R e s e a r c h A r t i c l e P h y s io t h e r a p y S e r v ic e P r o v i d e r s ’ V ie w s o n I s s u e s o f A s s i s t a n t s : A r e P h y s io t h e r a p y A s s is t a n t s N e e d e d ? A B S T R A C T : This p a p er presents views o f physiotherapy service providers in selected areas o f the Western Cape M etropolitan Region, over the issue o f physiotherapy assistants and whether they are needed. Data were collected through semi-structured interviews. A them atic analysis resulted in fiv e pre-determ ined categories. While the participants agreed that assistants are needed, they had divergent views over issues o f name and role o f assistants. The lack o f both standardised training f o r assis­ tants and knowledge o f delegation by professionals was highlighted. The training o f assistants should be examined seriously i f the shortage o f physiotherapy services in general has to be alleviated, suggesting that the recommen­ dations o f the national qualification fram ew ork (NQF) should be applied to the training o f physiotherapists together with the assistants. WAZAKILI M, DIP. PT, BSc Hons Pi'; MPOFU RMB, PhD, MSc Rehab, MCSP1 1 Department o f Physiotherapy, Faculty o f Com m unity an d Health Sciences, University o f the Western C a p e . KEYWORDS: PH YSIO TH ERAPY ASSISTANTS, CARER, CRWS, THEM ATIC ANALYSIS, A N D TRAINING. INTRODUCTION In Africa, physiotherapy is not accessible to m any people because o f a shortage o f professionals caused by the lack o f training in some countries and inade­ quate numbers o f qualified staff in others. C onsequently, p erso n n el o th er than physiotherapists perform services that are physiotherapy related. In this paper, the term physiotherapy service providers includes personnel who, with or in the absence o f physiotherapists, perform some services that are norm ally done by physiotherapists and the m anagers o f organisations w hich include physio­ therapy services. At international and national confer­ ences, physiotherapists have expressed CORRESPONDENCE: M pofu RMB Senior Lecturer, D epartm ent o f Physiotherapy, Faculty o f C om m unity and Health Sciences, U niversity o f the W estern Cape, P O Box X17 Bellville 7535 Tel: (021) 959-2542 (w) Tel: (021) 671-4648 (h) Fax: (021) 959-2804 (h) Email: rm pofu@ uw c.ac.za divergent views over the need for assis­ tants, their nam e, role and training. P h y sio th erap y a ssista n ts’ training is different from country to country, from province to province and even within a province. T he differen ce betw een p h y sio th erap y assistants and o th er groups o f midlevel workers, like grass­ roots workers, support workers, com m u­ nity rehabilitation workers (CRWs), is not often clearly defined. These names may signify the different roles that assis­ tants play in their different w ork set­ tings. These roles m ore often include some physiotherapy skills. H ealth and social policies are plac­ ing em phasis on the com m unity as the arena for care, a concept that has im pli­ cations for service providers, service recip ien ts and in fo rm al carers. T he perpetual shortage o f physiotherapists and lack o f physiotherapy assistants places the burden o f care on inform al carers (Kirk 1998). Despite the m any views in support o f the ro le assistants play in p h y sio th e­ rapy services and in rehabilitation, a small survey o f outpatients departm ents in the U K showed that som e physiotherapists did not recognise the need for training assistants (Ellis et al 1998). Here are som e o f the argum ents pointed out by Saunders (1997) and Lee (1997) against training and w orking with assistants: • Basic physiotherapy skills can be passed on w ithout the need for one to have form al training. • Flooding physiotherapy services with assistants low ers the standards o f practice. If and when these assistants are not supervised due to shortage o f staff, they pass as physiotherapists. • Governm ents cannot afford to fund or run both physiotherapy and assis­ tants training schools, and therefore should stick to training at professional level only. • All training should be at degree level since anything less is being devalued. • Independent m ushroom training o f assistants ... has placed considerable difficulties on the system because o f lack o f a consistent approach to assis­ tan ts’ role and training. Saunders (1996) argues that the role o f physiotherapists is to make clinical diagnoses, plan and carry out treatm ent and be involved in teaching as well as carrying out research and adm inistra­ tive duties. Pressure o f tim e m akes this obligation difficult to m eet (Parry and Vass 1997). Thus a trained assistant should be considered a valuable m em ber o f staff who should help to ease the burden o f the chronic shortage o f person- power. Furtherm ore, dem ographic and econom ic considerations constitute a pressing case in favour o f assistants. 22 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:rmpofu@uwc.ac.za OBJECTIVES The research sought to get the views o f physiotherapy service providers (PSPs) in selected areas in the W estern Cape M etro p o litan area, o v er issues su r­ rounding the need for physiotherapy assistants. METHODOLOGY Four centres, a tertiary and a secondary h ospital, tw o reh ab ilitatio n projects which provide a variety o f health care services including physiotherapy and em ployed assistants, were selected from the W estern C ape M etropolitan Region. Participants with hands-on experience with physiotherapy related services were selected as follows: 2 physiotherapy heads o f sections, 3 physiotherapy cli­ nicians, 2 physiotherapy assistants, 4 rehabilitation workers and 2 program m e m anagers from com m unity projects. All the participants, but 4, were inter­ view ed individually. The 4 participants at one centre requested to be interviewed in a group so as to support each other. Sem i-structured interviews were con­ ducted using open-ended questions and p robes. T he interv iew s w ere tape- recorded. The data were transcribed and sent back to the participants for check­ ing and corrections. The data were sorted into predeterm ined categories which w ere analy sed on n o n -lin ear m odel (M arshal and Rossm an, 1995). In order to respect participants’ anonymity, only codes are used. RESULTS AND DISCUSSION Five m ain categories em erged from the analysis and each is discussed below by h ighlighting som e o f the quotations which were representative o f what the participants said as well as referring to relevant literature. 1. Need for physiotherapy assistants: The participants confirm ed the shortage o f physiotherapists, assistants or rehabi­ litation workers to m eet the present demands for the service. They noted that there were areas o f practice which specifically suited assistants rather than physiotherapists. The danger o f assis­ tants being treated as cheap labour is real. The following quotations illustrate some o f the above interpretations. M anager ‘H ’: / d efinitely, recom­ m end w orking with CRWs, because the need f o r rehabilitation in the com m unity is great. The program m e runs under the concept o f prim a ry health care, there­ fore, it needs CRWs. The fin a n c ia l con­ straints also make it necessary that we should w ork with this group o f people who are cheaper to train and to m ain­ tain in terms o f salary. M anager ‘I ’: Current statistics tell us that there is one O T to 23000 people. There are probably sim ilar fig u res f o r physiotherapists. There is no way we could be able to train enough pro fes­ sionals to change the situation ... the trained people go to w ork abroad, while the country remains with chronic short­ age o f staff. R ehab w orker ‘V ’: I think both are needed, because physiotherapy assistants live aw ay fr o m w here the d isa b led are, while CRWs live within the com m u­ nity ... R ehab workers ‘W ’ ‘X ’ ‘Y ’ ‘Z ’: We are very short staffed, we cover large areas each. The need for assistants was not ques­ tioned, since they are an im portant w orkforce for the whole health service delivery, especially in the communities. One participant suggested that it would be beneficial if assistants o r rehabilitation workers were trained at-th e sam e rate as the professionals, because the two groups are com plem entary to each other. These views are different from those listed earlier against training and w ork­ ing with assistants. However, the need for assistants was expressed differently by the respondents depending on who they are and fo r w hat reaso n they thought the assistants were needed. The m anagers and assistants did not see their role as that o f filling in where there are no therapists, but as a perm anent one to fulfil certain needs in the' provision o f rehabilitation services. A s1 Saunders (1996) argues, the role o f physiotherapy involves m any duties, som e o f which can be done by assistants acting as valu­ able mem bers o f staff who could help to ease the shortage o f person-power. i 2. Common name for physiotherapy assistants: On being asked whether there should be a com m on nam e for assistants, some respondents answ ered as follows: P hysiotherapist ‘A’: I have no p ro ­ blem s with the nam e assistant, because that is w hat they are, they assist p h ysio ­ therapists to do their work. A ssistant ‘T ’: I have not thought about titles, titles do not make a person. However, ... one should be able to spe­ cialise in o n e ’s area o f interest and n ot be grouped under one umbrella with everyone else. A ssistant ‘U ’: I have no problem s with the nam e assistants. It is p erso n a ­ lities that matter. The lack o f clear-cut roles is w hat fru stra tes me. There is no way one can pretend to be a p h ysio ­ therapist when you are not. Physiotherapist ‘E ’: There is a stigma attached to the nam e assistant. There is a need to move away fro m the stigm a­ tising name to something like “health w orker”, which is broad. M anager ‘I ’: It is better to have rehabilitation workers who are given a variety o f skills fro m o ccu p a tio n a l the­ rapists, p h y sio th e ra p ists a n d so cia l workers, because the dem ands in the com m unity are higher and they require m ultidisciplinary approaches. Specific professional assistants w ould be lim ited in this kind o f work. B esides the name assistants carries a stigma with it. T hese quotations illustrate the diver­ gent views the respondents have on the name “assistants”. Respondents in tertiary and secondary hospital had different views from those working in com m unity settings. B y seeing the role o f assistants as that o f assisting physiotherapists to do their work, this could be interpreted as an attem pt to deny the assistant the role o f being an essential m em ber o f the rehabilitation team who could function in the absence o f physiotherapists. The nam e is found lim iting in that either by their own will or that o f others, assistants m ay not perform to their full potential. T he view that one should be able to spe­ cialise in o n e’s own area o f interest and not be grouped with every one else can­ not be ignored. This could explain the dilem m a faced by trainers who continue to train assistants for a specific need, be it; at provincial, com m unity or hospi­ tal level. SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 3. Role of physiotherapy assistants In describing the role o f assistants, some respondents im plied that physiotherapy assistants do ‘basic routine w ork’. Physiotherapist ‘B ’: Physiotherapists do the initial assessm ent and assistants take over fro m there. ... A ssistants have developed their own skills o f treating patients because o f their many years o f experience in this unit. Physiotherapist ‘C ’: A ssistants are dissatisfied with their work. They w ould like to be physiotherapists, but they do n ot w ant to take responsibilities. This makes one hesitate to improve them. ... some o f them are too intelligent f o r the basic w ork that they are doing, they actually should be doing more, but they c a n ’t, because they do not have the training. They need direct supervision, but the departm ent does not have the s ta ff f o r that kind o f thing. A ssista n t ‘T ’: We were in itially trained as “b o y s”, to prepare a p lace f o r them (physiotherapists) to come and work a n d then to go after them to clean up their mess, very dem eaning jo b indeed. The only contact with p atients was in transfers a n d the unbelievable passive m ovem ents. I w as tired o f standing around, cleaning the pla ce ... One day I assertively took a patien t fro m a p h y ­ siotherapist a n d asked them to watch me while I tr e a te d ... A fte r this they were sa tisfied a n d they sta rted givin g us pa tien ts a fter initial evaluation by q u a ­ lified staff. While you (researcher) sat there with the Physiotherapist, I was busy treating a post-operative patien t on my own. Rehab w orker ‘V ’: We see the clients first, because we live in the com m unity with them, once we have established the problem s a n d the needs o f the clients, we consult with the physiotherapist o r the occupational therapist f o r fu r th e r input. The literature also confirms that assis­ tants’ potential is under-utilised and that they are under-trained (Parry and Vass 1997), because o f no clearly defined roles. A ssistants w ork alongside physio­ therapists in patient care and som etim es they are called upon to perform varying am ounts o f dom estic and clerical work. T hese view s co n cu r w ith L o o m is’ (1997) that physiotherapists could not clearly differentiate betw een their rou­ tine w ork and that o f assistants. Some respondents assum ed that assistants are not capable o f perform ing challenging tasks, because o f less training. CRWs with less periods o f learning claim ed that they w ere capable o f doing more w ith the opportunities o f continuing education. 4 . Training of physiotherapy assistants. Problem s around issues o f physiotherapy assistants were seen as a direct conse­ quence o f lack o f national training. The physiotherapy assistants’ training has been initiated by physiotherapists mainly, w hile physiotherapists and other rehabi­ litation workers have initiated that o f CRWs. Som e participants inferred that the assistants are poorly trained and they neither m eet the expectations o f the physiotherapists nor are they satisfied with their own performance. Inadequacies in both physiotherapy and assistants training were cited, im plying that phy­ siotherapists are trained to be self-suffi- cient, hence their difficulties working with assistants. The following comments illustrate some o f these sentiments. Physiotherapist ‘D ’: The assistants received about a y e a r ’s training. Their training w as shallow, that is why all the assessm en ts are done by p h y s io th e ­ rapists . . . I t w ould be good i f they were trained a t a national level f o r uniform standards o f practice. Physiotherapist ‘E ’: Physiotherapy assistants are largely trained to take orders and not to think around the rea­ sons why they do things, hence the lack o f recognition fo r their work. A ssistant ‘U ’: I received 18 months training in both theory a n d practice. The training was very shallow, I cannot do more, and therefore it is boring ... I w ould also like to fe e l responsible and useful to the patients. R ehab w orker ‘V ’: I received 3 m onths training ... a n d I have received o n g o in g tra in in g fr o m o ccu p a tio n a l th era p ists a n d p h y sio th era p ists. The training was adequate, because it was supplem ented by the ongoing training ... in fu tu re it w ould be better to start national training in the country so that i f one leaves one p lace they can always work elsewhere in the country. There is not a lot written about assis­ ta n ts ’ train in g in A frica in general, except Zim babw e w hich runs a national 2 year rehabilitation technician course. Z im babw e has registered success in terms o f reaching m ore people for reha­ bilitation services, the benefits o f which are seen through the w ide coverage o f their com m unity-based rehabilitation p rogram m es. H ow ever, shortages o f professionals are still experienced, to the extent that m any rehabilitation techni­ cians w ork alone in large catchment areas w ithout supervision from any rehabilita­ tion personnel (O ’Donnel 1991), despite the fact that the num ber o f physio­ therapists and occupational therapists is increasing. This confirm s w hat Saunders (1997) m entions that the developm ent o f physiotherapy assistants should be m atched w ith in creased num bers o f p h y sio th erap ists to en su re co n stan t supervision. In South Africa, it is said that in 1987 associations o f occupational therapy, speech and hearing therapy and physio­ therapy nom inated a com m ittee which was m andated to look into the training o f CRWs. T heir proposal for training was rejected by academ ic institutions, b ut they w ent ahead and trained them anyw ay and established a num ber o f training centres aro u n d the country (Taukobong 1999). Taukobong further asserts that in 1987 the South African Society o f Physiotherapy also discussed the training o f CRW s, noting that some o f them are currently em ployed in phy­ siotherapy departm ents o f certain hospi­ tals, and are directly supervised by phy­ siotherapists. Taukobong associates this seem ing rejection or non-support o f CRWs to ignorance o f future health service developm ent and to lack o f clearly defined roles for this cadre. 5. Delegation M ost PSPs perceived delegation to assis­ tants as a problem . The physiotherapy assistants felt frustrated by the type of tasks delegated to them. They attributed the com plexity o f the m atter to several factors as illustrated by the follow ing quotations: 24 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Physiotherapist ‘E ’: Delegation is a problem because physiotherapists are not trained to delegate, nor are they prepared to work with assistants. A physiotherapist is trained to think as an all-encom passing person ... It is neces­ sary f o r physiotherapists to learn some delegation skills. The demand fo r services in the com m unity is very high and the only way to stretch the lim ited staffing situation is to delegate to assistants. Clearly defined jo b descriptions would ease the problem s ... O ur training iso­ lates us, we do not learn to w ork as a team. Teamwork m ust be incorporated into training, and then it w ill filte r through our work situation. Physiotherapist ‘C ’: Yes, delegation is a problem, one w ould rather do all the work alone because then you are sure that yo u r work is done. M anager ‘I ’: The problem is with p ro fessio n a l training that d oes n ot prepare people to w ork in a team, but prepares them to protect the profession fro m unknown ills. A ssista n t‘T ’: A fter a year we started to challenge the system. We were fr u s ­ trated with the boring routine... the only contact we had with patients was transfers and the unbelievable passive movements. Loom is et al (1997) say that a lack o f specificity o f roles is what leads to pro­ blem s w ith delegating responsibility. Further, Saunders (1998) suggests that delegation can be organised to improve efficiency, but physiotherapists are not investing in delegation due to lack of recognition o f the potential value o f dele­ gation. It m ay also be easier for physio­ therapists to perform the tasks them ­ selves rather than to build the skills in assistants. Saunders also argues that task analysis is necessary to enable deci­ sions to be made on whether subtasks are know ledge-, rule- or skill-based and thus suitable for delegation. CONCLUSION AND RECOMMENDATIONS This paper presents the varying views o f physiotherapists, physiotherapy assis­ tants, rehabilitation w orkers and pro­ gramme m anagers in selected areas o f the W estern Cape M etropolitan area. All respondents would like to see changes for the better, in terms o f assistants’ training and role. T hey m entioned the need to increase num bers o f staff by training both physiotherapy assistants and other groups o f midlevel workers depending on their function. This is in line with what Loomis (1997) said that an expanded role for support personnel is a viable means o f increasing availability to physiotherapy services. The assum ption is that this paper has not only clarified issues, but that present and future policies regarding the train in g o f p h y sio th erap y assistants will be influenced positively. Tireless efforts must be made for physiotherapy services to reach the com m unities that need it most, but are disadvantaged by the present system whose operations are lim ited by shortage o f staff. An attem pt to clarify the roles is through the national qualification fram e­ w ork (NQF) which was established to provide for registration o f national stan­ dards and qualifications in South Africa. T he N Q F states that com petency in any particular field will be achieved through capacity for continuing perfor­ m ance within specified ranges and con­ texts resulting from the integration of a num ber o f outcom es. The recognition o f com petence in this sense is the award o f a qualification. As learners meet, the criteria which show they have achieved the outcomes for required unit standards, they accum ulate credits towards a par­ ticular qualification. W hen they have the required num ber o f credits they achieve the defined degree o f competence in that area and receive a qualification (Academic D evelopm ent Bureau 1998). Physiotherapy educators should be challenged to consider the all-encom ­ passing nature o f the NQF, perhaps by allowing the assistants to acquire enough credits to becom e physiothera­ pists eventually. There is no doubt that continued undefined separate training retards the intentions o f the South African Q ualifications A uthority and the jo b satisfaction o f physiotherapy assistants. REFERENCES Ellis B, Ellis-Hill C, Connell N A D 1997 Role training and jo b satisfaction o f physio­ therapy assistants. 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