Physical Therapist Assistant Education Over the Decades

Physical Therapist Assistant Education Over the Decades

Carpenter-Davis, Cheryl A

This article reviews the history of the physical therapist assistant (PTA) and PTA education programs and the professional, political, and social issues that have shaped PTA education over the past four decades in the United States. The author discusses the role of the American Physical Therapy Association (APTA) in the creation of the role and function of the PTA and PTA education programs and considers the future of PTA education.

Key Words: History, Physical therapist assistant.

INTRODUCTION

In 1971, Dr Nancy Watts wrote,

There is still little real consensus among professional therapists about the appropriate answers to such practical questions as: Who should do what-how will the professional and assistant he different…It would he comfortable to postpone change until these questions have been thoroughly answered, hut the urgency of the demand for new patterns of practice is inescapable.1(pp23-24)

This issue has plagued the profession for more than 30 years. The profession continues to demand that the questions above be thoroughly answered and continually re-examined before action can be taken to define the physical therapist assistant (PTA) and the role PTAs fill within the physical therapy profession.

In the 1940s, initial conversations began regarding the need for a trained assistant to work alongside the physical therapist (PT) and “assist” with treatment.2 The importance of training, rather than education, placed the position in a technical rather than professional standing within the physical therapy profession as it was envisioned in the 1940s.

The political and social issues that have shaped PTA education throughout the years are a mirror image of the issues that influenced PT education. Societal need for physical therapy services increased the need and value of the educated physical therapy practitioner. The profession struggled with issues related to the level of education for the ITA and appropriate delegation patterns of patient care. This article will review how PTA education programs evolved and will discuss considerations for future directions in ITA education.

The evolution of PTA education has its roots in the beginnings of the physical therapy profession. As the profession of physical therapy evolved, the variety and number of patients referred for physical therapy services expanded, as did manpower needs. The recurrent outbreak of poliomyelitis in the 1940s and 1950s produced rapid growth in the physical therapy profession.3 Physical therapists developed muscle-testing techniques and experimented with electrical current, heat, and hydrotherapy to increase a person’s mobility and to decrease pain that accompanied disease. Physical therapists gained recognition for the contributions made in the rehabilitation of children with poliomyelitis, further solidifying the expanding role for physical therapy providers.4

EARLY EXTERNAL INFLUENCES ON THE CREATION OF THE PHYSICAL THERAPIST ASSISTANT

With the expanding work possibilities for PTs, it became evident that they would need an “assistant.” Informal training of physical therapy aides was instituted in the 1950s. Societal pressure had a great influence on the creation of the PTA and many other allied health workers. With the development of antibiotics and enhanced medical care, mortality and morbidity rates were significantly altered. Childhood diseases such as poliomyelitis affected many youth, subsequently leading to long-term disabilities as adults. The development of rehabilitation and treatment facilities resulting from the 1946 Hill -Burton Act5 created an increased demand for therapy services. Reimbursement for medical services was improving with the implementation of Medicare in 1965. To meet these rehabilitative demands, legislators felt that there needed to be different levels of health care providers and provided funding for the development of technical programs.

As medicine had evolved, physicians had utilized nurses and other health care personnel as an extension of their care. Physical therapy utilization had expanded from the management of war veterans and people with childhood diseases to the management of people with orthopedic dysfunction and cardiopulmonary disorders. Physical therapy services were becoming a part of the new hospital environment, with further expansion to outpatient sites. Physical therapists enjoyed greater utilization of the unique services they could provide in areas of consultation, education, and research.4 The expanding demand created an overwhelming need for more qualified providers of physical therapy services.

In the 1960s, health care manpower issues were studied by researchers at Harvard University.^ In 1971, Congress passed the Comprehensive Manpower Training Act to meet the increased need for health care providers. This act accelerated awareness of the need to expand and formalize education and training efforts and recognized the importance of allied health professions. At the time, supportive personnel training programs ranged from simple housekeeping duties to substituting for the PT during vacation periods.2

THE PUSH FROM CALIFORNIA AND THE CREATION OF THE PHYSICAL THERAPIST ASSISTANT

Studies conducted in California demonstrated that 36% of the staff PT’s time was spent on duties that could be assigned to nonprofessional personnel.2 At the 1964 American Physical Therapy Association (APTA) House of Delegates (House) meeting, die Northern California Chapter introduced a resolution requesting that a committee be appointed to investigate the use of nonprofessional personnel. The committee was charged with the development of a specific policy proposal, which would reflect the stand of APTA regarding tide, responsibility, education, training, supervision, regulation, and all other areas related to nonprofessional personnel. The resolution passed the APTA House by a vote of 215 to 139.2 The shortage of PTs in the 1970s provided the opportunity for PTA education to be formalized by APTA. The Comprehensive Manpower Training Act provided a means for a formalized education program that would reside in an accredited technical school or junior college and equip PTAs with a common set of skills needed for entry into the profession. The 89th Congress enacted additional laws related to supporting and funding health care and education at junior colleges.2,7

In 1907, the APTA House officially created the occupational category of “physical therapy assistant.”18 Miami Dade Community College in Florida and St Mary’s Campus of the College of St Catherine in Minnesota were approved as the first two PTA education programs in 1967.9 Shortly thereafter, criteria were established for PTA programs by the professional organization later known as the Commission on Accreditation in Physical Therapy Education (CAPTE).

Simultaneously, APTA established guidelines for the utilization of the PTA that specified what tasks could and could not he delegated to the technically trained assistant.3 This document evolved over time and is currently the policy entitled “Direction and Delegation in Physical Therapy.” The policy continues to define the role and work of the PTA in the profession’s terms.

GROWTH OF PHYSICAL THERAPIST ASSISTANT EDUCATION PROGRAMS IN THE PROFESSION

The 1970s were an era of growth for ITA programs in the community college system. Federal legislation enacted in the mid 1960s provided financial assistance and basic improvement grants for junior colleges with training in allied health fields.2’7 The 1975 House approved the Essentials of an Accredited Education Program for Physical Therapist Assistants.^ At the beginning of 1970s, nine PTA programs existed. By the end of the decade, 47 PTA programs were accredited. The growth of PTA programs continued into the next decade with 60 accredited programs in 1985 (Figure).

THE PHYSICAL THERAPIST ASSISTANT AND EDUCATIONAL CHANGE

Physical therapist assistant programs grew rapidly during the late 1980s and 1990s in response to increasing demand for physical therapy services. Skilled nursing facilities, free-standing rehabilitation hospitals, home care, school-based therapy services, private practices, and ambulatory care clinics created new employment opportunities for PTAs. Community colleges developed new PTA programs and expanded existing PTA programs to meet local demands in the community. The paucity of qualified physical therapy educators that had long plagued physical therapy education now influenced PTA education programs. Community colleges hired PTA program directors and educators based on their primary role as clinicians. Thus, many were not skilled in curriculum development and classroom teaching and were not clear regarding the differentiation between the roles and responsibilities of the PT and the PTA. In some cases, these new PTA educators may have had little to no experience working with PTAs in the clinical setting. As a result, PTA curricula at this time were fraught with great variability in expectations for graduates who would enter the workforce as PTAs. Concurrently, the profession was embroiled in significant debate regarding the role and responsibility of the PTA and whether or not the role of the PTA should he defined more narrowly or expansively.

PHYSICAL THERAPIST ASSISTANT EDUCATION PROGRAMS IN THE 1990S

By 1990, there were 96 accredited PTA education programs in the United States (Figure). Physical therapist education was transitioning from the baccalaureate to the postbaccalaureate professional degree level. In 1992, Lynn Lippert, PT, MS, and Carol Davis, PT, PhD, in collaboration with the APTA Department of Education developed a Colloquium for Physical Therapist Assistant Educators. The intent of the colloquium was to provide a forum for the leaders and educators of PTA programs to exchange information and to offer creative solutions to program management. The group hosted four colloquia between 1992 and 1994. The first colloquium was held in November 1992 at Southern Illinois University in Carbondale, Ill.11 The meeting lay the groundwork for future colloquia as the participants indicated the need to discuss and determine the appropriate curricular content for the preparation of the PTA for entry into the profession.

The next two colloquia, titled “Defining the Outer Limits of Subject Matter in PTA Curricula,” were held at Mt Hood Community College in Gresham, Ore, and at Hahnemann University (now Drexel University) in Philadelphia, Pa. The meetings challenged participants to explore the boundaries of PTA curricula by identifying educational rationales for including or excluding curricular components in key content areas: therapeutic exercise, anatomy/kinesiology, documentation/communication, pathology, development, modalities, measurement, and rehabilitation.

Participants divided into groups to discuss content areas, identifying what they felt did and did not belong In PTA curricula, and what elements they felt were in the “gray zone.” The gray zone identified die category of skills and requisite knowledge which the participants could not agree were either appropriate or inappropriate for PTA curricular content; the gray zone also included areas perceived as controversial within the profession. Facilitators of the small groups reported curricular content areas that were included, excluded, and associated with the gray zone. The large group then discussed the items in the gray zone and the educational rationale for inclusion or exclusion of those areas in PTA curricula.

The colloquia challenged participants to apply sound educational principles to the PTA curriculum. Educators discussed issues related to cognitive, psychomotor, and affective domains and identified appropriate outcomes. The participants identified the need for PTA textbooks. Publishers were apprised of the findings of die meeting and were made aware of the educational needs of PTA educators. The colloquia provided a forum for discussion, debate, and creative thought. The group shared, mentored, and supported each orner, which ultimately resulted in greater communication among PTA educators. There were no written recordings of the deliberations, which disappointed the PT educators. In 1995, shortly after the PTA colloquia ended, the APTA Education Division under the leadership of Joseph Black, MDiv, PhD, initiated a series of conferences titled “Coalitions on Consensus.”12 The APTA Department of Education invited stakeholders from a nationwide audience of PT and PTA members to attend the conferences and discuss issues related to the practice of physical therapy. In total, six conferences were devoted to the topics of PT education and the preferred role and relationship between the PT and the PTA.

The Coalition on Consensus for Physical Therapist Assistant Education Conference began with a set of controlling assumptions. These assumptions served as the boundary for the group’s deliberation by providing a mechanism to focus member consultants’ discussion, thus enabling the group to move forward within a structured consensus-building and decision-making process. The conference purposes were to define the roles and responsibilities of the PTA and to define the preferred relationship between the PT and the PTA. The desired outcome of the process was to define a normative model of PTA education. Controlling assumptions for the conference related to the use of language and terminology included the following: (1) terminology should be consistent with existing APTA policy, (2) terminology should be consistent with the Guide to Physical Therapist Practice, Part I12 and the patient/client management model put forth in that document, and (3) language used should minimize the cause of unnecessary divisiveness, resentment, or controversy.12 Resources for the conference included an article published in 1971 by Nancy Watts, PT, PhD, in the journal Physical Therapy entitled “Task Analysis and Division of Responsibility in Physical Therapy.”1 The group utilized the framework proposed by Watts to define the scope and “work” of the PTA.

The work of the PTA Education Coalition on Consensus resulted in the Normative Model of Physical Therapist Assistant Education.12 CAPTE most recently approved the Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapist Assistants13 in 2000. The Evaluative Criteria identify didactic and clinical education parameters. The criteria outline the expected competencies for data collection (Table 1) and intervention techniques (Table 2) for the PTA.

The Evaluative Criteria define competencies for the PTA beginning professional practice. Physical therapy clinicians use terms such as “assessment” and “evaluation” interchangeably, which may result in underutilization or inappropriate utilization of the PTA.11 Jan Gwyer, PT, PhD,14 has written that increasing the efficiency of the current workforce includes an analysts of various providers of care and an analysis of the type of care given. Bashi and Domholdt15 studied the use of support personnel in physical therapy and found that when professionals are in short supply, the use of support personnel to extend the reach of each professional becomes attractive. Both of the articles focused on improving utilization of existing physical therapy personnel to meet health care needs.

PHYSICAL THERAPIST ASSISTANTS AND CLARIFICATION OF THEIR IDENTITY AND ROLE WITHIN THE PROFESSION

Increasing numbers of PTA education programs resulted in more PTAs in the workforce who desired a “voice” within the profession and greater clarity regarding their roles and responsibilities and defining their identity within the profession. After several years of intensive work, the Guide to Physical Therapist Practice16 was developed and then approved by the APTA House of Delegates in June 1995. The Guide described the scope (depth and breadth) of PT practice, including practice parameters for the profession of physical therapy, the use of the patient/client management model for care delivery, and a comprehensive glossary of terms to ensure greater consistency in the use of language within the professions for terms such as “examination,” “evaluation,” “diagnosis,” “prognosis,” “intervention,” and “outcomes.” APTA encouraged PT clinicians, educators, researchers, students, policy makers, administrators, managed care providers, third-party payers, and other professionals to use the Guide to describe PT practice, the roles of PTs, and practice settings; to standardize terminology; to delineate tests, measures, and interventions; and to delineate preferred practice patterns.

The Guide to Physical Therapist Practice added clarity to language used by PTs in their daily practice and provided a mechanism whereby documentation throughout the profession and APTA could be more consistent. The Guide, however, did not directly address the issue of terminology that had previously been used in PTA education documents such as “assessment,” “measurement,” and “practice.” Thus, within the profession, there was still some degree of confusion surrounding terminology used to reflect the activities of PTAs as they carried out their roles and responsibilities in patient care. Other issues that contributed to confusion about the role of the PTA within the profession were terms used in the Guide such as “paraprofessionals” and technicians who “worked” rather than “practiced.”16 To some degree, separation of these and other terms used by the PT and PTA fueled divisiveness between PTs and PTAs and contributed to ongoing identity issues regarding the PTA within the profession.

The 2001 Guide to Physical Therapist Practice17 sought to further clarify the role and relationship of the PT and PTA relative to patient care and the patient/client management model. The Guide defined the PT’s scope of practice and supported reimbursement of examination, evaluation, diagnosis, and prognosis only when provided by a PT.17 Furthermore, the Guide defined reimbursement for intervention us appropriate when performed by a PT or by a PTA under the direction and supervision of a PT. Today, there are still some PTA identity issues that remain unclear and unresolved. The profession as a whole still needs to grapple with these issues to ensure greater clarity and cohesiveness among all people who provide physical therapy services for our patients. Tills will benefit both the public we serve and the profession.

APTA GOVERNANCE AND THE “VOICE” OF THE PTA

The issue of PTA identity and role within the profession is complicated by the need for PTAs to find a venue and mechanism whereby their “voice” can appropriately he heard within the profession. Thus, the issue of the role of the PTA in practice and the need for a mechanism for the PTA to have a voice within the profession are often seen as synonymous and, therefore, misunderstood. Historically, PTAs were involved in APTA’s governance structure as part of their respective chapter (state associations) and were provided limited representation and a one-half vote within the House of Delegates, which consists predominantly of PTs. In an attempt to provide a mechanism to allow for an expanded voice for the increasing number of PTAs, an organizational task force met in 1987 to discuss membership rights, privileges, and the structure of APTA. Task force members included Marilyn Gossman, PT, PhD, FAPTA, Jerome Connolly, PT, and Cheryl Carpenter, PTA. The task force forwarded a recommendation to the APTA Board of Directors, which included proposals to meet the needs of the PTA membership. The APTA Board of Directors then forwarded RC-1 to the 1989 House of Delegates.10 The House of Delegates adopted the proposal, which, in part, formed the Affiliate Assembly. The Affiliate Assembly structure provided a mechanism for PTAs to independently meet, confer, and promote the interest of their respective membership class. This change in Association policy and structure prompted some members to express concerns that there would he a concomitant expansion of the PTA role in patient/client care within the practice setting.

THE FUTURE

In thinking about the future, it is helpful to remember the past. In an editorial published in a 1963 issue of the Journal of the American Physical Therapy Association, Helen Hislop, PT, PhD, FAPTA, wrote:

The continued debate on the use of nonprofessional assistants in physical therapy is rapidly moving further afield from our doorstep…. A host of self-appointed specialists outside of physical therapy have been attracted to the arena of debate, each sponsoring a panacea especially concocted to solve the ills that beset us with regard to manpower shortages.18(p711)

We are still trying to answer Nancy Watt’s original question: “Who should do what-how will the professional and the assistant be different?”1(p23)

At the current juncture in health care, an honest effort is required to determine what level of personnel is appropriate to provide patient care. The conversation must address issues of patient acuity, diagnostic complexity, and treatment expertise and must create a reliable algorithm for delegation, supervision, and decision making. My view is that the profession must move beyond the consistent response of the physical therapist always performs the initial patient evaluation and determines the type and course of physical therapy treatment, delegating only those elements of care that can be performed safely by supportive personnel.17 The profession must ask the difficult question: Does the treatment require the skills of the PT, or could the PTA, working under the supervision of a PT, provide highquality service at a lesser cost to the patient?

Additionally, the question of novice versus master clinician may influence the delegation of patient care to the PTA. To what degree must PT graduates perform routine physical therapy procedures and establish a sense of confidence before they can effectively delegate to and use the skills and knowledge of others? Likewise, PTAs with years of experience must somehow be recognized for their own acquisition of skills, knowledge, and experience that comes with continuing education and skill proficiency. Physical therapy educators must make continued efforts to educate physical therapy students about the efficient and appropriate use of physical therapy personnel. Effective education models require physical therapist students to delegate aspects of patient care to physical therapist assistants. The students must be able to provide sound rationale for their decisions to delegate based on patient complexity, education of the physical therapist assistant, and efficient practice management. When possible, physical therapist and physical therapist assistant students should jointly discuss issues of appropriate delegation, the role of the physical therapy team in prevention, and wellness, in addition to rehabilitation post disease or trauma, prior to clinical rotations. This concept is echoed by the Association of Academic Health Centers in their statement: “Education and training of other health professionals is also based on outmoded hospitalbased learning systems. Radical changes in instruction must address public health, preventive medicine, consumer empowerment, and related issues.”19

Physical therapists and PTAs alike would be better challenged provide a patient outcomes-based rationale for current delegation patterns. Health care has moved toward outcome-oriented care. Osterweis et al wrote:

The evolving marketplace is looking at outcomes, not levels of training. If we are short of physical therapists, and the work of physical therapist assistants shows similar results, the marketplace is going to say, “Let’s have more physical therapist assistants.”20(p184)

As the physical therapy profession transitions toward the professional Doctor of Physical Therapy (DPT) degree for PT education (see the article by Stohs et al in this issue), some have asked how PTA education may change in relation to a profession in transition. Physical therapists will need to more consistently understand how and what types of patients/clients should be directed to the PTA for care under the PT’s supervision. Physical therapist education programs need to continue to ensure that students and graduates understand the competencies and skills of the PTA and how and when to delegate services and direct and supervise the PTA in providing appropriate aspects of patient care.

The distinction between the associate degree for PTA education programs and the doctoral degree for PT education makes for distinct career choices in physical therapy. The option of transitioning from the PTA degree to the PT degree is more difficult than it was in the past, given that some associate degree courses may not be applicable to a baccalaureate degree and may require that an individual complete additional courscwork to earn an undergraduate degree. The great majority of DPT programs require a completed baccalaureate degree and the completion of specified prerequisite course work for admission to the professional program. In addition, transfer credit for lower-division PTA courses rarely exists in postbaccalaureate PT programs. Community college PTA faculty and counselors usually encourage students to seek an undergraduate degree if they are interested in pursuing a career as a PT. If, however, the individual is interested in becoming a PTA, then the counselors and advisors will guide the student toward a 2-year assistant program. More frequently, counselors now recognize that the PTA degree is not intended as a stepping-stone to the PT degree and advise students accordingly. This is clearly different than past practice for advisors.

Two PTA-PT transition programs currently exist at Findlay University and Loma Linda University. CAPTC accredits both of these Master of Physical Therapy degree programs. To what degree the foundations provided by the PTA curriculum are extended and built upon in the graduate program is uncertain and beyond the scope of this article. There are other schools that offer weekend PT programs, making it possible for one to continue to earn an income as a PTA and attend a PT education program.

Education is not a finite act but rather a lifelong experience. A larger question remains: How can the current educational environment afford lifelong education for PTA improvement and career laddering? A profession must address the ongoing educational needs of the members who contribute to the growth and potential of the profession. APTA House passed RC-27 in June 2003.21 The policy, titled “Post Entry-Level Education and Recognition of Enhanced Proficiency for the Physical Therapist Assistant,” recognizes the need for PTA career development, to enhance skills at the appropriate skill level, but is not recognized as ensuring enhanced competence in a particular skill set.

Geographic and economic limitations will continue to influence a student’s choice of physical therapy career, affecting the ability to educate and retain a diverse work force. One of the missions of community colleges is to provide educational opportunities for first-generation college students and underserved populations. History shows that they have fulfilled this mission.

The societal need for and value of physical therapy services contributed to the creation of PTA education programs. The professional debate regarding the appropriate utilization of the PTA continues to shape the core curriculum. The dichotomy created by associate degree for PTA education programs and the doctoral degree for PT education programs needs to be a continuing consideration as we attempt to create a physical therapy work force that optimally, effectively, and efficiently meets the diverse needs of the patient population we seek to serve. Physical therapist and PTA educators need to continue to consider and address levels of appropriate utilization of the FIA and reach a higher level of consensus on how they are most appropriately and consistently utilized. I believe and hope that the PTA will remain a viable and valued contributor to the profession of physical therapy and will be the preferred paraprofessional of choice for the delivery of physical therapy services in lieu of other potential providers.

REFERENCES

1. Watts NT. Task analysis and division of responsibility in physical therapy. I’hys Ther. 1971;51:23-35.

2. Blood H. Ad hoc committee to study the utilization and training of nonprofessional assistants. Phys Ther Rev. 1967;47(11 pt 2):3139.

3. Blood H. Supportive personnel in the healthcare system. Phys Ther. 1970;50:173-180.

4. Murphy W. Healing the Generations: A History of Physical Therapy and the American Physical Therapy Association. Lyme, Conn: Greenwich Publishing Group Inc; 1995.

5. Hill Burton State Plan Data: A National Summary, January 1962. Washington, DC: US Department of Health, Education, and Welfare; 1962.

6. Weis J. The Changing Job Structure of Health Manpower [thesis]. Cambridge, Mass: Harvard University; July 1966.

7. America’s Community Colleges: A Century of Innovation. Washington, DC: American Association of Community Colleges; 2002.

8. Annual Report of Supportive Personnel. Phys Ther. 1967;47:34-39.

9. Fenderson DA, Larson CW. Planning and establishing a physical therapy assistant program. Phys Ther. 1968;48:963-967.

10. House of Delegates Handbook. Alexandria, Va: American Physical Therapy Association; 1989.

11. Robinson AJ, DePalma MT, McCall M. Physical therapist assistant’s perceptions of the documented roles of the physical therapist assistant. Phys. Ther. 1995;75:1054-1066.

12. Coalitions for Consensus: A Shared Vision for Physical Therapist Assistant Education. Alexandria, Va: American Physical Therapy Association; 1997.

13. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapist Assistants. Alexandria, Va: Commission on Accreditation in Physical Therapy Education; 2000.

14. Gwyer J. Personnel resources in physical therapy: an analysis of supply, career patterns, and methods to enhance availability. Phys Ther. 1995;75:56-65.

15. Bashi HL, Domholdt E. Use of support personnel for physical therapy treatment. I’hys Ther. 1993;73:421-429.

16. Guide to Physical Therapist Practice. Alexandria, Va: American Physical Therapy Association; 1995.

17. Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001:40.

18. Hislop HJ. Man power versus mind power [editorial]. J Amer Thys TherAssoc. 1963;43:711.

19. Larson PF, Osterweis M, Rubin ER. Health Workforce Issues for the 21st Century. Washington, DC: Association of Academic Health Centers; 1994:34.

20. Osterweis M, McLaughlin CJ, Manasse HR, Hopper CL. The US Health Workforce: Power, Politics, and Policy. Washington, DC: Association of Academic Health Centers; 1996.

21. 2003 House of Delegates Minutes. Alexandria, VA, American Physical Therapy Association, 2003.

Cheryl A Carpenter-Davis, PTA, MEd

Chetyl A Carpenter-Daws is associate dean, Blue River Community College, 20301 E 78 Hwy, Independence, MO 64057

(chetyl.carpenter@kcmetro.edu).

Copyright Journal of Physical Therapy Education Winter 2003

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