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The Internet Journal of Allied Health Sciences & Practice
A journal dedicated to allied health professionals
  Feature Review - Vol. 1 No. 2 - ISSN 1540-580X

Physiotherapy in Australia - Where to Now?

Janet C. Struber, BPthy (PT), MHS
Director of Primary Health Care
Cape York Health Service District
Queensland Health - Weipa

Correspondence and requests for reprints should be directed to:

Janet C. Struber, BPthy (PT), MHS
37 Langan Street
Earlville, Cairns
Queensland, 4870
AUSTRALIA
Email: struber@westnet.com.au

Citation:
Struber JC: Physiotherapy in Australia - Where to Now? The Internet Journal of Allied Health Sciences and Practice. July 2003. Volume 1 Number 2.

ABSTRACT

The physiotherapy profession in Australia appears to have been caught unawares by the rapidly changing demography of health services and now seems to lack a clear identity and vision. Despite being a highly competitive profession to enter, attrition rates are high. This paper reflects on the history of physiotherapy in Australia and the dichotomy of paradigms it now faces, and suggests a possible option for the future, given that existing physiotherapy roles appear difficult to sustain in our current health care climate.
 
 
Key words and terms: physical therapy, physiotherapy services, Australia

Introduction

Physiotherapy is defined by the World Confederation of Physical Therapy (WCPT) [1] as “services to people and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan”.  It constitutes one of the oldest and most prestigious components of a loosely defined group referred to as allied health professionals, which is generally understood to exclude medical and nursing practitioners [2, 3]. While 15,722 registered physiotherapists constitutes a large group in allied health terms, their 1998 ratio of 60.4 physiotherapists per 100,000 population was dwarfed by 244.5 medical practitioners and 1,064 nurses per 100,000 population [4, 5, 6].

Qualifications

Formal physiotherapy training began in Australia in 1907, and has subsequently evolved, in line with WCPT guidelines, into a four-year bachelor degree course, or an entry-level masters degree course [1, 2]. Training programs are independently validated and accredited by the Australian Council of Physiotherapy Regulating Authorities to ensure competencies are attained as determined by the Australian Physiotherapy Competency Standards document [7, 8]. Requiring a very high academic standard for admission, training is currently offered at nine tertiary institutions in five states, graduating some 893 physiotherapists in 1999 [4]. Registration is an essential pre-requisite for practice, and is conferred by State Physiotherapy Registration Boards under State Physiotherapy Acts [7]. The Australian Physiotherapy Association (APA) has voluntary membership and acts as a professional self-regulatory body advising on issues such as ethical practice, mandatory continuing education and fee structures [1, 9].

Professional Development

The role of physiotherapists has changed considerably over the last few decades with autonomous professionals replacing clinicians who applied technical skills under the direction of medical practitioners [10, 11]. While in 1958 physiotherapists were advocating direct medical supervision [13], by the late 1970s, calls were being made for them to move away from even a medical referral model and to become first contact practitioners [14]. A review of medical referrals to physiotherapists between 1982 and 1989 showed a gradual reduction in diagnoses and specified treatments, suggesting that medical practitioners were also expecting greater levels of clinical autonomy of physiotherapists [15]. Current developments in health service delivery models, with an increased emphasis on skill mixing and a team approach are anticipated to lead to further shifts in the boundaries between physiotherapists and medical practitioners [16].

Working Conditions

Now universally acknowledged as an autonomous profession, physiotherapy in Australia enjoys a positive reputation and is generally well regarded, holding a position of prestige both within the profession and amongst the general public and other health workers [1, 17,18]. Yet physiotherapy appears to lack a clear identity with the public and health professionals, who demonstrate limited awareness and understanding of the scope of the profession’s role and have difficulty differentiating it from alternate practitioners [18, 19, 20, 21].  It also seems that physiotherapy students may not have a full appreciation of the demands of their future role or an accurate perception of their working conditions [22].

Students enrol with expectations of job accessibility, economic advantage and professional prestige, with most aspiring to work in private practice [17, 23, 24]. Despite fulfilling demanding and stressful academic requirements, on entering the workforce new graduates report they feel unprepared for the realities of their jobs [11, 12, 22, 25, 27]. This can be explained in part by the diversity and breadth of the current scope of practice which means they are expected to be immediately accountable for their clinical decisions in as many as twelve different areas of practice [8, 9, 28]. However, graduates also identify other important gaps between the knowledge and skills gained as a result of their university education and those required in the workplace. These relate particularly to coping strategies such as time management, stress control, flexibility and interpersonal skills; knowledge of the health industry, bureaucracy and politics; and caseload and workplace management [22, 25, 26, 27].

Occupational stress is prevalent for physiotherapists, with frequently cited work stressors including: feelings of inadequacy regarding patients and patient outcomes; role conflict and ambiguity; lack of management and support; and organisational problems such as staff shortages, long hours and high work demands [11, 25, 27, 29]. Such stressors are implicated in burnout, which occurs “when a person has reached a state of mental and physical exhaustion combined with a sense of frustration and personal failure” [29]. Burnout in physiotherapists is well documented, and has a significant impact as early as five years after graduation [25, 30]. As well as producing physical and psychological symptoms, it is related to reduced quality of care for clients, absenteeism and attrition from the profession [27, 29, 30].

Organisational Issues

As the Australian health system was drawn into the debate on what constitutes health and the best way to achieve it [31] physiotherapy began to face not so much a paradigm shift as a paradigm divergence. By the mid 1970s the profession’s own perception of the role of physiotherapists was being challenged by concepts such as holistic and community based services [32, 33, 34] and the need to take a more active role in preventative rather than restorative health care [35, 36]. Yet they were also being berated to demonstrate evidence-based practice in treatment modalities and clinical programs, based on sound scientific principles validated by rigorous research [37].

The profession, whose role concepts are largely grounded in tradition, has struggled to come to terms with these changes and find a balance [28]. This confusion is still evidenced at the conceptual level by a number of inconsistencies in terminology. For example:

· Internationally the profession is undecided as to whether their title should be Physiotherapist or Physical Therapist.
· While descriptions of services all include the word ‘physical’ it can refer either to physical health, as in the condition of the client’s body, or to physical treatments, relating to the non-invasive modalities used.
· Definitions of the role of a physiotherapist tend to be broad or vague, but while they always refer to restoration and rehabilitation of movement after injury or illness only about half refer to prevention of injury or disability.
At the practical level the confusion is exemplified by the disparities of work practices between private practitioners working in an individual or insurance funded free market, fee-for-service environment, and salaried employees of predominantly publicly funded health services striving to adopt horizontal models of care; representing the two extremes of current government health policies - privatisation and prevention [1, 38, 39].

On the one hand 43% of the workforce are employed in private practice and sports clinics [4] following a traditional biomedical model using interventions which:

  • are grounded in scientific knowledge of physiology and pathology
  • are aimed at addressing physical problems identified by standardised assessment and diagnostic procedures
  • use evidence-based techniques that require specific training and result in measurable outcomes
  • provide education in the form of expert instruction [40]
    • On the other hand, the 50 % of practising physiotherapists working in hospitals or rehabilitation units [4] are finding their work practices modified by the combined drive for economic rationalisation and the impetus of the ‘health promotion movement’, fed by Commonwealth funding in the form of Regional Health Service grants [31, 39, 41]. This has seen an attempt to combine:
  • evidence based best practice across a wide range of clinical areas
  • inter-sectorial and community collaboration and integration
  • primary health care principles, balancing equity of access with long waitlists
  • health promotion and population based strategies attempting to maximise lay health care networks [38, 39, 42].
    • Physiotherapy is a predominantly female profession, and yet, while males account for only 23% of practitioners overall, they account for 36% of the more prestigious and highly paid managers and private/sports practitioners, and only 13% of hospital/ rehabilitation workers; adding a further socio-cultural dimension to this dichotomy [4].

    The Dilemma

    The physiotherapy profession appears to have been caught unawares by the rapidly changing demography of Australian health services and now seems to lack a clear identity and vision [18, 21]. While the public predominately associates physiotherapists with exercise and the treatment of musculoskeletal conditions, in the private practice style, for large sectors of the profession the emphasis is increasingly on community-based services with small inter-sectorial teams of health workers focusing on community access, continuity of care and integrated services, rather than the hands-on use of treatment modalities [8, 20, 21, 40].

    Unfortunately, concepts of health promotion and utilising the expertise of the lay networks are not core components of physiotherapy education [40, 41]. Thus, traditionally trained physiotherapists, imbued with the norms and values of the biomedical model and its recognition of technical expertise, can find this new approach, in which they are no longer the ‘expert’, particularly challenging, and a threat to professional recognition [28, 40]. Practitioners desiring evidence-based practice would traditionally concentrate on bio-medically styled ‘gold standard’ quantitative research, yet this must be melded with systematic ‘humanistic’ qualitative research to establish a basis of patient-centred care. There is also a reluctance to let go of traditional, time honoured techniques despite lack of evidence for their efficacy [8].

    Possible Option

    If we accept that a vision is critical to organisational improvement [11], it would appear that the time has come for the physiotherapy to re-think its role in health care delivery in light of the ‘new public health’, as a common vision is clearly lacking [36]. Will the profession then be able to address the complex issues it is facing and reconcile the divergent directions that it is currently taking, both with their own increasing evidence base - or will a total re-structure be required?

    Educational institutions have begun tinkering with programs in an attempt to make the training less stressful and the transition to the workplace less daunting [22, 25, 27]. However, in light of the exponential growth of knowledge in relation to health and health care management, academics are calling for a re-definition of the core business of physiotherapy and a total re-structuring of training programs and workplace competencies to reflect current research, attitudes and work practices, rather than the present array of technical, clinical skills [8, 21, 27]. As an adjunct to this, the profession would need to adapt or discard traditional notions of what constitutes the scope of physiotherapy practice [28], and perhaps relinquish some historical components to other health practitioners, such as antenatal and postnatal education to midwives.

    Primary health care principles call for equity of access to health care as a fundamental right yet neither field of physiotherapy currently delivers this, the private sector because of cost and the public sector because of workloads, disparity in the distribution of service providers and difficulty in keeping even existing positions filled [4,11]. Could these issues be better addressed by totally restructuring training programs away from discipline specific ‘practitioner centred’ siloed models towards broadly skilled practitioners focused on ‘client or family centred’ delivery of care and knowledge [43, 44]?

     If client density dictates that there should be three allied health practitioners in a region, you would currently expect to see three therapists from different disciplines (eg Speech Pathology, Occupational Therapy, Physiotherapy) each attempting to address the particular needs of their clients across the spectrum from paediatrics to geriatrics. Clients may be required to see all three practitioners, unless through philosophy or necessity they use an integrated or trans-disciplinary model. How much more efficient to have, for example, one paediatric, one adult and one aged care therapist able to address holistically the total integrated needs of each client [42, 44]. Could physiotherapy and other therapies as they currently exist disappear, to be replaced by more generically skilled practitioners with specific patient-centred rather than disease-centred roles? Would professional rivalry and the belief in professional prestige allow this to happen? Only time would tell.

    Conclusion

    Although numbers of trained graduates increased by 30% between 1969 and 1999 [4] the physiotherapy profession in Australia struggles to keep up with attrition, with exit rates exceeding 20% annually [45, 46]. High levels of attrition are contributed to by burnout [29, 30], disillusionment [40], high stress levels [48], lack of management support [11], family responsibilities [29, 47], leakage to postgraduate medical courses [12] and desire for change [45]. Sustaining either of the current divergent physiotherapy roles will be increasingly difficult  in the evolving health care climate. The more traditional private practise style role is threatened by the philosophical shift away from paternalistic biomedicine and the developing team role by the lack of a clearly articulated scope of practice, allowing encroachment of other practitioners into traditional physiotherapy fields. With all the philosophical and pragmatic changes occurring in health service delivery, it is time for the profession to re-invent itself with a vision and organisational structure appropriate for the twenty-first century.

    References

    [1] World Confederation of Physical Therapy. The Nature of Physical Therapy web page [cited 2002 Oct 12]; Available from: URL: http://www.wcpt.org/policies/description/whatis.html

    [2] University of Sydney. School of Physiotherapy, p112-122, University of Sydney Handbook, 2002.

    [3] Health Professions Council of Australia. Promotion Sheet, June 2002.

    [4] Australian Institute of Health and Welfare. Physiotherapy Labour Force 1998. AIHW cat. no. HWL 22. Canberra: AIHW (National Health Labour Force Series No. 22), 2000.

    [5] Australian Institute of Health and Welfare. Medical Labour Force 1998. AIHW Cat. No. HWL 15. Canberra: AIHW (National Health Labour Force Series no. 16), 2000.

    [6] Australian Institute of Health and Welfare. Nursing Labour Force 1998. AIHW Cat. No. HWL 14. Canberra: AIHW
    (National Health Labour Force Series), 1999.

    [7] Department of Education, Science and Training. NOOSR Guide to Professional Recognition in Australia - 2001. DEST Website, Commonwealth of Australia [cited 2002 Oct 12]; Available from: ULR: http://www.dest.gov.au/noosr/leaflets/noosr_guide8_12.htm

    [8] Crosbie J, Gass E, Sullivan J, Vujnovich A, Webb G, Wright T. Sustainable undergraduate education and professional competency. Australian Journal of Physiotherapy 2002 48: 5-7.

    [9] Australian Physiotherapy Association. Referrals to Physiotherapists web page [cited 2002 Oct 10]; Available from: URL: http://apa.advsol.com.au/scriptcontent/aboutphysio_referrals.cfm?section=aboutphysio

    [10] Terry W, Higgs J. Educational programs to develop clinical reasoning skills. Australian Journal of Physiotherapy 1993 39: 47-51.

    [11] Paskevicius A Editor. Western Australian Allied Health Taskforce on Workforce Issues: Initial Report 2002, Health Department of Western Australia: Perth, 2002.

    [12] National Rural Health Alliance. Allied Health Professionals in Rural and Remote Australia. A Position Paper, 2001.

    [13] Wedlick LT. The physical medicine department in hospital service. Australian Journal of Physiotherapy 1958 4: 58-61.

    [14] Galley P. Patient referral and the physiotherapist. Australian Journal of Physiotherapy 1976 22:117-120.

    [15] Wong WP, Galley PM, Sheehan MC. Changes in medical referrals to an outpatient physiotherapy department. Australian Journal of Physiotherapy 1994 40: 9-14.

    [16] Daker-White G, Carr AJ, Harvey I, Woolhead G, et al. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health Oct 1999 53(10): 643.

    [17] Turner P. The occupational prestige of physiotherapy: Perceptions of student physiotherapists in Australia. Australian Journal of Physiotherapy 2001 47: 191-197.

    [18] Whitfield TWA, Allison I, Laing A, Turner PA. Perceptions of the Physiotherapy Profession: A comparative study. Physiotherapy Theory and Practice 1996 12: 39-48.

    [19] Lee K, Sheppard L. An investigation into medical students' knowledge and perception of physiotherapy services. Australian Journal of Physiotherapy 1998 44: 239-245.

    [20] Sheppard L. Public perception of physiotherapy: implications for marketing. Physiotherapy 1994 40(4): 265-271.

    [21] Royeen, C Paschal KA Zardetto-Smith AM. Promoting awareness and understanding of occupational therapy and physical therapy in young school aged children: An interdisciplinary approach. Occupational Therapy in Health Care. 2001; 15(3-4): 89-99.

    [22] Clouder L, Dalley J. Providing a ‘safety net’: fine-tuning preparation of undergraduate physiotherapists for contemporary professional practice. Learning in Health and Social Care 2002 1(4): 191–201.

    [23] Ohman A, Solomon P, Finch E. Career choice and professional preferences in a group of Canadian physiotherapy students. Advances in Physiotherapy 2002 4(1): 16-22.

    [24] Ohman A, Stenlund H, Dahlgren L. Career choice, professional preferences and gender - the case of Swedish physiotherapy students.  Advances in Physiotherapy 2001 3(3): 94-107.

    [25] Balogun JA, Pellegrini EA, Miller TM, Katz JS. Pattern of physical therapist students' burnout within an academic semester. Journal of Physical Therapy Education 1999 13(1) 12-17.

    [26] Hunt A, Adamson B, Harris L. Physiotherapists' perceptions of the gap between education and practice. Physiotherapy Theory and Practice 1998 14(3): 125-38.

    [27] DiGiacomo M, Adamson B. Coping with stress in the workplace: implications for new health professionals. Journal of Allied Health 2001 30(2): 106-111.

    [28] Schleifer T, McGlynn-Vitori M, Ellerton C. A Conceptual Role-Shift Model: Shaping and Defining Future Physical Therapy in Hospital Settings. Physiotherapy Canada 1997 49(3): 171-177.

    [29] Balogun JA, Titloye V, Balogun A, Oyeyemi A, Katz J. Prevalence and determinants of Burnout Among Physical and Occupational Therapists. Journal of Allied Health 2002 31: 131-139.

    [30] Scutter SD, Goold M. Burnout in recently qualified physiotherapists in South Australia. Australian Journal of Physiotherapy 1995 41: 115-118.

    [31] Leeder S. Valuable Health: what do we want and how do we get it? Australian Journal of Public Health 1992 16: 6-14.

    [32] Doring LA. An elaboration on holistic physiotherapy. Australian Journal of Physiotherapy 1976 22: 83-89.

    [33] Webster IW. Physiotherapy and community medicine. Australian Journal of Physiotherapy 1980 26: 45-54.

    [34] Short S. An holistic approach towards disabled persons and their rehabilitation. Australian Journal of Physiotherapy 1981 27: 145-147.

    [35] Lewis IC, Health in the community. Australian Journal of Physiotherapy 1977 23: 95-99.

    [36] Ritchie JE. Keeping Australians healthy: The challenge to physiotherapy practice posed by the concept of the new public health. Australian Journal of Physiotherapy 1989 35: 101- 107.

    [37] Ritchie JE. Using qualitative research to enhance the evidence-based practice of health care providers. Australian Journal of Physiotherapy 1999 45: 251-256.

    [38] Treloar S, Posner N, Taylor G. The Australian Health System. Brisbane: University of Queensland, 2002.

    [39] Hancock L. Health, public sector restructuring and the market state, In L Hancock Editor. Health Policy in the Market Place, p.48-68. Allen and Unwin: Sydney, 1999.

    [40] Litchfield R, MacDougall C. Professional issues for physiotherapists in family-centred and community-based settings. Australian Journal of Physiotherapy 2002 48: 105-112.

    [41] Leeder S. The Health of Australians in Healthy Medicine: Challenges facing Australia’s health service. Chapter 1: 1-21.Allen and Unwin Health: Australia, 1999.

    [42] Queensland Health. Health Service Integration in Queensland. Queensland Government: Brisbane, 2000.

    [43] M’kumbuzi VRP, Eales C J. Merging Physiotherapy and Occupational Therapy Training: A Paradigm Shift. The South African Journal of Physiotherapy 2001 57(3): 32 - 39.

    [44] Aleksandric V. ACT looks to ‘integrated care’ to deliver fundamental systematic change. Healthcover 1999 February-March: 34-39.

    [45] Fitzgerald K, Hornsby D, Hudson L. A Study of Allied Health Professional in Rural and Remote Australia. Bathurst: Services for Australian Rural and Remote Allied Health (SARRAH), 2000.

    [46] Health Workforce Planning. Queensland's practising allied health workforce: geographic location and turnover rates of the allied health workforce. Queensland Health: Brisbane, 1999.

    [47] Wolpert R, Yoshida K. Attrition survey of physiotherapists in Ontario. Physiotherapy Canada 1992 44(2): 17-24.

    [48] Casey M, McKavanagh M. Rural Connect: Rural Allied Health Mentor Program, Sharing experiences, sharing stories, building healthy relationships and communities. Conference Paper: World Rural Health 2002, International Conference: 1-3 May 2002:  Melbourne.

    [49] Faculty of Health and Social Care Sciences. Kingston University & St. George's Hospital Medical School web page [cited 2002 Oct 6]; Available from: ULR: http://www.healthcare.ac.uk/schools/physiotherapy/default.htm

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