Professional articles

Introduction

Physiotherapy assistants are a well-established group working withinphysiotherapy departments in the UnitedKingdom, helping in the delivery of care.They form approximately one-fifth of all staff employed in physiotherapydepartments (JNPMI, 1995). Thephysiotherapy assistant’s role is relativelyundefined, with guidelines publishedperiodically by the Chartered Society ofPhysiotherapy (CSP) regarding duties and tasks (CSP, 1999a). Studies to date

indicate that there is considerablevariation in tasks undertaken (Saunders,1995; Ellis et al, 1998). Further definitionof their role and career opportunities isreported to be necessary (Smith, 1998).

Recently there has been increasedinterest in the development of the scopeof practice of unqualified support staffnationally (DoH, 2000) in order to meetthe demands of changes in healthcaredelivery, shortages in qualified staff andan increasing emphasis on cost-effectiveskill mix (Hunter, 1995; DoH, 2000).

Interest in this issue within physio-therapy has also increased, with the CSPundertaking a national survey mappingthe current scope of practice and trainingof physiotherapy assistants (CSP, 1999b).Interest in the development of the scopeof practice and training of assistants is notlimited to the UK. Throughout the worldthe scope of practice of assistants wasreported as being developed to improveand extend access to physiotherapyservices for elderly people (Sutcliffe,1989). A recent study in Canadademonstrated development in the scopeof practice of assistants (Loomis et al,1997).

A further issue in the development of support staff is the promotion of the ‘generic worker’ or ‘rehabilitationassistant’ fulfilling the combined roles of physiotherapy asistant, occupationaltherapy assistant and, on occasion, speechtherapy assistant (Hunter, 1995). Concernregarding this development has beenreported among both physiotherapyassistants (Ellis et al, 1998) and physio-therapists (Physiotherapy Frontline, 1999a).

In the UK there is great variation in thenature and extent of physiotherapyassistant training. In the past they havereceived little formal training and havedepended on ‘on-the-job’ training todevelop their capabilities. Since 1993, in

Factors Determining theCurrent Use of Physiotherapy Assistants Views on their future role in the South and West UK Region

Summary Physiotherapy assistants form approximately 20%of the work force within physiotherapy departments andaccount for a large proportion of the delivery ofphysiotherapy care. There is great interest in developing thescope of practice of physiotherapy assistants and evidencethat this is under way. Little is known about the factorsdetermining use of physiotherapy assistants and their viewson their future role. The purpose of this study was toinvestigate how the role of physiotherapy assistants waschanging, identify the factors that affect the development ofthe physiotherapy assistants’ role and determine the views ofphysiotherapy assistants and physiotherapists on the futurework of physiotherapy assistants. Semi-structured interviewswere carried out with a stratified random sample of 18physiotherapy assistants from the South and West Regionand separately, with their 18 physiotherapy supervisors. Thephysiotherapy assistants worked in a range of settings –elderly care, paediatrics, outpatients and primary care.Analysis of the interviews showed that there was variation inscope of activities of physiotherapy assistants and in the levelof supervision. Supervision was reduced primarily in particularspecialty areas, such as elderly and primary care. Changeswere primarily locally determined. A change or shortage ofqualified staff was regarded as being instrumental in thedevelopment of practice. Training, levels of responsibility andsupervision, and the development of generic workers wereissues of concern for this changing workforce..

Key WordsPhysiotherapy assistants, tasks, role, training,supervision, future.

by Bridget Ellis N A D Connell

Ellis, B and Connell,N A D (2001). ‘Factorsdetermining thecurrent use ofphysiotherapyassistants: Views ontheir future role inthe South and WestUK Region’,Physiotherapy, 87, 2, 73-82.

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line with national developments, therehas been an initiative to develop thetraining of physiotherapy assistants usingthe structure of the National VocationalQualification (NVQ) programme (CSP,1994). This is a structured trainingprogramme to develop the practical skillsof workers. Training occurs at the place of work and is assessed in the workenvironment. Further commitment to thisapproach by the professional body isevident (CSP, 1998a). Ellis et al (1998)reported that in the South and WestRegion (SWRHA) most initial trainingremained ‘on the job’, and there wasgreat variation in the structure of on-going training and uptake of the NVQwas low. The CSP reported that there wassupport among managers for this system(CSP, 1999b). There is evidence of the useof such vocational training with supportworkers working with other professionsallied to medicine such as occupationaltherapists (Newton and Kirk, 1999).

A questionnaire survey of physiotherapyassistants was carried out in 1996/97within the SWRHA and received aresponse rate of 85% (359 assistants).This compared their tasks and activities,supervision and responsibilities over afive-year period (Ellis et al, 1998). Itshowed that physiotherapy assistants werespending more time working with patientsindependently; 46% were spending morethan half of their time with no immediatesupervision in 1996/97 compared with27% in 1991. More physiotherapy ass-istants (80%) were also being allocatedindividual patients to care for than in1991 (66%). Increased scope and skilllevel of physiotherapy assistant activitieswere also evident, such as the delivery of electrotherapy. Assistants were alsobeginning to take an active role in thecommunity physiotherapy services. Theresults of the national survey in 1999(CSP, 1999b) indicated that this was anaccurate reflection of the national use ofphysiotherapy assistants, although thereremained confusion over some aspects oftheir scope of practice and the extent towhich this could be developed.

Aims of the StudyThis study formed the second stage of the survey of physioterapy assistants in the SWRHA (Ellis et al, 1998). Thequestionnaire survey in 1996/97 providedquantitative data on their tasks, training,

job satisfaction and related issues.However, the reasons for the findings of areduction in the levels of supervision,increase in responsibility and increase inthe scope of activities undertaken werenot apparent. Semi-structured interviewswere therefore undertaken to gain greaterdetail regarding the apparent differencesin the use of assistants in differentlocations and the apparent changes in usemore recently. Use of semi-structuredinterviews allowed for the development ofa fuller, richer picture rather than thestrict quantitative categorisation of thepostal questionnaire. The opportunity to question more closely with moreprobing questions gave greater depth of information and a more roundedevaluation of the information gainedfrom the large-scale survey (Smith, 1995;Seale and Barnard, 1998).

The aims of this stage were to:

� Investigate details of current work andsupervision.

� Investigate how the role ofphysiotherapy assistants was changing.

� Identify the factors that affect thedevelopment of their role.

� Determine their views on the futurework of physiotherapy assistants.

� Determine the views of the supervisingphysiotherapists the future work ofphysiotherapy assistants.

MethodSubjectsSince the primary purpose of this studywas to explore the possible reasonsbehind the variation in the levels ofsupervision and independent practice of physiotherapy assistants – the areashowing the greatest change in the large-scale study (Ellis et al, 1998) -- a stratifiedrandom sample was taken from the 246physiotherapy assistants from the initialsurvey in the SWRHA who were preparedto be interviewed. In order that thesmaller sample who were interviewedwere reflective of the larger sample, keycharacteristics were identified andstratification was made on the basis ofamount of supervision while treatingpatients. Classification of supervision wasmade according to the proportion ofpatient contact time with no immediatesupervision by a physiotherapist, ie withphysiotherapists absent from the area. Six

75Professional articles

assistants were randomly selected fromeach of the following groups:

Physiotherapy assistants who spent

� less than 25% of their patient contacttime unsupervised.

� 50% to 75% of their patient contacttime unsupervised.

� 75%+ of their patient contact timeunsupervised.

The senior managers supplied thenames of the 18 physiotherapists whowere responsible for the supervision and work of each assistant identified, and agreed that they could also beapproached for interview. Thus 36interviews were undertaken. The samplesize reflected the need to interviewrepresentatives from the sub-group ateach level of independent practice andinvestigate the views of the physio-therapists with whom they worked mostclosely. This allowed for triangulation ofthe information gained from the assistants(Robson, 1993) and further explanationof differences in practice (Mason, 1996).

ProcedureAgreement of the senior managers toapproach the 18 assistants was soughtbefore contacting each member of staff,as was agreement to approach the 18supervising physiotherapists (identified by the senior managers) who wereresponsible for the supervision and workof each assistant. Each assistant andsupervising physiotherapist was contactedindividually, initially by letter with afollow-up telephone call, to agree aconvenient time for interview. Oneassistant declined to participate andtherefore a further assistant was randomlyselected from the group receiving thesame level of supervision, and theprocedure of contacting the seniormanager to identify the supervisingphysiotherapist and contact for interviewwas followed.

InterviewsFollowing analysis of the postalquestionnaire from the previous study(Ellis et al, 1998) the specific issuesaffecting physiotherapy assistants wereidentified and used in the individualinterviews. They were:

� Tasks undertaken.

� Supervision and responsibility.

� Personal and professionaldevelopment.

� Changes in role and training.

� Future role.

Pilot interviews were undertaken withnon-participating assistants and super-vising physiotherapists in order to test the interview procedure and clarity ofquestions. Pilot data were not included inthe data analysis.

The 18 assistants and 18 supervisingphysiotherapists were interviewedseparately. Each interview took appro-imately 45 minutes. All interviews wereundertaken by the research assistant atthe physiotherapy assistants’ place ofwork. All the interviews took place in aprivate setting and were tape-recorded aswell as short notes being taken at the timeof interview (Smith, 1995).

Data AnalysisThe first three interviews of assistants and supervising physiotherapists weretranscribed and a content analysis (Sealeand Barnard, 1998) of the interviews was undertaken by two independentresearchers for initial construction ofcategories for analysis. A review of thechoices of categories was undertaken bythe two researchers together in order toproduce a final list of categories (Robson,1993). Subsequent interviews were thenanalysed using this categorisation.Following full categorisation of theinterviews by the initial researcher thesecond researcher repeated the analysis to ensure its reliability.

FindingsDescription of SampleThe assistants who were interviewedworked in a variety of geographicallocations which included inner city, ruraland island areas. Table 1 gives details ofthe sex, age distribution and work-relatedinformation about the assistants inter-viewed. All 18 were female; reflecting thehigh proportion of therapy assistants ingeneral who are female (CSP, 1999b).

The areas of work of the assistants andthe percentage from each are indicated inthe figure overleaf. The areas of workwere representative of main clinical work

Authors

Bridget Ellis MScMCSP is a part-timelecturer at the Schoolof Health Professionsand RehabilitationSciences, University ofSouthampton, and asenior physiotherapistat Poole HospitalNHS Trust.

N A D Connell PhDMBCS is seniorlecturer in theDepartment ofManagement at theUniversity ofSouthampton and wasco-grantholder of thefunding for this study.

This article wasreceived onSeptember 6, 1999,and accepted onSeptember 26, 2000.It is an adaptation of apaper ‘A follow-upstudy to investigatethe factors affectingthe changing role, jobsatisfaction andtraining ofphysiotherapyassistants in oneregion of the UnitedKingdom’, given bythe same authors atthe 13th InternationalCongress of the WorldConfederation forPhysical Therapy, heldin Tokyo, Japan, inMay 1999.

Funding for this studycame from NHSExecutive South andWest R&DDirectorate.

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areas in which physiotherapy assistantswere employed (CSP, 1999b). As themajority of assistants in the SWRHAworked in elderly care (Ellis et al, 1998)the greatest proportion of therapistsinterviewed worked in this area. Thenational profile undertaken in 1999 alsoindicated that many physiotherapyassistants worked with elderly patients(CSP, 1999b).

All the supervising physiotherapists hadmore than three years’ experience. Theirgrades ranged from senior II (threerespondents), through senior I (ninerespondents) to superintendent (sixrespondents). One supervising physio-

therapist was male, again a reflection ofthe proportion of men to women in thephysiotherapy profession. All supervisorsworked in the same clinical area of workas their assistants. Three of the super-vising physiotherapists were trained NVQassessors.

Tasks undertaken by PTAsThere was agreement among all assistantsand supervising physiotherapists that thephysiotherapy assistant role was diverseand needed to remain so in order to beresponsive to the changes in the nature ofservice delivery. Only five of the 18 sitesvisited had drawn up specific guidelinesfor assistants in addition to thosepublished by the Chartered Society ofPhysiotherapy. Two of these includedchecklists of criteria against which toassess specific skills with review dates forindividual assistants.

All the assistants and supervisingphysiotherapists stated that the assist-ants supervised exercise and mobilityprogrammes. The assistants working inelderly care and outpatients also reportedundertaking some electrotherapy treat-ments with specific training as shown in table 2.

There was complete agreement of eachpair (assistant and physiotherapistsupervisor) on the reported tasks. Nineassistants reported that their role wasrepresentative of all the physiotherapyassistants who worked in their dep-artment, and the remaining ninereported that their duties were tailoredspecifically to their work area or theirskills. A reason for this was considered tobe the variation in practice of differingsupervising physiotherapists, which both

Table 2: Electrical treatments given byphysiotherapy assistants

Application No of assistants

Trancutaneous electrical nerve stimulation 7Hot packs 5 Ice 5Wax 5Pulsed short-wave diathermy 2Ultrasound 1Interferential 1

One assistant applied all the modalities listedabove.

Table 1: Age, sex and work-related information about physiotherapy assistants

Numberof assistants

Sex Female 18Male 0

Age (years) < 26 126 – 35 236 – 45 5> 45 8Non-response 2

Type of work Part-time 17Full-time 1

Years of employment as Range < 1-16physiotherapy assistant Mean 5.6

NVQ3 qualifications Physiotherapy related 3Not physiotherapy related 2

Grade Technician grade iii 3Physiotherapy assistant 15

Paediatrics 11%

Outpatients 33%

Community11%

Elderly care 45%

Clinical areas of work

77Professional articles

supervisors and assistants acknowledgedas being a factor. In 14 pairs it was evidentthat a close relationship existed betweenthe supervising physiotherapist and theassistant and they attributed this to theconfidence in task allocation.

Eleven of the 18 interviewed assistantswere allocated a specific caseload, and afurther three reported that they wereinformally allocated one, which wasconfirmed by their supervising physio-therapists. The reason given for not beingallocated a caseload was the brevity of the course of treatment, primarily inoutpatient situations. However, it wasacknowledged that all assistants wereprimarily responsible for the delivery ofon-going patient care, for example onesupervisor reported:

‘Before we had four assistants we oftenended up being just an assessmentservice. ... Now we can give helpers alist and they will go off and do things’(supervisor 16).

The process of allocation of work variedaccording to whether or not thesupervising physiotherapist workedcontinuously at the same site as theassistant. Where they were both based inthe same place then allocation wasgenerally oral with some writteninstructions at the start of each day. Infour partnerships the supervisingphysiotherapist and the assistant wouldsee patients together at the first contactand then tasks would be allocated. In twosituations it was reported that the assistantmight be the first contact with the patient.One supervising physiotherapist reportedoccasionally allowing the assistant toundertake a first contact without herhaving undertaken the initial assessment.This would occur only if the assistant wasalready familiar with the patient, forexample in the case of a readmission. Thesupervisor felt that this should not reallyhappen but she was over-extended andnot always on site to initiate treatment. Inthe second situation, the assistant workedin the community and issued walking aidsto new patients.

There was complete agreement amongall supervisors that tasks should be carriedout by assistants only following an initialassessment by a supervising physio-therapist, despite two delegating firstcontact on occasion to their assistant. Six supervisors mentioned that elect-

rotherapy was also an area that assistantsshould not undertake. The assistantsreported most frequently that assessment(nine assistants) and electrotherapy(eight assistants) were tasks that anassistant should never undertake.Assistants and supervising physio-therapists also identified alteration orprogression of treatment as another areathat was the sole domain of a qualifiedmember of staff.

When asked to compare the role ofassistants with that of a junior physio-therapist, both assistants and super-visors highlighted that the fundamentaldifference was in assessment skills. Inaddition, although a junior physio-therapist might be less familiar with thespecific procedures in certain areas, it wasanticipated they would gain a broaderrange of experience and ultimatelyassume full responsibility for patients.

The assistants fulfil a variety of roles,reflecting the varied needs of physio-therapy practice. That developments areprimarily locally determined is reportedelsewhere in current literature (Wright,1995; Saunders, 1997; Parry and Vass,1997; CSP, 199b). This variety offersopportunities for innovation but leads todifficulties in structuring assistants’ roleand training. Although in the literature itis reported that task analysis is beingapplied in various physiotherapy spec-ialties (Saunders, 1995; Smith, 1996), thiswas not reported as being a primary factorin task alteration in this study. Similarly astructured approach to calculate staffingneeds (Squires and Hastings, 1997) wasnot discussed as a major issue in thisstudy.

Confusion over whether assistantsshould undertake certain tasks, such aselectrotherapy, remains an issue whichhas also been reported nationally (CSP,1999b). One area of high assistant use waselderly care, and with the nation’s ageingpopulation (HMSO, 1995) this is likely torequire sustained growth. Assistants arealso increasingly used in general out-patient settings and the community team,reflecting the national trend towardsincrease in care in the community.

Despite the general nature of thecurrent national guidelines for the use ofassistants (CSP, 1999a), there was overallagreement between assistants andqualified physiotherapists about thespecific limits of the remit of assistants’

Address forCorrespondence

Miss B Ellis, School ofHealth Professionsand RehabilitationSciences,University ofSouthampton,Highfield,Southampton SO17 1BJ.

Acknowledgements

The authors wouldlike to thank the NHSExecutive South andWest for funding thisproject; Sheila Payneand Wendy Mills fortheir assistance on thesteering committee;and all thephysiotherapyassistants andphysiotherapists fortheir participation inthis study.

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work. Subjects also agreed on whichactivities were regarded as the exclusivedomain of a qualified physiotherapist.However, there was evidence that incertain situations these boundaries werebeing eroded due to the constraints of thework setting. As this is already happening,it is important that the CSP guidelinesstate categorically if this is acceptablepractice.

Supervision and ResponsibilityNone of the supervising physiotherapistsinterviewed had undergone any trainingin supervision or task delegation. Four ofthe assistants had no immediate super-vision as the supervisors were working offsite. In all situations there were regularmeetings (at least once a week) andadditional contact by telephone. In all ofthese cases there was no evidence ofdissatisfaction with the level of supervisionoffered. The other 14 assistants had asupervising physiotherapist on site but not necessarily at all times. All theassistants were confident that the level of supervision was appropriate andunderstood the chain of communicationwhen any issues arose. When there was ashortage of qualified staff the supervisorsheld varied views about the supervisionand use of assistants:

‘At times when there are staffshortages then really the assistantscome into their own’ (supervisor 6).

This must be compared with :

‘If we are short [of] qualified staff wecould not use any more assistants.... We could reach saturation pointbecause you’ve got so many staff tosupervise’ (supervisor 16).

All the supervisors acknowledged thatthe level of responsibility of assistants wasconsiderable:

‘They have, I think, a lot ofresponsibility ... and I do rely on themvery heavily’ (supervisor 1).

The assistants themselves all felt thatthey were given a large scope of practiceand were confident of the level ofresponsibility:

‘I’m given as much responsibility as Iwant within the role that I’ve got, notvery often would I be unhappy doinganything’ (assistant 9).

There were tensions cited on threeoccasions when there were changes instaff or staffing levels, for example:

‘I could do more, it depends oncircumstance and the job is funny forthat because I’ve taken on a lot ofresponsibility when we’ve been shortof a physio on the wards and that’stended to come to me … but then asthe physios come in place again thenobviously you give that responsibilityup’ (assistant 5).

The three assistants who were graded asTechnical Level iii undertook a greaterrole in independent management ofpatients and a ward. The supervisingphysiotherapist remained in contact andwas available for reference. Threeassistants had undertaken NVQ level 3training and this gave the supervisorgreater confidence in the delegation ofduties, and the assistant adopted a moreindependent role. There were alsoexamples of extended practice of the twoassistants working in the community andpaediatrics, for example undertakingindividual caseload management withminimal supervision.

In this study the reduction in the levelof assistant supervision was reported tohave resulted from:

� A shortage of qualifiedphysiotherapists.

� Some resultant staffing re-structuring.

� Locally initiated training schemes.

� The development of NationalVocational Training schemes.

The shortage of qualified physio-therapists has been reported nationally(JNPMI, 1995) and continues to be ofgreat concern in certain specialty areassuch as elder care. If this trend continues,it seems likely that an increasing use ofassistants in such areas might beanticipated. Increasing use of assistants in the community and in non-hospitalsettings has also led to an increasingindependence of assistant practice. It wasevident that the primary reason for the higher levels of supervision for some assistants was that their workingenvironment was different and theyworked in close proximity with thesupervising physiotherapist, but this didnot influence the nature of the tasksundertaken to a great extent.

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Personal and ProfessionalDevelopmentEight of the assistants were included in aregular staff appraisal scheme rangingfrom six-monthly to annually. In threeinstances this was specifically related totraining needs, in the other situationsgeneral issues were also addressed.

Initial training for all assistantsconsisted of inclusion in the availablelocal service induction training schemeand personal ‘on-the-job’ training. On-going training varied greatly among thoseassistants interviewed, with regularityranging from once a week as part of ageneral assistants’ training programme toapproximately once every six months.Formal training was not directly related to individual needs or to intendeddevelopment, it generally reflected thelocal assistants’ training policy, ie thetraining was a general programmedesigned to meet the needs of allassistants and the availability of staff toundertake training. All assistants andsupervising physiotherapists acknow-ledged the difficulty of formulating astandardised training programme to meet individuals’ needs due to therecruitment of staff at different times, the varied levels of competency onrecruitment, and the lack of resources to meet these needs.

The option of undertaking an NVQ wasnot available to 12 of the assistants. Thiswas the result of decisions by the hospitalmanagement not the physiotherapy staff.Six of these assistants were keen toexplore the possibility of such training.One assistant was intending to train as aphysiotherapist. Five assistants felt theywere too old to embark on such a process.Views regarding specific NVQ trainingvaried considerably. The three assistantswho already had an NVQ3 qualificationhighlighted the immense amount of workrequired from both assistant andsupervisor. The ultimate value was vieweddifferently by the supervisors with whomthey worked, for example:

‘It has made [the assistants] think moreabout what they are doing and I thinkthat they have learnt quite a bit’(supervisor 5).

This contrasts with an assistant’s view:

‘I felt having been in the job for somany years [the NVQ] did not really

expand very much so I did not get a lotof satisfaction out of doing it’ (assistant 5).

However, the timing might be crucial:

‘If I had done it when I had first takenthe job it would have been atremendous help’ (assistant 5).

Training remains largely unstructuredand is an important area of concernamong assistants and their supervisors. Apublication by the CSP (1998b) givingmore specific guidelines on in-servicetraining for assistants may go some way toremedying this. Training methods variedand were reported to be inadequate,primarily owing to limited resources. Withthe national initiative and wish to improvethe training of support workers withfunding in the form of individual trainingaccounts (DoH, 2000), this could beremedied or show an improvement in the near future. The NVQ programme,although in many situations regarded asdesirable, was felt to be unwieldy anddifficult to implement.

Timing of such training could becritical, being of use in the initial stages toimprove practice, but as indicated by thisstudy and in the literature (Saunders,1995), the training offered may be at alower level than tasks now being under-taken by assistants.

Changes in Physiotherapy Assistants’Role and TrainingAnalysis of the interviews showed that thesupervisors believed that the assistantswere undertaking more of the role ofjunior physiotherapists in elderly care andrehabilitation. In the community theywere undertaking a new role, extendingthe availability of physiotherapy care. Inthe outpatient setting there weredifferences in approach with someassistants assuming new extended roles or tasks, for example undertakingelectrotherapy.

Assistants’ role development wasreported by the supervisors to haveresulted from both national and localchanges in service. National issues citedwere:

� A shortage of qualified staff leading toalteration in posts (eight supervisors).

� The increasing service demands madeby the growing elderly population (ten supervisors).

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Local catalysts were felt to have had agreater impact. These were:

� Changes in hospital service at the locallevel – for example increases inrehabilitation services (three supervisors).

� Recruitment of new supervisory staff(three supervisors).

� Alterations in funding of posts (three supervisors).

� National or specific locally initiatedassistants’ training schemes (eight supervisors).

Skill mix analysis was not reported ashaving been undertaken in any formalway. With the greater governmentalcommitment to the development ofsupport workers and a funding initia-tive under way (DoH, 2000), considerablechanges may be expected in this area overthe next three years.

Future Role of Physiotherapy AssistantsThis area generated the greatest variety of opinions. Five supervisors found itdifficult to envisage any further extensionof the assistants’ role because they wereunable to undertake assessment andtreatment progression. Nine supervisorsreported that changes were already underway within healthcare and foresaw furtherchanges but were unspecific as to theirexact nature. Four supervisors envisaged aformal development of their role with aclearly defined nationally recognisedcareer progression.

The assistants’ views similarly varied,with six identifying specific careerprogressions with additional training inmore specific activities such as electro-therapy and some respiratory care (forexample setting patients up for posturaldrainage and simple lung function tests).Four assistants wanted the situation toremain unchanged and the rest expressedthe view that there would be changes butdid not exactly specify their nature.

Areas of concern identified by all ass-istants and supervisors were:

� Funding and management of adequatetraining.

� Ensuring adequate supervision.

� Lack of career progression and anequitable nationally recognised systemof progressing from assistant totechnical grades.

� Lack of recognition of training andresponsibilities in monetary terms orstatus.

With the exception of the two assistantsand their supervisors working in a smallrehabilitation community environment,the use of a generic worker answerable to nurses, occupational therapists andphysiotherapists was not viewed positively.Anticipated problems were:

� Potential lack of continuity of patientcare.

� Inability to develop specific skills.

� Lack of identity with a department.

� Divided accountability of assistantsleading to difficulty in workingallocation.

The development of a career path forassistants was discussed and was supportedin theory by all of them. The proposedadvantages were that this would offergreater opportunity for assistants wishingto develop a career and reward thosestudying for additional qualifications. It was assumed that the career path would also lead to greater remuneration.However four assistants felt that theywould not wish to pursue such a careerpath themselves; they were very satisfiedwith their current levels of responsibilityand felt threatened that this might not beallowed to continue. The supervisorsidentified the benefits for assistants butalso highlighted the potential problemswith the development of a two-tier system,and the difficulty in undertaking anationally recognised and acceptabletraining programme.

This study reveals that there is agree-ment by both assistants and supervisorsthat there have been some significantchanges in the work of assistants and inlevels of supervision, as reported by others(Saunders, 1997; Parry and Vass, 1997;CSP, 1999b). This coincides with thegeneral trend to delegate healthcare toless trained people (Hopkins et al, 1996)and the Department of Health’s recomm-endations to develop the potential ofunqualified staff (DoH, 1997, 2000).

The development of a grading system

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for assistants remains a complex issue inthis and other countries. The lack of anationally recognised and implementedpolicy regarding the grading of assistantsto technical grades was a major issue ofconcern and resentment among thoseinterviewed. This has been reflected inthe national physiotherapy press on anumber of occasions. Research in theUnited States, for example, showed thatungraded and graded assistants frequentlycarry out the same tasks (Schink et al,1992) and grading has led to a further tierof personnel, with attendant problems oftask allocation and role.

ConclusionThese findings highlight important issuesand areas that the physiotherapyprofession needs to acknowledge andaddress in the future. It is evident that assistants play a major role in thedelivery of ongoing physiotherapy care.

The extension of the activities andresponsibility of assistants can beattributed to changes in workingsituations such as extending the role inthe community, reduction in levels ofsupervision, increased training, anddifficulty in recruiting qualified staff. The situation is acknowledged to becontinually changing and this is reflectedin the changes in practice.

Political initiatives are also promotingchanges in practice with development ofsuch personnel within the NHS (DoH,2000).

The key issues that emerged as needingto be addressed are a more standardisedapproach to the role of physiotherapyassistants and associated grading structurefor assistants; further development of thenational training programme with greateraccess; and clear rewards for undertakingsuch training.

References

Chartered Society of Physiotherapy (1994).‘N/SVQs explained’, Information Paper, CSP,London.

Chartered Society of Physiotherapy (1998a).‘The CSP’s approach to lifelong learning forphysiotherapy assistants: Policy statement’,CSP, London.

Chartered Society of Physiotherapy (1998b).‘Guidelines on in-service training forphysiotherapy assistants’, Information Paper16, CSP, London.

Chartered Society of Physiotherapy (1999a).‘The criteria for the delegation of tasks toassistants’, Information Paper PA6, CSP,London.

Chartered Society of Physiotherapy (1999b).‘Physiotherapy assistants role mapping project:Final report’, CSP, London.

Department of Health (1997). Skillmix and JobDescriptions, NHS Executive, London.

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Key Messages

� The work undertaken byphysiotherapy assistants is diverse andneeds to remain so in order to beresponsive to changes in the nature ofthe services.

� The close relationship that frequentlyexists between physiotherapyassistants and their supervisingphysiotherapists determines taskdelegation.

� Physiotherapy assistants and theirsupervising physiotherapists haveclear and agreed understanding ofthe scope of practice of aphysiotherapy assistant.

� Some physiotherapy assistants areundertaking independent assessment,for example assessing the need forwalking aids.

� Recent reduction in the levels ofsupervision of physiotherapy assistantshas been attributed to the shortage ofqualified staff, as well as thedevelopment of locally and nationallyinitiated training schemes.

� A more standardised nationalapproach to the grading structure forphysiotherapy assistants is required,with reward for undertaking furthertraining.

Saunders, L (1997). ‘Issues involved indelegation to assistants’, Physiotherapy, 83, 3,141-147.

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