings like outpatient, when you're together quite a bit in the same clinic, it's almost like a marriage—you spend more time with that person than your spouse sometimes. And just learning what helps each other out, that's very important. [PTA team]

Uniformly, participants indicated that it takes time for PT and PTAs to become effective team members. As these clinicians noted,

I don't think I've been an effective team, with any of the PTAs I've hired through the years, right away. It's always taken 60–90 days or longer to have the time to communicate with each other, get to know each other, do some training and even just being able to grow together. I don't think that happens right away. [PT team]

It took us a good 6 to 9 months to really get into our groove. [PT team]

Both clinicians and students indicated that being on the same page and in tune with each other was critical for patient care. These quotes illustrate this point:

If they're [PT/PTA] on 2 separate pages, that can really hinder the rehab of the patient. [PTA year 1 student]

[P]ut the patient in the center … good communication between the PT and the PTA …. Then everyone is on the same page … it took a little time. I don't know if you learn that in school. [PT team]

The benefits of a bonding were recognized as extending patient care that was consistent. The following quotes illustrate this point:

The importance of the PT-PTA relationship is that it allows the PT to offer services they couldn't do as an individual … if we train our PTAs well, it's such a huge patient extender and allows us to service a bigger population. [PT team]

If both of them [PT/PTA] are on the same page about the patient's goals and treatment plan then the patient gets consistency with is the best way for a patient to make progress. There's 2 sets of eyes on them. [DPT year 3 student]

Interviews: Suggestions for Education

The participants provided information about the educative needs pertaining to the PT–PTA relationships. Participant responses partitioned into 4 categories. Table 3 summarizes what participants were taught in school and their perspectives on what they believe should be taught. Furthermore, participants stated that education about PT–PTA relationships should occur frequently through experiential activities inclusive of classroom, simulation, and clinical experiences. Most participants believed that these learning experiences would be best placed before clinical education experiences.

Table 3. - Educational Strategies to Teach Students About the Physical Therapist (PT) Physical Therapist Assistant (PTA) Relationship
Interview Question Sample Quotes
What is currently taught
 Nothing specific I can't remember what I learned in school about supervising PTAs, but I don't believe it was much, or it wasn't memorable. [PT team]
During my education, I don't remember much being discussed about the PT/PTA relationship. [PTA team]
They [teachers] basically told us what PTAs could do, but didn't go into what you should interact. [PT team]
 Roles PTs are able to do the evaluations and the PTAs cannot [DPT year 1 student]
We have been taught about the logistics of the differences between PT and PTA but it's hard to understand the relationship until you get in there [clinic] and see if for yourself. [PTA year 2 student]
They [PTA] are there to help you about, take the workload off but still give good care. [DPT year 2 student]
What PT–PTA content should be taught
 PTA scope of practice and curriculum Everything in the PTA's scope of practice so the PT knows exactly what they are and aren't allowed to hand off to the PTA. [DPT year 3 student]
What they [PTA] can and can't do. I had no idea … I would like to know what their curriculum is about. [DPT year 2 student]
 Team building So, it's really important to emphasize those strong relationships now or you're going to have a bunch of students out in the workforce as practicing clinicians that just don't really understand the relationship or respect the relationship. And I think building that foundation early on is helpful. [DPT year 3 student]
 Direction through clear communication How to delegate, how to write notes that your PTA can follow. [PTA year 2 student]
 Become a treatment expert I would tell the PTAs in school to go to as many CEUs as you can…if PTAs were constantly trying to improve themselves, that would help the respect portion from the PTs. [PTA team]
 Professional respect It needs to be reinforced that we're not just a helping hand, that we know what we're doing …. [PTA year 1 student]
CEU = Continuing Education Unit; DPT = doctor of physical therapist.

DISCUSSION

The purposes of this research were to explore the qualitative characteristics that comprise an effective PT–PTA relationship from 3 perspectives and identify pedagogical approaches to facilitate relationship development. Analysis of 32 clinician and student interviews elucidated 4 essential elements that constitute an effective PT–PTA relationship. The data from the 3 stakeholder perspectives—clinician and DPT, PTA students in academic programs—were consistent and complementary. Each theme contains quotes from each stakeholder to illustrate this point and is depicted in the resultant Figure 1.

Exchange theory provides a framework for interpreting these results.32 Exchange theory defines relationships as the function of net outcomes (rewards minus costs) and maintains that relationships thrive if rewards outweigh the costs and benefits are realized. Principles for strong relationships rely on clear communication of purpose and goals and are built on mutual trust and respect.33 In line with exchange theory, our participants identified communication, trust and respect, and bonding as critical factors for effective teaming. Regarding communication, our participants noted preferred forms or qualities—collaborative, honest, open—for both written and verbal interaction. Communication served the function for ensuring that each partner understood their role in patient-centered care.32 Clear communication of purpose and goals in health care practitioner relationships is critical for effective patient care delivery.34

Our research also revealed that trust and respect were reciprocal. Each partner in the relationship desired that the other trusted and respected them as individuals and as clinicians possessing the knowledge and judgment to do their job effectively. High levels of trust and respect result in harmonious relationships.33 Our data revealed that elements critical for building bonds began with getting to know people as individuals and that building bonds takes time. Participants noted that a good PT–PTA relationship was critical for coordinated and optimal patient-centered care. Exchange theory is based on the tenant that action by one person is similarly reciprocated by another. Reciprocal relations occur when individuals are jointly responsible for the outcomes of a task and the results, such as patient care delivery.32 Collectively, communication, centered on the patient and grounded in reciprocal trust and respect, was the fundamental construct of an effective, task-oriented, relationship bond.

Notably, effective PT–PTA teaming is contextual. Environments play an integral role in creating a culture conducive to effective PT–PTA collaboration and patient-centered care.35 Successful environments identified by our participants were collaborative, patient-centered, and fun. In support of our findings, research in physical therapy education maintains that a culture of excellence in organizations includes shared beliefs and values—trust, respect, and collaboration—leadership, drive for excellence, and partnerships.36 Moreover, patients recognize the collegiality of therapists and the positive ambiance of the clinic as important aspects of their physical therapy experience.37 Exchange theory affirms that creating an environment that supports the collaboration of PTs and PTAs (trust, respect, communication) and a convivial workplace may facilitate workplace bonding and ultimately better patient care.

Our second research purpose explored what has been taught about PT and PTA roles and responsibilities and suggestions for educational approaches to foster effective teaming. These data partitioned into what is taught, what could be taught, how it could be taught, and how often.

Based on a number of comments from both clinicians and students, it appears that students are cognitively learning the basics regarding roles/responsibilities but are limited in both affective knowledge and in person interaction regarding working intraprofessionally. Research supports that DPT students lack knowledge related to working with PTAs.7,8 Payers, too, are inconsistent in their regulations about the provision of PT services by PTAs and their supervision.14 Several factors contribute to the knowledge gap: 1) PT programs were not required by Commission on Accreditation in Physical Therapy Education, until 2007, to provide curricular content regarding the supervision of PTAs14 and 2) one item related to assessment of competence of DPT student's direction and supervision of personnel is included on the Clinical Performance Instrument (CPI),38 yet not all programs use the CPI. In addition, there are various degrees of support personnel (e.g., interns, aids, cooperative students) that a PT may work with. Supervision of and collaboration with the PTA should not be considered equivalent to supervising an aide. Doctor of physical therapist students must be educated appropriately to supervise and direct the PTA in various clinical settings in a manner that promotes work satisfaction and optimizes the patient's health care experience.6 Clarification of and reciprocal knowledge of each role may assist with optimizing health care performance, patient satisfaction, and cost of care and reducing problems related to coordination. Additionally, the affective domain elements (communication, trust, and respect), which are hard to teach, must be integrated with education about the cognitive elements of the PT–PTA relationship. Physical therapist educators are challenged to consider including curriculum that is appropriate for contemporary practice expectations and covers more content related to the development of an effective PT–PTA professional relationship.

Our participants overwhelmingly recommend that educational approaches include face-to-face interaction between DPT and PTA students in ways that promoted active learning using educational strategies, such as simulation, role play, cases, and joint clinical education experiences. In a qualitative study of intraprofessional fieldwork placements between occupational therapists (OTs) and occupational therapy assistant (OTA) students, findings supported the importance of developing intraprofessional relationships through shared learning experiences that focused on communicating effectively and building trust and respect.39 Educational strategies for PT professional education are most effective when active, experiential learning activities such as simulation are employed.40-42 Shared learning approaches have been used to promote teamwork between dentists and dental assistants,43,44 OTs and OTAs,39,45 and in nurse education.46,47 Research that examines shared learning approaches between PTs and PTAs is needed. We advocate for an educational model that longitudinally partners and integrates PT and PTA academic settings to promote continuity of instruction and knowledge transfer and sets a foundation for the future of professional education. Research supports that educational approaches which are interactive and communication focused can positively impact PT and PTA students' attitudes toward working in a team, direction and supervision, preparation for effective communication, and respect for and the value of the PT/PTA team.48 Our findings suggest that DPT and PTA programs should create curriculum that develops both cognitive and affective skills pertaining to this relationship.

Limitations

Study participants were limited to PT–PTA teams from the North Central and South Atlantic regions of the United States and DPT and PTA students from educational programs in the North Central and New England regions. As such, they may not be representative of PT–PTA teams and students throughout the United States, which may limit the generalizability of these findings. That the student participants were essentially self-selected was an additional limitation. It is not known whether the opinions and experiences of the students who chose not to participate or could not participate due to sample size restrictions would be similar to the 23 who participated in the study. Future research is needed that includes input from other stakeholders involved in the PT–PTA relationship including patients treated by PT–PTA teams and clinic administrators who oversee the organizational culture impacting the PT–PTA relationship. Additionally, further investigation in the development and implementation of pedagogical strategies for developing effective PT–PTA teams and measurement of student outcomes and patient satisfaction is warranted.

CONCLUSION

A model was developed from the themes that included a triad (PT–PTA–patient) with the patient centrally located. Respondents indicated that DPT and PTA programs should create curriculum that develops both cognitive and affective clinical skills pertaining to the PT–PTA relationship. Academic and clinical practice settings can play an integral role in creating pedagogy and environments conducive to effective PT–PTA teaming. Role clarification may optimize health care performance, patient satisfaction, and cost of care and reduce problems related to miscommunication.

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Keywords:

Education; Teamwork; Physical therapist-physical therapist assistant relationship; Intraprofessional

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