Treatment. Use of Support Personnel for Physical Therapy

Research Report Use of Support Personnel for Physical Therapy Treatment Background and Putpose. This study determined the extent to which unlicensed aides employed in physical therapy settings administer physical therapy treatments. Metbods and Subjects. A 48-item suwq questionnaire was mailed to 300 physical therapists in Indiana. The suwey assessed aide utilization and supewision for 21 physical therapy treatments and sought therapists' opinions about the use of aides. Results. One hundred sixty-one responses were received (53.7% return rate). Sixty-eight percent of the respondents indicated that aides were involved in patient treatments at their facilities. Four treatments were given by aides without supenhion in the facilities of at least 20% of the respondents: hotlcold packs, whirlpool, para@n, and ultrasound. Sixty-seven percent of the therapists indicated that their use of aides had presented them with ethical dilemmas, and 73% desired more specijic guidelines on aide utilization. Dtsdn and ConcZdorrs. There was signijicantly greater unsupervised use of aides when tbq were not identfied as "aides" to consumers than when they wm ckarly identijied. Therapists who approved of the unsupervised use of aides described in a scenario wm signijicantly more likely to use aides in an unsupervised manner There were no dtferences in unsupervised we of aides on the basis of setting or hours of aide training. [Bashi HL, Domholdt E. Use of support personnel for physical therapy treatment. Phys Thm 1993; 73:421436] Harrlette Laden Bashl Ellrabeth Domholdt Key Words: Education: support personnel; Physical therapy pmfesnesnon, supportive personnel. All professionals must wrestle with performed only by qualified profes- under the direction of the profesthe issue of which activities within the sionals and which can be delegated to sional. As a profession becomes more scope of their profession must be support personnel to implement developed and its practice consists of both technical and decision-making tasks, technical tasks are often delegated - to non~rofessionals. In addition, HL Bashi, FT, is Staff Therapist, General Hospital Rehabilitation Center, Eureka, CA 95501. Ms Bashi when professionals are in shoa supwas a student in the Krannen Graduate School of Physical Therapy, University of Indianapolis, when this research was completed in partial fulfillment of the requirements for her Master of Sci- the use personnel ence degree. extend the reach of each professional becomes attractive. These two fac- E Domholdt, EdD, FT, is Associate Professor and Dean, Krannen Graduate School of Physical Therapy, University of Indianapolis, 1400 E Hanna Ave, Indianapolis, IN 46227 (USA). Address all correspondence to Dr Domholdt. Ponions of this repon were presented at the 1991 Annual Conference of the American Physical Therapy Association, Boston, MA, and at the 11th International Congress of the World Confederation for Physical Therapy, 1331, London, United Kingdom. The protocol was reviewed and approved by the Committee on Research Involving Human Panicipants of the University of Indianapolis. This study was funded by the Indiana Chapter of the American Physical Therapy Association. This article was submitted June 15, 1992, and was accepted Febwry 23, 1993. tors--complexity of practice and shortage of professionals-have been cited as reasons for the use of unlicensed personnel to support the activities of registered nurses.' Both hctors also exist within the profession of physical therapy. The complexity of physical therapy practice today is illustrated by the number of states in 10 / 421 Physical Therapy/Volume 73, Number 74~1~ 1993

which therapists are able to evaluate and treat patients without physician referral2 and by the proportion of referrals for "evaluation and treatment" that are received by physical therapists.3 The shortage of physical therapists is illustrated by a 1991 survey of the American Hospital Association showing a physical therapist vacancy rate of 16.6%.4 Although these factors may promote the use of support personnel, the use of nonprofessional support personnel in physical therapy has a long history, as does the debate surrounding this practice. In the 1950s and 1960s, the professional literature emphasized the need for and benefits derived from the use of nonprofessionals in physical therapy.59 Among the benefits cited for the use of support personnel were relief of therapists from more routine t:asks and the cost effectiveness of delegating tasks not requiring professional skills or judgment.6 Several auth0rs5~6.9 made recommendations about the need for adequate training and supervision of support personnel. By 1967, the American Physical Therapy Association (APTA) had developed policies that separated support personnel into the current levels of phys-. ical therapy aides and physical therapist assistants and that differentiated between their training requirements and functions.lojl The current APTA Guide for Professional Conduct12 and Standards of Practice for Physcal Therapy13 continue to provide guidelines related to delegation of responsibilities to support personnel. Current APTA House of Delegates policy is that physical therapy aides may provide direct services to patients "only with the continuous on-site supervision of the physical therapist... or physical therapist assistant."l4 In the early 1970s, Sentersls studied support personnel utilization by physical therapists in Washington state. She found that less than half of the therapists reported using "auxiliaries" (defined as physical therapy aides and physical therapist assistants) to assist with patient care. The auxiliaries were most likely to participate in whirlpool, hot and cold pack, gait training, therapeutic exercise, and paratfin bath treatments. Also in the 1970s, several articles1618 were published that discussed the potential benefits and dangers involved in the use of support personnel. Among the risks discussed were the substitution of inadequately qualified personnel to compensate for shortages of physical therapists, the resulting decline in quality of patient care, and the liability of therapists for the actions of support personnel. Watts19 provided a thorough analysis of factors involved in appropriate delegation of tasks to support personnel. She proposed a taxonomy of physical therapy practice based on the degree to which "doing" or "deciding" behaviors are required and the degree to which these behaviors can be separated. She concluded that few procedures are simple or complex under all circumstances and that it is impractical and potentially dangerous to routinely assign specific procedures to a specific level of worker. The idea of a taxonomy of tasks was further developed in a 1990 study of Alabama physical therapists.20 In this study, 24 physical therapy procedures were classified as being of high, moderate, or low complexity, according to the responses of the therapists. Results indicate that the level of a procedure's complexity affecrs whether the procedure is delegated to support personnel and that high-complexity procedures are delegated infrequently. This study, however, did not differentiate between delegation to physical therapy aides or physical therapist assistants or between various degrees of supervision once the task is delegated. In Nova Scotia, where only one level of support personnel exists (ie, physical therapy aide), a study revealed that on-thejob-trained aides were performing activities normally performed by a licensed physical therapist (ie, making entries into patient records; interviewing patients; and applying ultrasound, traction, and transcutaneous electrical ~tirnulation).~~ Although physical therapists are regulated in all 50 states, the laws within many states provide scant guidance about delegation of tasks to support personnel. The laws range from those in, for example, California, which are very specific about supervision of physical therapy aides22, and Maryland, where patient care tasks may be delegated,23 to those in, for example, Indiana, in which physical therapy aides are not mentioned.24 In light of the continuing shortage of physical therapists, reports of widespread use of physical therapy aides to deliver patient treatment, and controversy surrounding this practice, we wished to obtain a baseline of information about the practices and opinions of physical therapists in our state (Indiana) relative to utilization of on-the-jobtrained support personnel. Specifically, we had three research questions: 1. To what extent do physical therapists delegate patient treatment to physical therapy aides in Indiana? 2. What are therapists' opinions about aide utilization? 3. Does aide utilization for patient treatment differ based on the setting, the way in which aides are identified to patients, the training received by aides, and the opinions of physical therapists about use of aides for patient treatment? Method Physical therapists' practices and opinions were determined via a questionnaire that was mailed in early 1990 to 300 physical therapists who were systematically selected from the Medical Licensing Board list of approximately 1,200 physical therapists licensed and living in the state of Indiana. As recommended by Gay,25 the sample size was planned so that if a 50% return rate was achieved, the respondents would represent more than 10% of the population. Because the sample was based on individual physical therapists, we were unable to Physical Therapy /Volume 73, Number 7/July 1993 422/11

- Appendh 1. Lds of Physical Therapy Aide Supervision for Patient Treatment Tasks Unsupervised Independent: Physical therapist is not within visual or voice range. Unobserved: Physical therapist does not observe treatment at any time but is within voice range. Supervised Observed: Physical therapist observes setup before treatment or at some time during the treatment and is within voice range. Assisting: Physical therapist provides treatment with assistance of physical therapy aide. Not Involved determine how many different facilities were represented. Instrument Ideas for the questionnaire were generated through free-form interviews with several physical therapists, physical therapy aides, and physical therapy students working as physical - therapy aides. The ideas developed in the interviews were then used to generate a draft questionnaire. The draft was pilot tested with 12 selected physical therapists within the state (ie, colleagues who we knew had an interest in the issue). Several items Appendix 2. Patient Care Scenario were modified based on the results of and feedback on the pilot instrument. The final questionnaire was divided into four sections. In the first section, physical therapy aides were defined as individuals who receive on-the-job training for their roles in physical therapy departments. Three major levels of aide utilization for patient treatment tasks were then defined (unsupervised, supervised, and not involved), with subdivision as shown in Appendix 1. The definitions were followed by a list of 21 treatments. Respondents were asked to indicate the minimum level of super- You are a physical therapist working in a large hospital and are expected to give 25 bedside treatments today with the help of a physical therapy aide. It is Saturday; you are unfamiliar with the patients and feel pressured for time. After reviewing the summary notes left by the regular bedside therapist, you split up the load, sending the aide to treat some of the patients. Circle the letter below that corresponds to the choice that reflects your OPINION regarding the appropriateness of aide utilization in the above scenario. a. Generally acceptable. b. Acceptable, because you had information on which to base your assignment of patients. c. Acceptable, if the aide is a physical therapy student. d. Acceptable, if the aide has received on-the-job training covering the types of treatments that will be required. e. Acceptable, if the aide has been assisting with bedside rotation all week. f. Acceplable, if the aide had been used in this way on the bedside rotation all week, because the primary therapist is responsible for the aide. g. Acceptable, because most bedside treatments involve a low level of expertise. h. Acceplable under the following other conditions. Please write in: i. Acceplable only if two or more of the above conditions are met simultaneously. Please list letters of necessary conditions: j. Unacceptable for the following reason(s). Please write in: vision provided for aides performing each type of treatment at their place of employment. A "not applicable" category was also listed so that respondents could identify techniques not used at their facility. The second section of the questionnaire contained the scenario presented in Appendix 2, which described a situation in which a therapist sends an aide to treat patients independently, without the therapist reviewing the chart for the day or seeing the patients first. Therapists were asked to indicate their opinion regarding the appropriateness of this scenario and their knowledge of, or personal involvement in, practices similar to that described in the scenario. The third section contained several opinion items regarding aide utilization, and the fourth section requested background information regarding the respondents and their place of employment. Date Analysis Data analysis consisted largely of tabulating frequencies. Because of the large amount of data contained on each survey, we derived a summary variable called "percent unsupervised" to provide an indication of the overall level of aide involvement for the 21 procedures. Unsupervised use of aides was selected as an indicator of inappropriate utilization because APTA guidelines specify that any direct care of patients by physical therapy aides must be done under the direct supervision of a physical therapist or physical therapist assistant. To derive this variable, we first counted the number of the 21 listed treatment techniques that aides administered without supervision (sum of the "independent" and "unobserved" categories) at the respondent's facility. We divided this number by the number of treatment techniques that were applicable at the facility and multiplied by 100 to generate a percentage. For example, if 5 of 20 applicable treatments were 12 /423 Physical Therapy/Volume 73, Number 7/July 1993

administered without supervision, a value of 25% was recorded. If 3 of 4 applicable treatments were administered without supervision, a value of 75% was recorded. To assess whether aide utilization differed based on setting, aide identification (ie, the way in which the aide's credentials are communicated to the patient), aide training, and physical therapist opinion about the scenario, we conducted four one-way analyses of variance, with Scheffe post hoc analysis when appropriate, using each of the above factors as the independent variables and the percentage of unsupervised treatments as the dependent variable. There were four settings: hospital, outpatient clinic, nursing home, and rehabilitation center. Aide identification had three levels: name tag read "aide," introduced as "aide," and not identified as "aide." Aide training had four levels: none, low (0-10 hours), medium (11-30 hours), and high (greater than 30 hours). The physical therapist's opinion about the scenario had two levels: acceptable and unacceptable. Alpha w~s set at.05 for each analysis. Results Return Rate and Background Informatlon A total of 161 of the questionnaires were completed, a 53.7% response rate. Respondents were distributed across employment settings as follows: 31% in hospitals, 30% in outpatient clinics, 12% in nursing homes, 10% in rehabilitation centers, and 15% in other settings. The mean age of respondents was 34.9 years (SD=8.27, range=2242). Eighty percent of the respondents had earned entry-level bachelor's degrees in physical therapy, 7% had certificates in physical therapy, and 13% had entry-level master's degrees in physical therapy; 75% were APTA members. The mean age and proportion with bachelor's degrees in physical therapy are similar to those found in a 1987 APTA active member survey (average age of surveyed members, 35.7 years; 74.3% of surveyed mem- Physical Therapy /Volume 73, Number bers received entry-level bachelor's degrees).26 Extent of Physlcal Therapy Alde Utlllurtlon There are three components to our results on the extent of aide utilization: overall utilization, utilization for specific treatments, and utilization as described in the scenario. Overall, 68% of the respondents worked in facilities at which physical therapy aides were involved in patient treatment at some level. The average percentage of techniques administered without supervision was 12%, with a range of 0% to 100%. The extent of aide utilization varied for the specific treatment techniques, as shown in Table 1 and in the Figure. For 14 of the 21 treatments, the most frequent response was that aides were not involved in delivering the care; for 5 treatments (whirlpool, endurance activities, transfer and gait training after orthopedic injury, transfer and gait training of patients with central nervous system pathology, and tilt table), the most frequent response was that aides assisted the therapist in delivering the care; and for 2 treatments (hot/cold packs and exercise with equipment), the most frequent response was that aides performed the treatment with observation by the therapist. The number of responses varied from procedure to procedure because of either missing data or indications that the procedure was not used at the facility. Thus, the percentages are based only on those therapists who used a given procedure. The Figure combines the percentages in the independent and unobserved categories in Table 1 to show the proportion of respondents who indicated that the procedure was performed by aides without supervision at their facilities. Of therapists who work in facilities at which aides are involved in patient treatment, 7.3% reported that aides receive no training in treatment procedures. With respect to the scenario we presented, 57% of the therapists had experience with a practice situa- tion in which a therapist sent an aide to provide bedside treatment to a patient without the therapist first reading the patient's chart or examining the patient on that day. Thirty-two percent indicated that they had observed other therapists practicing in this way; 25% indicated that they, themselves, had practiced in this way. Oplnlons About Physlcal Therapy Alde Utlllzatlon The second purpose of our study was to determine therapists' opinions about aide utilization. There are two components to our results on this question: (1) opinions about the bedside scenario and (2) responses to the set of opinion items. Forty-five percent of the therapists found the therapist's behavior in the scenario to be unacceptable; 55% found the therapist's behavior to be acceptable under certain circumstances. No respondents indicated that it was acceptable without qualification. The most common set of circumstances under which the respondents found the therapist's behavior acceptable were that the aide has received on-the-job training in the types of treatment required and that the aide had assisted with the bedside treatment during the week. Responses to the opinion items are summarized in Table 2. Again, the number of responses varies slightly from item to item because of missing data. Sixty-seven percent of therapists indicated that aide utilization had presented them with ethical dilemmas at some time. Seventy-four percent of the therapists were comfortable with aide involvement in patient treatment at their current job. A total of 54% of the therapists were either undecided or neutral in their satisfaction with current aide utilization guidelines within the Indiana Physical Therapy Practice Act. A total of 73% of the therapists felt that more specific aide utilization guidelines should be developed and adopted. Twelve percent of the therapists thought that the APTA should

- Table 1. Minimum Level of Physical Therapy Aide Supervision develop and adopt such guidelines, 4% thought that the state should do so, and 57% thought that both should do so. Percentage of Responsesa NO^ Factors Related to Physlcal TreatmenP Independent Unobserved Observed Asslstlng Involved Therapy Aide Utilization HoVcold packs (1 43) Whirlpool (139) Paraffin (1 25) Ultrasound (1 41) Passive range of motion (1 50) Endurance activities (1 43) Activelresistive exercise with equipment (1 46) Bandaging wound (1 32) Contrast baths (1 16) Electrical stimulation (1 39) Transferlgait training with assistive device, status postorthopedic injury (1 45) Lumbarlcervical traction (133) Transferlgait training of patients with central nervous system pathology (146) Exercise with manual resistance (146) Application of external medication to wound (132) lsokinetic exercise (133) Tilt table (113) Wound debridement (135) Instruction in new exercise (145) Soft tissue mobilization (142) lsokinetic testing (131) "Number of responses shown in parentheses. Table 3 reports the findings related to questions of whether the unsupervised use of aides in patient treatment differed based on four variables: setting (using only responses from the four most frequently represented settings), method of aide identification to patients (using all applicable responses), extent of aide training (using only respondents who knew how much time aides spent being trained for patient care roles), and physical therapist opinion about the scenario (using all responses given). A significant difference in percentage of unsupervised use of aides was found between clinics at which aides either had a name tag that identified them as an "aide" (mean percentage of unsupervised treatments, 11.8%) or were verbally introduced as an "aide" (mean percentage of unsupervised treatments, 10.6%) and those in which aides were not identified as such (mean percentage of unsupervised treatments, 25.7%). In addition, there was a significant difference in the percentage of unsupervised use of aides between therapists who found the bedside care scenario acceptable (mean percentage of unsupervised treatments, 16.9%) and those who found it unacceptable (mean percentage of unsupervised treatments, 5.8%). There was no significant difference in utilization of aides based on setting or hours of aide training. Dlscusslon For all treatments studied in this survey, a majority of physical therapists either do not delegate performance of the treatment to physical therapy aides or delegate the treaunent in a manner that permits therapist observation of the care being delivered by the aide. Thus, the majority of the therapists appear to delegate tasks in a manner consistent with the guidelines of the APTA, which specify that Physical Therapy /Volume 73, Number 7July 1993 a

Hot/coid pack Whirlpool Paraffln Ultrasound Passive range of motion Endurance activities Exerclse with equipment Bandaging wound Contrast baths Electrical stimulation Galt training, orthopedic Traction Gait trainlng, neurologlcal Exercise, manual External medication lsokinetic exercise Tilt table Wound debridement New exercise Soft tlsaue moblllzatlon leokinetic testing 0 10 2 0 30 40 50 Percentage Unsupervised levels of supervision of the support personnel. Despite these differences, these two studies, together with our results, show consistency in task delegation across three decades and three regions of the United States. 1 The finding that aide utilization has 1 presented therapists with ethical dilemmas is consistent with Guccione's I 1980 report that physical therapists 1 rated "delegating duties to support persons" as a frequently occurring I ethical decision they needed to I We believe that consistency of I results between our study and Guccione's study indicates that the issue of utilization of support personnel is one that physical therapy educators should address in fulfilling accreditation criteria related to ethical practice and supervision of support personnel28 We believe that students should be exposed to APTA's position on Flgure. Percentages of respondents indicating unsupervised use of physical therapy physical therapy aide utilization and aides for administering specifc physical therapy treatments at their facilities. that they should critically examine the position of the Association in relation use of physical therapy aides to de- timtments most frequently delivered to the laws under which they will liver direct care requires the direct with the help of "auxiliaries" (43% practice. Consideration also needs to on-site supervision of the physical and 39%, respectively, of therapists be given to helping students decide therapist or physical therapist assis- reported the help of auxiliaries with how to determine their own profestant.14 Despite this high level of prac- these treatments). Paraffin and ultra- sional practices in the face of corntice consistent with AFTA policy, policy- sound were also frequently applied mon practices that may violate state makers in Indiana should recognize with the help of auxiliaries (23% and laws or be at odds with hsociation that many respondents were either 12%, respectively, of respondents positions. Although educators cannot unfamiliar or dissatisfied with the reported help). The m~ount of super- hope to resolve such dilemmas for guidelines as written, and they should vision involved in giving help to the their students, they can provide them consider whether these policies physical therapist was not defined in with knowledge about guidelines and should be publicized (for therapists Senters' study. laws that will provide students with who are unfamiliar with them) or the tools needed to make informed revised (for therapists who are dissat- In 1990, Hart and associatesz0 re- decisions. isfied with them). In addition, Associa- ported the results of a factor analysis tion policymakers should consider of the complexity of 24 physical [her- We examined four factors that we clarification of APTA guidelines on apy procedures. Com~ldty was de- thought might be related to the extent aide utilization, given that more than termined by surveying therapists at of unsupervised use of physical thertwo thirds of respondents thought clinical education sites in Alabama. apy aides: setting, aide identification, that revision of Association guidelines Cryotherapy and ultrasound dia- aide training, and scenario opinion. were needed. themy fell into the low-com~ldt~ We also ran several exploratory analy- cluster; wound care and debridement ses on other factors such as satisfac- Four treatments-hot/cold packs, were in the moderate-complexity tion with aide utilization at current whirlpool, paraffin, and ultrasound- cluster. The researchers found that job and practice as depicted in the were delivered without supervision low- and moderate-com~lexit~ tasks scenario. We chose not to report by physical therapy aides in the facili- were significantly more likely to be these findings, however, because ties of 20% or more of the respon- delegated than were high-com~lexity small numbers in some subgroups dents. These frequently delegated tasks. Like Senters,15 Hart and associ- and widely varying standard d&aprocedures are consistent with the ates failed to distinguish between tions among subgroups made us findings of Senters15 and Hart and delegation to physical therapy aides uncertain of the statistical validity of asso~iates.~o Senters found that whirl- and physical therapist assistants, and these other comparisons. The factors pool and hot/cold packs were the they did not clearly define different Physical Therapy /Volume 73, Number 74~1~ 1993 426 / 15

- Table 2. Therapists' Opinions Regarding Aide Utilization for Patient Treatmen1 Statement* Percentage of Responsesm Strongly Dls- Strongly Unable to Agree Agree Neutral agree Dlsagree Determine vision. The statistical power for this test is low because of the small number of respondents to this questionover half of respondents did not know the extent of training of the aides to whom they delegate treatment. At some point during my career, utilization of aides for patient treatment has presented me with ethical dilemmas (157) I am comfortable with aide involvement in patient treatment at my current job (148) I am satisfied with the Indiana Physical Therapy Practice Act's guidelines regarding utilization of aides in patient treatment (1 51 I am legally responsible for any actions of an aide treating patients under my supervision (1 56) A physical therapy student employed as an aide does not require as much supervision as an aide who is not a physical therapy student (1 58) I feel aides involved in patient treatment need some amount of relevant, formal on-the-job training by a physical therapist (1 57) "Number of responses shown in parentheses. we did examine statistically all had at least 10 subjects in each subgroup. The four most common settings in which respondents practiced did not differ statistically in their extent of independent use of aides. This finding is consistent with information gained in the interviews that were done to assist with questionnaire development: The interviewees collectively recounted examples of overutilization of aides in a wide variety of settings. We believe there should be concern about our finding that physical therapy aides are more often used without supervision when they are not identified as aides than when they are identified as aides. We believe that physical therapy administrators and clinicians, regardless of their opinions and practices relative to aides providing patient treatment, have a duty to develop and implement policies that guarantee that consumers will receive information about who is providing treatment. Our findings, unfortunately, lead us to believe that those who use aides without supervision often do so without the knowledge of the consumers receiving the treatment. We had hoped to find that when physical therapy aides were used without supervision, they were at least trained more extensively for that role. We found, however, that extent of training was not related to the extent of aide utilization. Although we could not identlfy a statistically important relationship between training and utilization, note that aides with more than 30 hours of training performed a mean of 20.6% of treatments without supervision, and aides with lesser amounts of training performed less than 10% of treatments without super- Our finding that there was a significant relationship between therapists' opinions about [he scenario we presented and their unsupervised use of aides for patient treatment demonstrates consistency between the opinions and actions of our respondents, because therapists who found the therapist's behavior in the scenario acceptable had a higher mean percentage of unsupervised use of aides for patient treatment. Because of the nonexperimental nature of the research, we are unable to determine whether working in an environment in which aides treat patients independently shapes therapists' opinions, or whether therapists' opinions shape the policies and practices at their facilities. Our results must be considered in view of the limitations of the study. First, it is impossible to determine the frequency with which aides actually perform certain activities, or the number of aides and patients involved. A response that aides perform ultrasound independently could mean that a single aide does this on a rare occasion or that many aides do this on a daily basis to many patients in the respondent's facility. For numerous reasons, we chose to sample individual physical therapists, rather than facilities or aides. We were concerned that if we sampled facilities, we would get responses from administrators who do not participate in regular patient care and who might answer on the basis of facility policy rather than actual practice. We were also concerned that if therapists thought their responses could be linked to their facilities, they might not provide frank reports of behavior they realize is controversial. Because we do not know how many or which facilities are represented by the respondents, we cannot determine whether the practices described by respondents Physical 1 rherapy /Volume 73, Number 74dy 1993

- tion, Table 3. Relationship of Percentage of Treatments Performed Witbout Supervision (%KT) to Setting, Aide Identijication and Training, and Scenario Opinion %WS Factor N R SD F P Summary the wide variation in utilization patterns and comments indicated that respondents included a good representation of the ranne - of ~ossible opinions about this issue. Setting Hospital Outpatient clinic Nursing home Rehabilitation center Aide identification "Aide" name tag Introduced as "aide" Not idenlified as "aide" Aide training None Low (&I 0 h) Medium (1 1-30 h) High (>30 h) Scenario opinion Acceptable Unacceptable 'Significant relationship at Pi.05, are consistent with facility policies. Further research might focus on the issue of congruence between stated policies and actual practices of physical therapists. Methods for further research might include observations of actual practices, rather than relying on self-reports. Although our study moves beyond previous literature by focusing on physical therapy aides only and distinguishing among different levels of supervision of tasks performed by aides, wc: failed to make distinctions between the deciding and doing behaviors clescribed by Watts.l9 That is, we did not determine what type of interaction between physical therapist and patient occurs prior to and after delegation of a treatment task to an on-the-jobtrained aide. If an aide is the only person who sees a patient on a given treatment day, then independent performance of an ultrasound treatment consists both of deciding to perform the ultrasound and then actually doing the treatment. Con- sider, however, a situation in which the physical therapist evaluates the patient each treatment day, decides that ultrasound is appropriate, and then delegates the performance of the ultrasound treatment to a physical therapy aide, who delivers the treatment independently while the therapist is out of the immediate treatment area. In this case, independent performance of an ultrasound treatment consists only of doing the treatment, not on deciding whether the treatment should be done. This distinction between deciding and doing should be considered in future research related to use of support personnel in physical therapy settings. We did not follow up on nonrespondents to determine whether their practices and opinions differed from those of the respondents. We believed that the initial return rate of greater than 50% was excellent for a fairly lengthy questionnaire, and we met our original goal of sampling more than 10% of the population. In addi- Use of physical therapy aides for patient treatment is a common practice in Indiana, with 68% of respondents indicating that aides are used to deliver treatment. An average of 12% of the types of treatments studied, however, were administered by aides without supervision at the facilities of the respondents. Four treatments were given by aides without supervision in the facilities of at least 20% of the respondents: hotlcold packs, whirlpool, paraffin, and ultrasound. Sixty-seven percent of the therapists indicated that use of aides had presented them with ethical dilemmas, and 73% desired more specific guidelines on aide utilization. There were significant differences in unsupervised aide use based on type of aide identification and physical therapists' opinions about aide utilization. There were no significant differences in unsupervised aide use based on setting and hours of aide training. References 1 Sullivan PA, Brown T. Unlicensed persons in patient care settings: administrative, policy, and ethical issues. Nurs Clin North Am. 1989;24: 557-569. 2 Taylor TK, Domholdt E. Legislative change to permit direct access to physical therapy services: a study of process and content issues. Phys Ther. 1991;71:382-389. 3 Clawson A. Diagnosis and referral issues in physical therapy practice. In: Domholdt E, Clawson AL, Flesch PW, Taylor TK. Direct Access lo Pbysical Therapy Services: An Educational Module. Alexandria, Va: American Physical Therapy Association; 1991. 4 1991 AHA Human Resources Survqi. Chicago, Ill; American Hospital Association; 1992. 5 Curry FV. The role of nonprofessional assistants: a survey of physical therapy departments in California. Phys Ther 1991;33:587-588, 6 Gray JM. Function of nonprofessional physical therapy personnel. Phys Ther 1964;44: 103-109. 7 Killen MB. Supportive personnel in physical therapy. Phys Ther. 1967;47:483-490. 8 Perry JP. Responsibilities in patient care: the need for nonprofessional assistants in physical therapy. Phys Ther. 1966;46:25&255. Physical Therapy /Volume 73, Number 7/July 1993 428 / 17

9 Robins V. Training and use of nonprofessional personnel in hospital facilities. Phys Ther 1966;46:256258. 10 Training and utilization of the physical therapy aide. Phys Ther. 1367;47(suppl):33. 11 Training and utilization of the physical therapy assistant. Phys Thm. 1967;47(suppl):34. 12 Guide for Professional Conduct. Alexandria, Va: American Physical Therapy Association; 1987. 13 Standards of Practice for Physical Therapy. Alexandria, Va: American Physical Therapy Association; 1991. 14 Physical therapy aide (HOD 06-86-06-09). In: House of Delegates Policies. Alexandria, Va: American Physical Therapy Association; 1992. 15 Senters JM. Professionalization in a health occupation: physical therapy. Phys Ther. 1972; 52:385-392. 16 Blood H. Supportive personnel in the health-care system. Phys Ther. 1970;50:173-180. Commentaries 17 Feitelberg SB. Medico-legal aspects of supervision in physical therapy. Phys Thm 1970; 50:11961201. 18 Holmes TM. Supportive personnel and supervisory relationships. Phys Ther. 1970;50: 1165-1171. 19 Watts NT. Task analysis and division of responsibility in physical therapy. Phys Thm 1971;51:23-25. 20 Hart E, Pinkston D, Ritchey FJ, et al. Relationship of professional involvement to clinical behaviors of physical therapists. Pbys Thm 1990;70:179-184. 21 McNeil A, Biddulph G, Walker JM. Role of physiotherapy auxiliary personnel in Nova Scotia: a descriptive survey. Physotherapy Canah. 1990;42:175180. 22 Physcal Therapy Practice Act, California. Physical Therapy Examining Committee, Board of Medical Quality Assurance; 1988. 23 Laws and Regulations, Maryland. Board of Physical Therapy Examiners of Maryland; 1989. 24 Physical Therapy Practice Act, Indiana. Medical Licensing Board of Indiana; 1988. 25 Gay LR. Educational Research: Competencies for Analysis and Application. 3rd ed. Columbus, Ohio: Merrill Publishing Co; 1987: 114115. 26 1987 Active Membership Pmjile Survey. Alexandria, Va: American Physical Therapy Association; 1987. 27 Guccione AA. Ethical issues in physical therapy practice: a survey of physical therapists in New England. Phys Thm. 1980;60:1264-1272. 28 Evaluative Criteria for Accreditation of Education Programs for Preparation of Physical Therapists. Alexandria, Va: Commission on Accreditation in Physical Therapy Education, American Physical Therapy Association; 1990. Following are four commentaries on "Use of Support Personnel for Physical Therapy Treatment." In examining the issue of aide utilization, Bashi and Domholdt have provided us with an interesting look at a side of physical therapy practice that is often either taken for granted or ignored altogether. In a time of restructuring of our health care system, the appropriate allocation of resources may be the key that determines the survival not only of individual practices, but of our profession as a whole. It is no longer considered politically acceptable that the needs of patients, and the methods by which these needs are met, should be determined entirely on the judgment of a select few. The concept of "quality of care," that bastion behind which health care providers have traditionally determined standards of treatment, is now considered an insufficient justification for health care policy-making. With increasing frequency, physical therapists are being asked to provide information about the relationship between the cost of care and the results that may be expected from the treatment approach that is utilized. It is recognized that different approaches to treatment may involve significantly different investments of resources, time, and money. This information is frequently used to either justify or dispute the value of the services that physical therapists provide. We are compelled, therefore, to structure our practice environment so as to support approaches to treatment that are effective, yet as costefficient as possible. The appropriate utilization of physical therapy aides and physical therapist assistants is seen by some as an integral part of this effort. In this study, the authors collected a large body of data that indicated physical therapy aides were being utilized for a variety of treatments. They reported that "68% of the respondents worked in facilities at which physical therapy aides were involved in patient treatment at some level." The size of this figure surprised me. In a time of emphasis on cost-effectiveness, I would have expected it to be much larger. It is possible that some therapist replies relate to settings in which intensive one-on-one interaction between therapist and patient is the only mode of treatment. Nonetheless, this figure brought back memories of my earliest clinical experience, in which a staft of 10 physical therapists was supported by one aide. The figure in this study does not indicate such extreme disproportion. It does, however, cause one to speculate as to the degree of clinical support that the other 32% of therapists were receiving, and the cost-effectiveness of such services. As I reviewed the report, I found myself questioning the authors' use of the term "unsupervised" and the effect that this utilization had on their presentation of the data. They selected the "unsupervised use of aides as an indicator of inappropriate utilization." This is explained by noting "the guidelines of the APT4 which spec@ that use of physical therapy aides to deliver direct care requires the direct on-site supervision of the physical therapist or physical therapist assistant." In Appendix 1, "unsupervised" includes the categories of "independent" and "unobserved." "Unobserved" is defined as a treatment situation in which the "physical therapist does not observe treatment at any time but is within voice range." Physical Therapy /Volume 73, Number 74uly 1993