Navigating the Grey Zone of Physiotherapy Assistant Autonomy in Home Care: Perspectives of Physiotherapists and Physiotherapy Assistants

Abstract

Purpose: To explore perspectives and experiences regarding the autonomy of physiotherapist assistants (PTAs) among physiotherapists and PTAs providing home care services in Ontario since the introduction of PTAs into home care rehabilitation teams. Method: For this qualitative study, we conducted semi-structured interviews with 10 physiotherapists and 5 PTAs working in home care. We analyzed interview transcripts using the DEPICT model. Results: Participants described navigating a grey zone characterized by a lack of clarity about acceptable levels of PTA autonomy. Four interrelating factors shaped the extent to which PTAs practised with autonomy: system influences (number of physiotherapy visits, professional guidelines), patient complexity (status, comorbidities), perceived PTA competence (skills, training), and the physiotherapist–PTA relationship (trust, communication). Conclusions: New practice models in home care have impacted the role of both physiotherapists and PTAs. Home care agencies should facilitate emerging professional relationships and address autonomy-related challenges, such as trust and competence, to promote high-quality client-centred care.

The Canadian health care system is constantly adapting to pressures including an aging population, financial constraints, and human resource challenges.^1,2 In an effort to reduce costs, the system has shifted focus from acute care to community-based services, including home care, and increased use of physiotherapist assistants (PTAs).¹ As a result, the role of the PTA in Canada is evolving.¹ One standard of the College of Physiotherapists of Ontario (CPO) for professional practice is to manage the working relationship between physiotherapists and PTAs.³ The standard states that physiotherapists are responsible for all care PTAs provide and that PTAs are unable to assess, reassess, or make changes to a treatment plan.³ In addition, physiotherapists are responsible for assessing a PTA’s competence in a certain task before assignment.³

The literature shows a lack of clarity regarding the role of PTAs, specifically what physiotherapists can and cannot assign to a PTA and how much autonomy a PTA may have in practice.^5–8 For example, Robinson and colleagues⁷ found that physiotherapists did not have a detailed understanding of what the PTA scope of practice included. Other studies have shown that physiotherapists and PTAs disagreed on the types of tasks PTAs could perform, the amount of supervision required, and the level of task complexity physiotherapists could assign PTAs.^5,6,8

In home care settings, physiotherapists and PTAs practise with considerable independence and autonomy. In 2013, reorganization of physiotherapy (PT) funding in Ontario resulted in changes to home care funding streams and the establishment of new practice models in which PTAs became an integral part of patient care in the community. While the number of practicing PTAs in Ontario is unknown, all regions employ PTAs, to varying degrees, to provide support and access to rehabilitation care through the home care system. The allocation of government funding for home care in Ontario is managed by regional health authorities called Local Health Integration Networks (LHINs). LHIN personnel assess each patient who receives rehabilitation services, determine the appropriate care pathway, and designate a predetermined number of physiotherapist and PTA visits. The independent nature of home care⁹ and the fixed number of physiotherapist and PTA visits can exacerbate the challenges identified in the literature regarding PTA supervision and autonomy.^5,7,8

To our knowledge, the physiotherapist–PTA relationship has not been thoroughly investigated in the Canadian health care context and, more specifically, in the home care sector. The purpose of this study was to investigate the experiences of physiotherapists and PTAs providing home care services in Ontario since the introduction of PTAs into home care rehabilitation teams. This study can inform strategies to optimize the integration and utilization of PTAs in this unique care setting.

Methods

Study design

We used a qualitative descriptive methodology.¹⁰ The Research Ethics Board of the University of Toronto approved the study (approval 39586).

Participant recruitment

In 2018, we recruited homecare physiotherapists who had worked with a PTA in the previous 6 months from three LHIN regions in the Greater Toronto Area where the service provider organization was actively using PTAs (Mississauga Halton, Central, and Central West). We also recruited PTAs who had an active caseload (i.e., at least one patient they had visited and planned to visit again) from the same three LHIN regions.

We used a purposive sampling strategy to recruit participants across a broad geographic catchment area to ensure a breadth of perspectives and experiences given the potential for differences in practices across areas.¹¹ Based on a meta-synthesis of 25 qualitative, semi-structured interview studies,¹² we estimated that a total of six physiotherapists and six PTAs (2 from each region) would be sufficient to provide insights into the experiences of home care physiotherapists and PTAs.

A home care agency facilitated participant recruitment by using a targeted recruitment process.¹² First, the agency emailed a study invitation flyer to 59 physiotherapists and 18 PTAs working in the three geographic areas. The agency sent two follow-up emails 10 and 14 days later in the regions where recruitment targets were not yet met. Interested participants contacted the researchers directly (MJ, CJ, NF, EU & KL) to determine eligibility and schedule an interview. Study participants operated within an independent contract model and received their hourly clinical visit rate plus a small honorarium.

Data collection

We constructed two interview guides, one for physiotherapist interviews and one for PTA interviews (Figure 1). We created these guides on the basis of findings from the literature regarding the physiotherapist–PTA relationship, and we piloted the guides within the research team and with a physiotherapist who had not practised with a PTA in the previous 6 months to maximize participation by eligible PTs. We designed the interview questions to facilitate discussion; explore participants’ perspectives on and experiences with task assignment, supervision, and communication with PTAs; and identify their strategies to optimize the use of PTAs in home care. Three second-year physiotherapy student researchers (MJ, CJ, NF, EU & KL) first conducted five practice interviews with research team members to increase their familiarity with the interview guides and then conducted the participant interviews.

Figure 1 .

Semi-structured interview guides for physiotherapist and physiotherapist assistant participants.

PT = physiotherapist; PTA = physiotherapist assistant; VHA = VHA Home HealthCare.

Each interviewer conducted one-on-one, semi-structured interviews via either telephone or Skype. All interviews were audio-recorded. Before each interview, the interviewer reviewed the consent form with the participant, obtained verbal consent to the interview, and completed a demographic questionnaire. We made no changes to the interview guide after the study commenced. We obtained demographic information (sex, age, and years of employment in home care) to describe the participants. The audio-recordings were professionally transcribed, and the research team verified them for accuracy. The student researchers completed all interviews before we commenced data analysis.

Data analysis

All members of the research team analyzed data using the DEPICT model for collaborative qualitative content analysis.¹³ The model includes dynamic reading, engaged codebook development, participatory coding, inclusive review and summarizing of categories, collaborative analysis, and data translation. We reviewed the transcribed interviews for recurrent themes and developed a preliminary coding framework. We pilot tested this preliminary framework with six transcripts to establish a final codebook. Two team members working independently coded each transcript using the final codebook. We coded the data into categories and organized the categories using NVivo Version 10 qualitative analysis software (QSR International, Doncaster, Victoria, Australia). We created a descriptive summary of each code to identify themes and address the research question. The research team met eight times over 3 weeks to conduct the data analysis. Discussions were collaborative, and decision making was consensus based.

Results

Participants

The student researchers interviewed 10 physiotherapists and 6 PTAs; however, we excluded one PTA interview because of poor audio quality, resulting in a final sample size of 10 physiotherapists and 5 PTAs. Participant characteristics are listed in Table 1. Most participants were female (87%); the physiotherapists had been practicing in home care for an average of 7.75 years (range, min–max 2–15) and the PTAs for an average of 4.75 years (range, min–max 3–7).

Table 1 .

Participant Characteristics (N = 15)

Characteristic	Physiotherapists (n = 10)	Physiotherapist assistants (n = 5)
Sex
Female	9	4
Male	1	1
Age, y
< 30	1	0
30–39	0	0
40–44	5	2
45–49	2	3
50–54	2	0
Mean (range, min–max) years of employment in home care	7.75 (2–15)	4.75 (3–7)

Each participant shared their unique experiences. As a group, PTAs tended to see their role as holistic and concerned with patients’ mental and physical well-being, whereas physiotherapists tended to prioritize safety and patient progression. Both physiotherapists and PTAs described their commitment to quality patient care and recognized the need to follow CPO guidelines.

Physiotherapist assistant autonomy: A grey zone

Overall, participants described the challenges of navigating a grey zone of ambiguity regarding the level of autonomy PTAs should have in home care. Participant responses suggested that the degree of autonomy a PTA may have falls somewhere along a continuum from no autonomy (e.g., having to follow the treatment plan exactly as prescribed) to maximal autonomy (i.e., complete independence). Participants tended to agree on the no-autonomy end of the continuum – that is, that certain tasks should never be assigned to a PTA, such as making recommendations for gait aids, adding a new exercise to a programme or communicating a diagnosis. Moving toward the maximal-autonomy end of the continuum, however, participants described the PTA practice boundaries as unclear. One physiotherapist reported being uncertain what they could assign to a PTA:

I’m not even clear all the time as to how much [PTAs are] authorized to change or progress programs. (Physiotherapist [PT] 3)

Most physiotherapists stated that PTAs could alter the number of repetitions of an exercise, but not the resistance, while other participants (both physiotherapists and PTAs) stated that in certain scenarios, PTAs could change the resistance of an exercise as long as they used good communication practices with the supervising physiotherapist.

Although participants (particularly physiotherapists) reported that the vagueness of the CPO guidelines could be challenging, some noted that the lack of clarity was not always negative. Several participants acknowledged that giving leeway to PTAs to progress patients – made possible by the vagueness of the guidelines – could be beneficial. These participants noted that physiotherapist, PTA, and patient factors interact in such a way that it could be appropriate to have PTA autonomy fall anywhere on the continuum. They described four interrelating factors that impact the extent to which a PTA can practise with autonomy: (1) system influences, (2) patient complexity, (3) perceived PTA competence, and (4) the physiotherapist–PTA relationship. Participants reported using the latter two factors, which they could act on and improve in the short term, as strategies to navigate the grey zone. Figure 2 depicts the grey zone, where ambiguity exists as to how much autonomy to provide PTs when the patient complexity is high, authorized visits are restricted and awareness of the PTA and their competencies is limited.

Figure 2 .

Grey zone at the intersection of the four interrelating factors that impact the level of PTA autonomy in home care.

PT = physiotherapist; PTA = physiotherapist assistant.

System influences

System influences are the external factors that dictate how physiotherapists and PTAs deliver home care. Participants described three highly interrelated system influences: (1) the independent and autonomous nature of the home care sector, (2) the LHINs, and (3) the CPO guidelines. These influences impact how much autonomy PTAs have within this sector.

Physiotherapist participants explained that the LHINs typically assigned them a limited number of visits with patients: one for the initial assessment, one for a joint visit with the PTA to assign care and assess PTA competence, one for reassessment, and one at discharge. In contrast, they reported, the LHINs might allow PTAs more visits over an extended period depending on the complexity of the patient’s condition. Physiotherapists stated that having only one visit for reassessment makes it challenging to progress patients and that communicating with PTAs in home care is not as frequent, or as simple, as in the hospital setting. Because a patient’s status can change at any time, these two factors mean that PTAs encounter situations in which they must make judgment calls. Many of the physiotherapist participants reported that for this reason, they often gave PTAs responsibility to make decisions and progress patients to achieve additional gains. One PT explained,

The LHIN determines how many visits we get – it’s not up to us – and they determine how long we’re allowed to be in there for. If [a PTAs is] just asking to progress an exercise, I won’t necessarily go in, because that’s using up one of my visits. … If I know the PTA, and I know that they know what they’re talking about, then I’ll just let them progress an exercise by themselves. (PT8)

In contrast, physiotherapists who desired to adhere to CPO guidelines often gave PTAs less autonomy. Several physiotherapists stated they felt more comfortable limiting the amount of autonomy their PTAs had in order to adhere to guidelines and avoid jeopardizing patient safety. At times, physiotherapists designed simple exercise programmes that PTAs could follow without the need for progression.

Overall, the physiotherapists described feeling pulled in two competing directions: (1) the desire to give PTAs more autonomy to achieve the best patient outcomes within the system constraints and (2) the obligation to adhere to CPO guidelines:

On the system level, I think the LHINs are very unrealistic with what they’re giving us. I think they really have to understand the College guidelines. It’s hard to keep up with the clients when you’re in there 3 months and you’ve got basically your two visits after your assessment and your joint visit. I don’t think it’s realistic. I don’t think it’s enough monitoring of the client in order to let the PTA know how much they can do and how far they can take the client. (PT3)

Patient complexity

Participants reported several factors regarding patient complexity that influence the level of autonomy a PTA has in home care. Most physiotherapists and PTAs agreed that for patients with a stable medical status, and the treatment goals are to maintain function and build confidence, PTAs can operate with more autonomy. However, several physiotherapists had concerns about PTAs treating complex patients, such as patient’s post-surgery or fracture:

There are multiple comorbidities that these patients have that are complex, … and most of the time there is a safety issue in terms of falls risk. … I would not assign a task that I know that a PTA would not be able to perform safely, and potentially we are limiting the patient’s improvement and progress. (PT7)

When patient status changes from day to day, some reassessment is necessary at each visit. Several physiotherapists felt uneasy allowing PTAs the level of autonomy that would be required of them in these situations, as it would force them to operate in the grey area, where the line between an acceptable and unacceptable degree of autonomy is unclear.

Generally, the PTA participants did not share this concern. Most reported feeling confident in their skills. They also reported that they had faith that their physiotherapist would provide them with the necessary guidance or would not assign them a patient who was too complex for them to handle:

Yeah, I think [the amount of supervision] is enough because like I said, if it’s a hard case, they’re usually doing the joint visit with us, explaining then if it’s something particular that we need to know; then we go through that together with them. (PTA3)

While several physiotherapists stated that they simplified the treatment plan when using PTAs with complex patients, some described scenarios in which increased patient complexity led them to ask PTAs to operate with a broader scope:

Well, I have a stroke client, who’s a very heavy stroke, … and they got sent home from rehab too early. So I’m trying to show the PTA things that I’d be doing myself, which I’m not sure how much beyond her scope it is. I’ve kind of simplified it as much as possible. (PT3)

Perceived PTA competence

The perceived competence of a PTA strongly impacted the level of autonomy physiotherapists were comfortable providing them with. Physiotherapist participants explained that they allowed PTAs whom they perceived as highly competent more independence in patient visits and often gave them some leeway to progress or change programmes. In addition, both physiotherapists and PTAs stated that physiotherapists tended to give more autonomy to PTAs who had trained as physiotherapists in other countries.

System influences, specifically the independent and autonomous nature of the home care sector and the restricted number of joint visits, sometimes impacted physiotherapists’ perceptions of PTA competence by limiting opportunities to evaluate PTAs’ skills. One PTA felt that the physiotherapists she worked with undervalued her skills and training. Although she had substantial work experience and supplementary training, the physiotherapists were unaware of how competent she was because of the limited opportunities to work together:

[The physiotherapists] just come for the joint visit. They don’t know your hands-on skills. They don’t know everything [about] you. And then they don’t know exactly your qualifications. (PTA1)

Physiotherapist–PTA relationship

Participants consistently reported that the level of trust between a physiotherapist and a PTA and the quality of communication between them were major factors that impacted PTAs’ autonomy. Physiotherapist participants described four factors that influenced trust and the quality of the working relationship: (1) the ability to know the PTA before assigning tasks, (2) the PTA’s communication skills, (3) the PTA’s ability to follow a treatment plan without deviating, and (4) the PTA’s general professionalism. Physiotherapists and PTAs also explained that trust and excellent communication helped them safely navigate the grey zone.

Many physiotherapist participants spoke of the importance of knowing the PTA to whom they assigned tasks. Beyond knowing that the PTA met a minimum level of competence, several physiotherapists highlighted the importance of both clinicians knowing each other’s style in terms of performing tasks the same way. Participants reported that getting to know someone results from spending time together in person (vs. talking on the phone or via email) and working together over time. Many participants stated that challenges with task assignment and supervision tended to happen at the beginning of a physiotherapist–PTA relationship and eased once a trusting relationship was established:

I personally work with just one PTA, … and I know him. … We have been working together for a couple of years now, but it would be different if there was a different staff because, at least at that time, I wouldn’t know them. But I know what I can expect, and he knows my style, so we work together well. I think this is important – that we work with a PTA that we can trust, and we know their skills. (PT7)

Physiotherapists tended to trust PTAs who had good communication skills with both the physiotherapist and the patient, and whom they could trust to communicate any important patient information, such as a fall or change in status. Physiotherapists also noted that the PTA’s ability to follow a treatment plan is important to building their trust and ensuring patient safety. In addition, physiotherapists and PTAs alike reported that general qualities of professionalism affected the amount of trust between the physiotherapist and PTA. These qualities included punctuality, reliability, work ethic, flexibility, and openness to feedback.

Participants reported that the level of trust between a physiotherapist and a PTA and the quality of their communication had a huge impact on the PTA’s autonomy in practice. Physiotherapists who trusted a PTA were more inclined to give them more autonomy. Both physiotherapists and PTAs reported that a trusting relationship and excellent communication were crucial for working effectively. Because of the challenges with following the CPO guidelines and progressing patients in the unique context of home care, most participants strongly suggested that physiotherapists and PTAs meet more often – for example, in team meetings, for joint case study discussions, in informal gatherings to provide opportunities to connect and share stories, and in workshops for newly hired PTAs to clarify expectations regarding communication.

Discussion

This study is the first to explore the perspectives of physiotherapists and PTAs in home care, and it contributes to the growing body of literature regarding the evolution of the PTA role.^1,14 Researchers have identified uncertainty around the acceptable level of PTA autonomy as an issue in several health care settings,^1,6 and our participants described this grey area as well. Since PTAs in home care do most of their visits independently and the number of physiotherapist visits is limited, the uncertainty surrounding PTA autonomy is amplified in the home care sector. Physiotherapists and PTAs alike described the challenges of maintaining quality of care while adapting to the system’s changing demands¹⁴ and adhering to CPO guidelines around task assignment and supervision.

The description of the PTA role in the PTA Profile⁴ aligns closely with the PTA role our participants described in home care settings, but the CPO guidelines do not allow PTAs to assess patients or modify a treatment plan.⁹ A physiotherapist interviewed in Colbran-Smith’s¹ white paper reported that PTAs commonly practise with some autonomy and perform some components of assessment in their everyday work (e.g., distance walked by patient at each visit). The PTA Profile refers to these assessment-type skills as “demonstrates effective problem-solving and judgment.” In another study, PTAs described performing ongoing assessment to ensure safe execution of assigned tasks, and they contrasted these observational and ongoing assessment skills with the initial assessment, which they noted is clearly the physiotherapist’s domain.⁶ The element of assessment that is outside a PTA’s scope of practice (i.e., at the no-autonomy end of the continuum) is the interpretation of assessment findings and, closely linked to this, determining and progressing interventions.^4,15

Although the PTA Profile helps clarify what constitutes an acceptable level of autonomy for a PTA to have, the grey zone remains.¹⁵ For example, the PTA Profile states that interpreting assessment findings and changing the treatment plan are not within a PTA’s scope, yet PTA profile indicates a role for PTAs to identify adverse reactions to interventions and take appropriate action by communicating with the PT.⁴ Furthermore, PTAs are not permitted to progress interventions, and yet one clause in the PT Profile allows them to “progresses therapeutic interventions within the parameters assigned by the physiotherapist (e.g., endurance, strengthening exercises).”⁴ The grey zone can be advantageous because it allows physiotherapists freedom to assign more challenging tasks to skilled PTAs. There is potential for the PTA role to grow and better complement the role of physiotherapists in home care, but the PT profession must include physiotherapists and PTAs in discussions to strategically outline the added value of PTAs¹ rather than expanding the PTA role solely in response to system pressures. Future versions of the CPO guidelines should define assessment in a way that reflects the evolution of the PTA role in home care.

There is no single set of competencies that will prepare PTAs for all scenarios in home care. The physiotherapists in our study rarely talked about PTAs failing to meet a minimum level of competence. Rather, they discussed whether PTAs had the experience, training, and assessment skills to deal with complex scenarios or whether PTAs had traits that allowed them to problem solve, adapt to different situations, and learn new skills. These traits are not required in a traditional view of the PTA role³ but are required for optimal patient outcomes in the current home care sector, where PTAs need to go beyond simply following a treatment plan.

The literature suggests that more training for PTAs would better equip them for the growing number of tasks they are completing,^5,15 but our results suggest that physiotherapists want to be directly involved in training the PTAs they work with, as they tend to trust PTAs who adopt a similar style as themselves. Consistent with current literature,^1,16 we found that communication and trust are paramount in physiotherapist–PTA teams and strongly influence the PTA’s level of autonomy. Our results also indicate that physiotherapists are not always aware of the training and skills individual PTAs have. Participants recommended that home care agencies facilitate opportunities for physiotherapists to get to know the PTAs they work with, assess their skills, and participate in PTA training and that each physiotherapist–PTA team discuss expectations for how, when, and what to communicate early in the relationship.

Several physiotherapists felt that having more visits to reassess patients could allow better progression of interventions and improve patient outcomes, leading to potential cost efficiencies. In addition, they noted that providing physiotherapists flexibility in the number of reassessment visits would allow them to visit patients whose status has changed without contacting the LHIN to request additional visits. Moreover, physiotherapist participants felt that rather than the LHIN, physiotherapists should be able to assign PTAs to patients at their own discretion.

There is also the potential for PTAs to become regulated service providers. Increased regulation of support personnel is a global trend, and the 2003 regulation of PTAs in Quebec is now mostly seen as a positive change by PTs and PTAs.¹ If the CPO and Ontario Ministry of Health were to allow PTAs to practise under their own license, physiotherapists would be freer to assign more complex tasks to skilled PTAs without fear of endangering their own license, potentially contributing to a broadened scope of practice for PTAs.

The results of our study must be interpreted considering several limitations. We had difficulty recruiting PTAs, who are a small percentage of the home care clinicians practicing within the agency where recruitment occurred. Additional PTA interviews might have provided further insights. In addition, our research team did not include a PTA, which may have influenced how we formulated our interview guides and interpreted the data. Although we recruited participants from only one home care organization, we used a purposive sampling strategy and interviewed participants from three different LHINs to gather a wide range of perspectives and to increase the applicability of our study findings.

Conclusion

The participants in this study described an ambiguous grey zone regarding how much autonomy PTAs can have in practice. System influences create a challenging environment in which physiotherapists, who are bound by CPO guidelines, must nevertheless find a way to give PTAs enough leeway to ensure patient progression and quality of care. Trust and good communication are crucial for navigating this grey zone. Our findings indicate that the unique nature of home care has pushed PTAs into a role that includes more autonomy than they traditionally have held. Home care agencies should provide further opportunities for physiotherapists and PTAs to get to know each other to facilitate interprofessional collaboration and high-quality client-centred care. Further research is needed to investigate the new role of PTAs in home care and to test strategies to mitigate the challenges associated with supervision and assignment of tasks.

Key Messages

What is already known on this topic

There is a grey zone of ambiguity regarding the role of physiotherapist assistants (PTAs), specifically related to autonomy and the tasks physiotherapists can assign to PTAs. Physiotherapists and PTAs working in the home care sector have additional challenges as a result of working in isolation with little direct supervision.

What this study adds

Our findings reveal four interrelated factors that determine PTAs’ level of autonomy in home care practice: system influences, patient complexity, perceived PTA competence, and the physiotherapist–PTA relationship. Home care agencies should consider ways to facilitate further opportunities for physiotherapists and PTAs to get to know each other to facilitate interprofessional collaboration and high-quality client-centred care.