Role overlap between occupational therapy and physiotherapy during in-patient stroke rehabilitation: an exploratory study
Julie Booth .MSc.DipCOT SROT.& Alistair Hewison RGN.BSc.MA Phd
Correspondence to: Julie Booth, Lecturer, School of Health and Social Sciences, Coventry University, Priory Street, Coventry CV1 5FB, UK. Tel: 02476 888796 Fax: 02476 888020 E-mail: email@example.com
Paper presented at the Qualitative Evidence-based Practice Conference, Taking a Critical Stance. Coventry University, May 14-16 2001
The concept of role overlap between occupational therapy and physiotherapy has been the subject of debate for at least three decades. Stroke rehabilitation is an area where role overlap between occupational therapists and physiotherapists occurs. This article reports an exploratory study carried out with nine physiotherapists and nine occupational therapists working in a variety of in-patient stroke rehabilitation settings. Analysis of qualitative data collected through semi-structured interviews revealed that the majority of the participants recognised the existence of role overlap as inevitable within collaborative healthcare and felt it was of benefit to patients. However, it appeared that the concept was also perceived as a challenge to role security by many when considered from a professional perspective. Acceptance of role overlap depended upon the extent to which it occurred in the particular setting. Generic therapy was seen as an extreme form of overlap and regarded as an undesirable progression by most participants. The main strategy used to challenge this development was to emphasize professional uniqueness through role delineation. However, this strategy was found to be weak in the context of increasing demands for collaboration at a policy level.
Keywords: Occupational Therapy, Physiotherapy, Role Overlap, Collaboration.
Distinction between the role of the occupational therapist and physiotherapist appears to have reduced in some areas of clinical practice, giving rise to mixed feelings among therapists in both professions. Although definitions of occupational therapy and physiotherapy (College of Occupational Therapists (COT), College of Speech and Language Therapists (CSLT), Chartered Society of Physiotherapy (CSP) 1993) suggest that the professions are approaching therapeutic intervention from different perspectives, recent changes in healthcare and the needs of patients have resulted in the two professions moving closer together in some clinical areas (Brown and Greenwood 1999).
One clinical field where extensive role overlap and collaboration does occur is stroke rehabilitation (COT & CSP Development Groups 1988). Bukowski et al (1986) suggest that the complex healthcare needs of stroke patients make them "particularly amenable to an interdisciplinary team approach." Therapists from both occupational therapy and physiotherapy however, argue that although "considerable overlap is acceptable, duplication is not" (COT & CSP Development Groups 1988).
This paper presents the findings of a study designed to examine the concept of role overlap among occupational therapists and physiotherapists working in in-patient stroke rehabilitation. The aim was to obtain therapists' views concerning role overlap, as a means of informing the discussion surrounding this development and thereby contribute to a debate which is crucial to all of the health professions. The research design was based on a conceptual framework (Jenson 1989), which incorporated key concepts identified in the literature review and employed semi-structured interviews as the primary means of data collection.
The concept of role overlap has been addressed independently by each profession (Blom-Cooper 1989, CSP 1988) collaboratively through the work of their members (COT & CSP Development Groups 1988) and has been a topic for consideration for at least three decades (Department of Health and Social Security 1973, McGiffen 1976). Opinion relating to role overlap has been expressed more recently by therapists from both professions in the British Journal of Occupational Therapy in 1998 (Clemence 1998, Golledge 1998, Metcalfe 1998). However, whilst ostensibly supporting co-operation and collaboration, the principal anxiety voiced related to fears concerning reduced role security.
A comprehensive study carried out by Shearer et al (1995) concluded that although there is overlap between occupational therapy and physiotherapy there is also "sufficient diversity for the professions to be regarded as different." With no clear conclusion, Shearer et al called for further research into role clarification.
In view of the paucity of research which specifically addresses this area, other relevant work was accessed to inform the study. Lowe and Herranen (1978) investigated role overlap between nursing and social work and found that it instilled feelings of fear, reduced status within the team, territoriality and defensiveness which led to conflict and ineffective clinical working. Richards (1998) and Clemence (1998) contend that research addressing territorial confusion is necessary to replace anecdote and opinion with evidence, if such conflict is to be resolved. It could be suggested that investigating role overlap in one setting is likely to uncover findings that will have applications in other similar situations.
The professions of occupational therapy and physiotherapy both lack a knowledge base founded on a body of research unique to each profession (Green 1991, Roberts 1994, Bassett 1995). The absence of profession specific knowledge can be seen as detrimental to the quest for professionalism (Hannay 1980). Freidson (1970) and Abbott and Wallace (1990) regard autonomy as a fundamental characteristic of a profession, and thus classify the professions of occupational therapy and physiotherapy as semi-professions because of their lack of role autonomy. In view of this, it could be suggested that the professions of occupational therapy and physiotherapy are engaged in role expansion horizontally through overlap into each others' domain to strengthen role, as described by Ritchey et al (1989), because vertical expansion into an enhanced professional position is not currently possible, although the concept of therapist consultants due to be introduced by 2004 may rectify this (DoH 2000a).
The healthcare teaching and clinical environments have a major influence on how practitioners fulfil their roles. The perceived benefits of intercollaborative education for healthcare professionals have been accepted for some time (Routledge & Wilson 1994, Alsop & Vigars 1998, DoH 1998a, Vanclay 1998, DoH 2000a). However, the relationship between education and role overlap is less clear.
There is a long history of professional rivalry and 'tribalism' in healthcare practice (Beattie 1995), which in the past has prevented effective interdisciplinary working. However, the government (Department of Health (DoH) 1998a&b, DoH 2000b) and public bodies, such as The Stroke Association (1994) and The Neurological Alliance (1996), are demanding teamwork and collaboration between healthcare workers to enhance the quality of patient care.
One of the concerns about increasing collaboration is that it will result in
"low level genericism in which every member does a bit of everything and none of it well, denying to clients and patients the expert skills and knowledge which each profession can deliver" (Loxley 1997p43).
It appears that within occupational therapy and physiotherapy circles there is a feeling of unease concerning the effects of collaboration on professional confidence, reflected in the call for therapists to 'go back to their roots' to establish the uniqueness of their profession (COT & CSP Development Groups 1988 , Thorner 1991, Wilcock 1991, Parry 1995, Yerxa 1995, Smart 1998). Collaborative working is a central issue in current health care policy, however many of its implications have not been fully explored. The study reported here was designed to examine one aspect of this trend, role overlap.
The lack of research in the area of role overlap suggested the need for an exploratory study of an inductive nature (Gilbert 1993) to access the experiences of therapists within a specific healthcare setting (in-patient stroke rehabilitation). It was appropriate therefore for the study to follow a qualitative methodological approach (Judd et al 1991, Robson 1993, Bird et al 1995).
A high degree of collaborative practice enhances recovery following a stroke (Garraway et al 1980, Smith et al 1982, Mead 1988), and this is more likely to occur in an environment focusing specifically on stroke care. In view of the potential for overlap to occur in collaborative settings theoretical sampling was used to target stroke rehabilitation settings as these were likely to be locations where occupational therapists and physiotherapists were addressing issues of role overlap. Ten in-patient stroke rehabilitation locations were selected.
The sample size was 18, including nine occupational therapists and nine physiotherapists from ten urban hospitals each in a different health authority.
Conduct of the Research
Individual semi-structured interviews using open-ended questions were conducted and the usual conventions of anonymity and confidentiality were observed throughout the study. All of the interviews were tape recorded and transcribed verbatim. The interviews were carried out at the participants' work place, at a time of their choice, and lasted approximately one hour.
The process of analysis occurred in three stages: description, analysis and interpretation. Wolcott (1994p49) regards these steps as the "three primary ingredients of qualitative research". Some of the descriptive data were managed quantitatively; a technique recognised by Strauss and Corbin ( 1998) as a useful way of providing background information, which offers some initial insights (Wolcott 1994).
A modified version of the grounded theory approach to conceptual analysis (Strauss & Corbin 1998) was employed because it is systematic, transparent and thereby enhanced the trustworthiness of findings.
FINDINGS AND ANALYSIS
Prior to considering the concept of role overlap it was important to clarify the participants' views of their own role and perceptions of their colleagues' role. Figures 1a and 1b indicate the role components described.
(figures 1a and 1b here)
Through examination of the descriptive data, it was clear that 15 interviewees identified that overlap did exist in the work setting, occasionally through joint intervention but mainly during individual sessions of the same activity. Of the remaining respondents, one felt there was no overlap, and the other two preferred to discuss the situation as "complementary to each others' roles" rather than role overlap. Figure 2 describes the main areas of overlap.
(figure 2 here)
The outcome of the analysis is explored further under the respective category headings.
Category 1: Role Overlap Can Cause Role Insecurity
On the surface role overlap was espoused by many of the participants as a positive concept. However, analysis uncovered an underlying concern relating to role security because traditional boundaries were being crossed by the professions. There appeared to be agreement that overlap was acceptable to a degree only, with education and training restrictions being advocated to ensure maintenance of autonomy. This reflects Hannay's (1980) view of education as a key factor to professional status, autonomy and thus perhaps security of role.
Concept 1: Overlap Instills Territorial Feelings
The extent of the overlap appeared to have some bearing on how protective therapists felt about their role. As one participant explained:
"If you have someone else working in the same way then it's good for the patient, so I really haven't got much of a problem with it, but if I did have an occupational therapist who was doing purely physical treatment then I might start getting a little bit tetchy about it, but if they were looking at a lot of functional work, say facilitating drinking from a cup, feeding, washing and hygiene, I mean we do that as well if we can" (PT7).
However it emerged that the extent of role overlap was not the only factor determining acceptance. The therapists' reaction to role overlap was also influenced by professional confidence:
"I think a lot of people are very protective with their role and I think maybe it's their insecurities themselves...and whether it's their lack of experience or lack of knowledge or things that have happened in the past I don't know; I know there are lots of reasons, but it's usually when someone's actually not that confident themselves" (OT4).
A number of reasons for reduced professional confidence seemed likely. Unequal professional status, as perceived by others, emerged as one suggested cause.
Concept 2: Perceived Unequal Professional Status
Role overlap appeared to highlight the difference in role clarity between the professions of the participants. 8 of the occupational therapists felt generally disadvantaged as they often perceived themselves as misunderstood by patients and other healthcare colleagues. This absence of role clarity was endorsed by 5 physiotherapy participants who also believed that occupational therapy was the less well known of the two professions and had the potential to be misunderstood.
However, there was not universal agreement among the physiotherapists that their role was clearer and two physiotherapists felt that role overlap contributed to a lack of understanding, on the part of colleagues and patients, of their role.
The participants of both professions appeared to be echoing the thoughts of Loxley (1997) on the importance of having a professional identity which was clear to others, to avoid role confusion arising as a consequence of collaborative practice.
Although there was some criticism of each other's perspectives among the participants, particularly in relation to level of importance to the client, there was also recognition of the benefits the different professions can bring when treating a stroke patient with multiple needs. These different perspectives were used as a marker to delineate roles and they also served as a coping mechanism. This is reflected in another theme which emerged.
Concept 3: A Continuum of Intervention not Overlap
Over half of the participants (six occupational therapists and five physiotherapists) described the need for their role and their colleagues' as a continuum, whereby intervention was sought from each at different times and in a way that complemented each other. This view was not context specific.
"The role of the occupational therapists is, well largely it is using the quality of movement that we have gained in physio and relating it to function skills" (PT5).
"Their role is very much to do with mobility and anything that involves that, so getting from one place to another and I would say it's what they do when they get there which becomes our responsibility" (OT2).
Role overlap was only acceptable to a degree and generic therapy was seen as a final consequence of increasing overlap. Stating the need for differing perspectives within the same therapeutic activity, to provide quality intervention, was the main means of challenging the prospect of generic therapy. Just over half of the participants who expressed an opinion (nine out of sixteen) were opposed to the notion of generic therapy, five felt it had potential in certain situations and two were unsure. The main sources of concern appeared to be professional in nature (for example, loss of role and perspective, too much to learn and do) and not the adverse effects on patient care. Hence it could be suggested that it was being viewed as a threat to role security, as pointed out by one advocate of generic therapy:
"are we just saying 'oh no we don't like this' because we are threatened, but perhaps it is the way forward" (OT6).
It became apparent that the therapists' immediate working environment (micro environment) and the wider setting (macro environment) had some impact on the way that role overlap was considered. This gave rise to two further concepts, from which a second category emerged.
Category 2: Collaboration affects overlap
The relationship between collaboration and role overlap is a complex one. In order to explore this connection, the analysis was initially focused on the micro environment of the participants.
Concept 1: Micro Collaboration Promotes Overlap
It could be, as Golledge (1998) suggests, that as the same skills are being taught on some joint post graduate courses then there is potential for duplication of skill to occur in the clinical setting. However, the majority of participants felt that such skills were influenced by the differing philosophical backgrounds of the two professions, resulting in a different perspective and use of the skills. Yet there were examples of these boundaries being crossed at times (see figures 1a, 1b, 2). Participants viewed the use of the same treatment approach as beneficial to patient care, but were concerned about its potential for destabilising professional security by the resulting explicit acceptance of the similarity in roles. As one physiotherapist explained:
"its very important not to be able to do two jobs in this profession...'cause the next minute you will end up with people saying 'well you don't need two groups of people if they are training at the same skill" (PT8)
In environments where the same approach to the treatment of physical disability following a stroke was being adopted universally by all healthcare staff (one stroke unit and one rehabilitation hospital), collaboration was described as a success and role overlap accepted without concern. In five settings where there was explicit use of a joint treatment approach to overcome physical disability, but little actual collaboration, there appeared to be some anxiety in relation to role overlap. This suggests that before role overlap can be accepted, collaboration needs to be in place.
Concept 2: Macro Collaboration Eases Overlap
Many of the therapists recognised that collaboration was being promoted in their working environment via multidisciplinary working. Some felt that the structure of the settings facilitated joint working, for example through close proximity of departments and shared management. These data suggest that highly collaborative environments can ease the introduction of overlap. However, this is not the complete picture. In two stroke units overlap was minimal but collaboration was high. Four participants involved in collaborative ventures such as Integrated Care Pathways (ICPs) described how these procedures promoted role delineation. Therapists from both professions involved in ICPs were keen to describe strategies which ensured they were recognised as still having skills in the areas of overlap that they had relinquished. This did cause some uneasiness on occasions.
"...well this is where the ICP came in and we had to make a compromise of who assesses what because otherwise we are duplicating assessments...I think there was perhaps a little bit of friction to start with but I don't think that was because of physio and OT I think it was bonding as a team really" (PT1).
Collaborative working was a difficult practice to adopt for some therapists and an unwelcome one if it resulted in a reduction of individual autonomy and specialism (Carrier and Kendall 1995). However, most of the therapists believed that boundaries are purely historic and that change is necessary to avoid restrictive practice in the dynamic environment of healthcare (Parry 1995, Clemence 1998, Richards 1998).
It has been demonstrated that role overlap is a complex issue and the way it is managed affects the extent and success of interprofessional working in stroke rehabilitation. The implications of this will now be explored. For many of the participants in the study, role overlap was embraced as a beneficial tool for quality patient care. However, on a professional level there were some concerns for security of role, giving rise to 'territorial feelings' which in turn resulted in recourse to 'professional roots' on occasion as a basis for ensuring role delineation. The mechanism of role delineation is recognised as a vital element in easing overlap (Clemence 1998) and its successful implementation has been described by some (Liston & Docking 1985, Mehn et al 1986), although it has not yet been objectively audited.
It would seem that with the advent of increased collaborative practice, which is being promoted at government level (DoH 2000a&b), and endorsed through public pressure and by the professional bodies (COT, CSLT, CSP 1993) the need to demonstrate uniqueness, in an environment of multi-skilling and flexible working, will increase if role security is to be maintained. This is consistent with the development of a unique knowledge base and specific expertise which are necessary to retain professional status (Freidson 1970, Hannay 1980 and Abbott & Wallace 1990). However, increasing commonality between occupational therapy and physiotherapy, within stroke rehabilitation, limits role delineation despite the use of different philosophical perspectives. Although it could be argued that formal collaborative practice encourages role delineation through the use of procedures such as ICPs, the demand for closer working and post-graduate training on a micro level seems to be moving the two professions even closer together in the area of stroke rehabilitation. Also, it has been identified that there is a need for multi-disciplinary teams, based on 'natural' work teams, to function effectively if evidence-based practice (EBP) is to become established (Halladay & Bero 2000.) Therefore issues of role overlap are of concern to the wider health care community as EBP is another 'priority' to be met, which can only occur when interprofessional work is achieved.
An outcome of role overlap could be the emergence of generic therapy, which was resisted in 1973 (DHSS 1973) and has been opposed by the professional bodies more recently (COT, CSLT, CSP 1993). Although this study confirms that the majority of participants shares this view, some are considering the generic approach as the way forward to meet the changing needs of clients.
There is a challenge to role security in role overlap. It would be useful to clarify whether concerns regarding role overlap are in fact a smokescreen to mask negative feelings relating to collaboration. In addition, by engaging in and observing the situations of potential overlap, the interpretative conclusions regarding the uniqueness of each profession could be refuted or reinforced and thus inform the development of theory relating to the stability of professions allied to medicine in healthcare today.
Role overlap among occupational therapists and physiotherapists during in-patient stroke rehabilitation, was recognised by the majority of participants as a phenomenon that exists and is occurring to varying degrees within their clinical settings. Occurrence was not context specific, however the degree of collaboration within the environments affected the explicit recognition of and acceptance of role overlap.
Role overlap was regarded as a challenge to professional security for many of the participants. It was discovered that retention of an element of professional uniqueness and expertise was necessary to maintain confidence in an environment of increased sharing and collaboration. Utilisation of a role delineation strategy, through endorsement of differing therapeutic perspectives, was a key mechanism adopted.
Although the respondents appeared to accept overlap as a positive concept in relation to patient care, it was acceptable to a certain level only. The ultimate outcome of increasing overlap was identified as generic therapy, an unwelcome development for the majority of participants.
Collaboration and interprofessional working are a central feature of current UK health policy, however the process of making this a reality in the clinical setting is fraught with difficulty. This study indicates that clarity concerning the unique contribution of each discipline is vital and that this can be achieved by the use of a profession-specific perspective towards intervention and collaboration. Issues surrounding overlap need to be addressed before genuine interprofessional working will occur.
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Figure 1a: Role components of Occupational Therapy as perceived by participants
ADL: Activities of Daily Living
PADL: Personal Activities of Daily Living
Figure 1b: Role components of physiotherapy as perceived by participants
This document was added to the Education-line database on 24 May 2001