Multidisciplinary team perception of physical therapists in emergency rooms in hospital in the inland area of the capital city of Rio Grande do Sul

ABSTRACT

The physical therapist inclusion at urgency and emergency remains an unexplored scenario, even though it has been getting attention and relevance. Thus, this study aims to check multidisciplinary team perception on physical therapist inclusion at the emergency of a hospital. This is a descriptive study with quality-quantitative analysis. The convenience sample was composed of nurse technicians, nurses, physicians, resident physicians, multidisciplinary residents and health science scholars who work at the unit, totaling 41 professionals. A self-applicable questionnaire was used to collect data, with identification information, objective, and subjective questions regarding the topic of this study, which was developed and validated by the authors. The continuous variables were expressed in mean and standard deviation, whereas categorical variables were performed by frequencies. Data obtained in descriptive questions were organized and analyzed with the hermeneutic-dialectical method. After analysis, we observed that more than 85% of the team referred that the physical therapist is considered part of the emergency team, with all of them presenting a good relationship overall. Besides, they recognize the importance of the physical therapist and the positive result of physical therapist in respiratory and motion. Thus, it was verified that the multidisciplinary emergency team understands and recognizes the physical therapist performance as well as the positive aspects that physical therapy brings to the emergency treatment, showing a positive perception of such professionals.

Keywords:
Health Services; Patient Care Team; Emergency Medical Services; Comprehension; Physical Therapy Department, Hospital

RESUMO

A inserção do fisioterapeuta na urgência e na emergência permanece um cenário pouco explorado, ainda que venha ganhando destaque e relevância. Diante disso, buscou-se verificar a percepção da equipe multiprofissional quanto à inserção do fisioterapeuta na emergência de um hospital. Trata-se de estudo transversal, descritivo e com análise quali-quantitativa. A amostra por conveniência foi composta de técnicos de enfermagem, enfermeiros, médicos, médicos-residentes, residentes multiprofissionais e acadêmicos da saúde inseridos na unidade, totalizando 41 profissionais. Para a coleta de dados foi utilizado um questionário autoaplicável, composto de informações de identificação e de questões objetivas e subjetivas referentes ao tema da pesquisa, o qual foi desenvolvido e validado pelos autores. Variáveis contínuas foram expressas em média e desvio-padrão, enquanto variáveis categóricas, em frequências. Os dados obtidos nas questões descritivas foram organizados e analisados com base no método hermenêutico-dialético. Após análise, observou-se que mais de 85% da equipe referiu que o fisioterapeuta se encontra inserido na equipe de emergência e tem boa relação com esta. Além disso, reconhecem a importância do fisioterapeuta e o resultado positivo da fisioterapia respiratória e motora. Dessa forma, verificou-se que a equipe multiprofissional compreende e reconhece a atuação desses profissionais, bem como os pontos positivos que a fisioterapia traz aos atendimentos da emergência, apresentando uma percepção favorável.

Descritores:
Serviços de Saúde; Equipe de Assistência ao Paciente; Serviços Médicos de Emergência; Compreensão; Serviço Hospitalar de Fisioterapia

RESUMEN

La inserción del fisioterapeuta en urgencias y emergencia sigue siendo poco explorada, aunque viene ganando prominencia y relevancia. Este estudio pretendió verificar la percepción del equipo multiprofesional con respecto a la inserción del fisioterapeuta en urgencias de un hospital. Este es un estudio transversal, descriptivo, con análisis cuali-cuantitativo. La muestra de conveniencia consistió en técnicos de enfermería, enfermeros, médicos, médicos residentes, residentes multiprofesionales y académicos de la salud de la unidad, un total de 41 profesionales. Para la recolección de datos, se utilizó un cuestionario autoaplicable, compuesto de informaciones sobre la identificación y preguntas objetivas y subjetivas relacionadas con el tema de investigación, el cual fue desarrollado y validado por los autores. Las variables continuas se representaron como media y desviación estándar, mientras que las variables categóricas como frecuencias. Los datos obtenidos en las preguntas descriptivas se organizaron y analizaron con base en el método hermenéutico-dialéctico. Después del análisis, se observó que más del 85% del equipo informó que el fisioterapeuta está insertado en el equipo de urgencias y que comparte una buena relación con él. Además, reconoce la importancia del fisioterapeuta y el resultado positivo de la fisioterapia respiratoria y motora. Por lo tanto, se constató que el equipo multiprofesional comprende y reconoce la actuación de estos profesionales, así como los aportes positivos de la fisioterapia a la atención de urgencias, y tiene una percepción favorable.

Palabras clave:
Servicios de Salud; Grupo de Atención al Paciente; Servicios Médicos de Urgencia; Comprensión; Servicio de Fisioterapia en Hospital

INTRODUCTION

The insertion of physical therapist in the urgency and emergency room remains little explored. However, their work have been recognized over the years - a reflection of the contribution to multidisciplinary and interdisciplinary team. In December 2018, the Federal Council of Physical and Occupational Therapy recognized the performance of the physical therapist in the emergency units^{1)- (3}. The positive results of techniques and physical therapeutic conducts in the hospital environment evidence the scientific progress and clarification about the role of this professional⁴.

The emergency department is part of the health system and it is the unit that helps users with or without risk of death, whose health problems require immediate care⁵. The physical therapist’s performance in this sector reduces intubation time or may even avoid it, they assist the selection of ideal ventilatory care, reducing the number of complications, infections and length of hospital stay, besides contributing to pain control and improvement of disability^{2), (6}. Although it is an environment that requires agility, patient care must be humanized, which corroborates the basic physical therapy tool - the hands - touching the individual as effectively as possible. In accordance with this statement, Lopes and Brito⁷ conducted a study with hospitalized patients and they concluded that physical therapy was highlighted by good care, patient care and quality treatment, indicating humanized care.

Although the evidence demonstrates the benefits of physical therapy, its inclusion in the emergency units of hospitals is not yet established in organizational management models and it seems to be questioned by other professionals. Nevertheless, it is known that the integration and articulation of the different professions are necessary for knowledge cooperation and exchange, to provide the best and most adequate care to the user in situations of emergency⁶. Thus, the actions and contributions of physical therapy are still unclear. In 2009, in Australia, it was found that the main barrier to the insertion of this professional was the lack of awareness of their role by other workers in the sector, who assumed they would have to readapt their usual activities⁵. Therefore, we sought to verify the multidisciplinary team perception regarding the insertion of the physical therapist in the emergency department of a hospital in the inner region of the Rio Grande do Sul state.

METHODOLOGY

This is a cross-sectional, descriptive, and qualitative-quantitative study, carried out after approval by the Research Ethics Committee of the University of Santa Cruz do Sul, under the opinion No. 1,876,620. The study was carried out in the emergency department of a hospital in the inner region of the Rio Grande do Sul state, between January 2017 and July 2017.

Health professionals, regardless of length of service and work shift, were included. The convenience sample was composed of nursing technicians, nurses, physicians, resident physicians, multidisciplinary residents and health students of the unit, who agreed to participate in the research and signed the free and informed consent form. Radiographers, receptionists and janitors were excluded.

A self-administered questionnaire was used for data collection, it was composed of objective and subjective questions, developed by the authors of this study to verify the perception of the individual regarding the physical therapist’s performance in the emergency sector. The questionnaire was sent to three specialists in the area, to validate it, and later, the pilot study was conducted in the Adult Intensive Care Unit of the hospital.

This questionnaire is composed of identification data and questions related to the research theme. The initial information was composed of nominal categorical data (gender, profession in the sector and work shift in this sector) and numerical data (age and length of service in the sector). Then, the questions were divided into answers with nominal categorical variables. The last four questions were descriptive, which aimed to understand individuals on their own terms.

Descriptive analysis of the results was performed for quantitative data. The numerical data were expressed in mean (x) and standard deviation (±SD), and the nominal categorical variables were expressed in absolute frequency (n) and relative frequency (%).

For qualitative analysis, the data obtained in descriptive questions were organized and analyzed based on the hermeneutic-dialectical method⁸, being ordered, classified and submitted to final analysis. A mapping was performed, for data ordering, based on the descriptive responses of professionals/residents/scholars. The classification consisted of an exhaustive reading of answers and, based on this, the thematic categories were identified.

RESULTS

This research was applied with 41 professionals/residents/scholars of the emergency team. Note that women and day shifts were predominant (Table 1).

Table 1
Characterization of subjects divided according to the profession in the emergency

Characteristics		Emergency professionals							Total n (%)
		Med. sch.	Nur. sch.	Res. phy.	Multi. res.	Nur. tech.	Nur.	Phy.
Gender
	Female	6 (100)	2 (100)	6 (100)	8 (88.9)	8 (80)	2 (66.7)	-	32 (78)
	Male	-	-	-	1 (11.1)	2 (20)	1 (33.3)	5 (100)	9 (22)
Age (years)		25.4 (1.1)**	30.5 (7.8)	28 (3.4)***	27.8 (4)	28 (6.1)**	35.7 (6.4)	32.6 (3.4)	28.97 (5.1)
Length of service in emergency (months)*		4.8 (9.4)	1.0(-)**	5.4 (6)**	7.4 (9.2)	24.6 (18.1)****	34 (34.1)	23.4 (21.7)	14.3 (18)
Work shift in emergency***
	Day shift	1 (16.7)	2 (100)	4 (80)	5 (55.6)	9 (100)	3 (100)	3 (60)	27 (69.2)
	Day and Night	5 (83.3)	-	1 (20)	4 (44.4)	-	-	2 (40)	12 (30.8)

• -: Zero value representation; *: mean (standard deviation); n: absolute frequency; %: relative frequency; **1 Missing; ***2 Missing; ****3 Missing; Sch.: scholar; Res.: resident; Tech: technician; Med.: medical; Nur.: nursing; Phy.: physician; multi: multiprofessional.
• Source: Research data, 2017.

More than 85% of the team reported that physical therapist is inserted in the emergency team and that they have good relationship. Moreover, they recognize the relevance of the physical therapist and the positive result of respiratory and motor physical therapy (Table 2).

Table 2
Questions regarding the presence of the physical therapist in the emergency room

Question		Total n (%)
The physical therapist is part of the team
	Yes	35 (85.4)
	No	3 (7.3)
	I cannot opine	3 (7.3)
The physical therapist is relevant for the functioning of the sector
	Yes	38 (92.7)
	Sometimes	2 (4.9)
	I cannot opine	1 (2.4)
Relationship of the physical therapist with the team
	Good	37 (90)
	Average	2 (5)
	I cannot opine	2 (5)
Perceives results when the patient performs physical therapy
	Yes	39 (95.1)
	I cannot opine	2 (4.9)
If yes:
	Respiratory and motor physical therapy	39 (100)
Acceptance of physical therapy is perceived by patients
	Patients accept	30 (73.2)
	Physical therapist has to insist	4 (9.8)
	Patients prefer motor physical therapy only	1 (2.4)
	I cannot opine	6 (14.6)

• Source: Research data, 2017.
• n: absolute frequency; %: relative frequency.

Regarding the question “What is your opinion about the organization of the team in the presence of physical therapist in the emergency sector?,” 18 subjects positively assessed the presence of the physical therapy team, characterizing it as organized, helpful, competent, resolutive, and attentive. However, 12 individuals considered the emergency team as adequate, but recognize the need for evaluation/intervention of physical therapy and request them when the patient is hospitalized. Four subjects did not respond and seven reported not having contact with physical therapists.

Descriptive answers focused on physical therapy:

“Good organization, however, it should not be exclusive to [sic] hospitalized patients” (multiprofessional resident 6, written communication, questionnaire, 2017).

“I see the team organized in readily conducting the necessary assessments and conducts for the case” (physician 3, written communication, questionnaire, 2017).

“I can only praise for the commitment and excellence of the work done by the physical therapy team in the PA-SUS” (physician 5, written communication, questionnaire, 2017).

Considering the emergency-SUS team:

“I think that sometimes they hinder the work-flow due to the requirements of hospitalization for physical therapy, we could enjoy better if we could ask in the emergency room without hospitalization” (medical scholar 4, written communication, questionnaire, 2017).

“I believe that the care of physical therapists is being increasingly requested by other professionals, because of evident positive result that such practices present on the health status of patients” (medical scholar 5, written communication, questionnaire, 2017).

“The team is well aware of the relevance of physical therapy care and the indications of which patients need this care” (medical scholar 6, written communication, questionnaire, 2017).

“Although physical therapy is a very important area, I believe that it needs more appreciation of the hospital and patients” (multiprofessional resident 1, written communication, questionnaire, 2017).

“I believe that, with the beginning of multiprofessional residency, the unit team began to perceive and to call for the physical therapist’s care more frequently” (multiprofessional resident 5, written communication, questionnaire, 2017).

For the question “How do you classify the performance of physical therapy team in the emergency sector?,” 38 subjects defined physical therapy as relevant and essential, especially regarding the respiratory system, stating that professionals are qualified for care. However, some professionals reported the need for the physical therapist to be more active in the unit, especially in the red room (emergency). One individual did not answer, and two could not report it.

“Initially there was a lack of knowledge about the relevance of the physical therapist in the emergency room. However, the multidisciplinarity has brought positive results, so that it is increasingly being accepted by professionals from other areas” (medical scholar 5, written communication, questionnaire, 2017).

“A beneficial and positive process that benefits all: patient, staff, and hospital” (nursing scholar 2, written communication, questionnaire, 2017).

“I think it’s very important, but they should act more in the emergency room” (resident medicine 1, written communication, questionnaire, 2017).

“Their performance is very important, often managing to mitigate a more critical picture of the patient. Professionals working in the emergency-SUS have the necessary knowledge and they are prepared to contribute with immediate care” (multiprofessional resident 1, written communication, questionnaire, 2017).

“Competence, disposition, patient care, humanization” (Nursing Technician 1, written communication, questionnaire, 2017).

“Of great importance, because in addition to help the patient physically, the professional sometimes helps the patient’s mental health without meaning to, providing company and necessary help” (nursing technician 8, written communication, questionnaire, 2017).

“The performance is important, since it varies greatly in each case, as already mentioned, it focus more in patients who will remain longer, who will be hospitalized and those that because of lack of bed remain in the emergency room, but also those who rarely need NIV [noninvasive ventilation] or CPAP [continuous positive pressure in the airways]” (nursing technician 9, written communication, questionnaire, 2017).

“Good care, they show quality and interest” (nurse 3, written communication, questionnaire, 2017).

“Primary and indispensable action” (physician 1, written communication, questionnaire, 2017).

Regarding the positive aspects of the physical therapist’s insertion in the emergency room, 39 subjects reported the reduction of hospitalization length and improved prognosis, referring to the performance of physical therapists from prevention to patient recovery, with emphasis on respiratory physical therapy. Two individuals did not respond.

“I believe that, like other areas, the participation of the physical therapist adds in technical knowledge to the service, as well as it adds value to having more professionals willing to help” (medical scholar 5, written communication, questionnaire, 2017).

“Motor improvement in patients with neurological sequelae. Improved respiratory function, prevention of infections, accelerates the cure of pneumonias. Integrates multidisciplinarity” (medical scholar 6, written communication, questionnaire, 2017).

“Improvement of comfort to patients (respiratory); possibility of physical therapeutic managements such as bronchial hygiene, postural drainage, NIV [noninvasive mechanical ventilation]” (nursing scholar 1, written communication, questionnaire, 2017).

“Patient improvement, possibility of discussion of cases aimed to improve the patient’s condition” (physician resident 4, written communication, questionnaire, 2017).

“Prevention of complications related to prolonged bed rest as vascular complications. Recovery of respiratory capacity and prevention of pneumonia. Early stimulus to recover the patient’s autonomy for their activities” (multiprofessional resident 3, written communication, questionnaire, 2017).

“The best patient care, integrality. Best team performance” (multiprofessional resident 6, written communication, questionnaire, 2017).

“Quality, humanism, improvement in the patients’ life who need physical therapy care” (nursing technician 2, written communication, questionnaire, 2017).

“Quality in service; the physical therapist often notices some issues that the medical team does not perceive” (nursing technician 9, written communication, questionnaire, 2017).

“Best functional assessment of the patient” (physician 4, written communication, questionnaire, 2017).

A total of 28 subjects reported the non-existence of negative points; two mentioned that the negative point was related to the physical space of the sector, and not precisely to the physical therapists; two commented that the high demand of patients in the service could interfere in the quality or availability of care; and the others were punctual answers, four individuals did not answer, and one could not express an opinion.

“I don’t think it has negative points, the professional always help, especially when we request for they assessment” (medical scholar 1, written communication, questionnaire, 2017).

“There should be a team present in the entire shift in the emergency” (medical scholar 3, written communication, questionnaire, 2017).

“Accumulation of professionals in the red room” (physician resident 3, written communication, questionnaire, 2017).

“Due to the great demand, sometimes we are not able to provide this service to all who need” (nursing technician 5, written communication, questionnaire, 2017).

“The emergency is small, if it is not organized causes turmoil and often hinders the care of the team, it is an extra good for the patient; one should see a strategy to not hinder the care of the medical team when they need to examine the patient and especially the nursing in the administration of medications, because the schedules must be met” (nursing technician 9, written communication, questionnaire, 2017).

“I see a negative point, not in the performance of the physical therapist in the emergency room, but rather the lack of an appropriate place to develop the necessary activities to optimize the treatment of patients” (physician 3, written communication, questionnaire, 2017).

DISCUSSION

In the past, the emergency department was composed only of doctors and nurses, specialists in acute diseases. Nowadays, some hospitals still have the same configuration, although it is perceived the relevance of a multidisciplinary and interdisciplinary team in the sharing of knowledge, articulation and integration among different areas of health, which enables better care to the subject in the complex environment of emergency/urgency^{9), (10}. Such recognition is observed in the qualitative data of this study, because professionals/residents/scholars from different areas report that with the insertion of multiprofessional work in the emergency unit an improvement in prognosis occurs as well as some more resources that enable effective and quality care. Integrality, automatically associated with multiprofessional action, stands out¹¹ since it is part of the humanization policy.

Therefore, although the presence of physical therapist in this sector is recent and little known by other professionals, its insertion is recognized as a good addition to the clinical evolution of patients, and physical therapists are considered a fundamental actors in the routine of the sector¹, since there is a high number of cardiopulmonary dysfunctions that require physical therapeutic interventions for better management of the patient. Furthermore, the emergency, because it is a hospital entrance door, hosts several diseases, of several orders, and the physical therapist can act in these range of situations⁵. This information is evidenced in this study, because it is generally observed that the team recognizes the importance of physical therapist, mentioning positive outcomes resulting from the conducts of these professionals. Thus, note that research proves the relevance of motor physical therapy associated with the respiratory therapy, for certain diseases impair the motor system. Thus, the physical therapist can reduce the length of hospital stay and also increasing the recovery rates after discharge^{4), (12}.

It was found that although professionals/residents/scholars perceive the result of physical therapy, both respiratory and motor, there is a highlight for respiratory approaches, since they were mentioned sometimes in descriptive responses, probably because it is an emergency sector that has as characteristic acute care. Studies have demonstrated the role of physical therapy in respiratory dysfunctions, assisting in ventilatory support, from the assembly and adjustment of the invasive and noninvasive mechanical ventilator to weaning from mechanical ventilation^{13), (14}.

In this sense, most at risk patients were the ones who most needed respiratory physical therapeutic approaches. Other studies^{5), (9} show a high percentage of physical therapy care in patients with red (emergency) and orange (very urgent) risk, proving the insertion of the profession in the sector, especially regarding more complex cases, reducing the chances of morbidity and mortality. Based on the answers presented here, it is verified that the professionals/residents/scholars desire to have the physical therapist’s performance directly in the red room, although, due to the physical space of the hospital, this presence is hindered by the routine of the sector, which makes the care performed only upon request.

A literature review¹⁵ reported that, in the UK and Australia, emergency is a sector that requires deeper knowledge, clinical skills, and experience, since it is an environment with complex situations, differing from traditional physical therapy. However, this review indicates a lack of evidence to demonstrate the efficacy, benefits, and quality of physical therapy services in this unit - facts that corroborate the perceptions of the multidisciplinary team, that mentioned the quality and competence of physical therapists who work in the emergency room in the state of Rio Grande do Sul hospital, highlighting that they are aware of their conducts. The study by Cordeiro and Lima¹, indicated that physical therapist’s main role is to provide care, evaluate, classify priorities, and treat, in addition to promote health and to act quickly in emergency situations, which highlights the complexity of the performance of this professional and reinforces the reason for having their presence in the unit, which contributes to teamwork.

Characteristics listed in terms of physical therapeutic care, which are humanization, provision, resolution and attention are also highlighted. Sheppard, Anaf and Gordon¹⁶ conducted a study with emergency patients who underwent physical therapy and they observed a high degree of satisfaction, reflecting the quality and clarification of diagnosis and treatment. Although this research present the multidisciplinary team as a sample, a comparison of ideas and perceptions is possible, emphasizing the relevance of the physical therapist presence in the unit.

Other studies show that physical therapy has positive consequences, highlighting the improvement of prognosis and the reduction of hospitalization length, resulting in lower hospital costs, besides promoting gain for society, since this patient returns to his activities in the shortest possible time^{1), (6), (12), (17), (18}. These data corroborate the perception of positive points highlighted by the subjects who answered the questionnaire.

De Paiva et al. ⁽¹⁸⁾ published an experience report of residents of the physical therapy area and revealed that physical therapists work 24 hours in the emergency department, both in the red room (resuscitation room) and yellow, being inserted in the team. In the hospital of this research, the unit has the care of resident physical therapists and, due to this, the care provided occurs on a daytime basis, according to the weekly workload. Furthermore, the negative points mentioned are related to the lack of physical space that allows the full presence of the resident, as well as the need for patient hospitalization receiving physical therapeutic care - which contrasts with the quantitative result obtained, since most individuals reported that physical therapist is inserted in the team, although despite providing effective and quality care, this occurs only when requested by prescription or in cases of emergency in the red room.

In Brazil, emergency services have high rates of occurrence, emphasizing the necessity of communication between public policies and emergency services¹⁸. Therefore, it is not yet clear what are the duties and rights of physical therapy in the emergency unit, since there are few studies proving these professionals interventions and their relevance¹⁹. This fact is evidenced in the results, since bureaucratic barriers, within the hospital, hinders the professional action in the unit. Moreover, it is important to highlight the recent regulation of this practice/insertion that provides safety to the patient, professional and the hospital itself.

Also, the relevance of studies addressing the point of view of the team must be highlighted, to improve physical therapeutic care and to improve multidisciplinary work in the unit. Thus, further research about the perception of health professionals regarding the performance of physical therapy in the emergency sector is necessary, considering that this is relatively new insertion area, but which has been demonstrating benefits to patients.

FINAL CONSIDERATIONS

Physical therapy in the emergency room is a recent area that has been gaining relevance in considering the results obtained with its interventions. With data, it was verified that the multidisciplinary team understands and recognizes the performance of professionals in this area, as well as the positive points that physical therapy brings to emergency care, presenting a positive perception on the subject. Notably, the negative elements were few and punctual. Furthermore, both scholars, residents and professionals highlighted relevant aspects that qualify physical therapeutic care in the emergency department of the hospital in the state of Rio Grande do Sul.

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• ¹⁹
  Crane J, Delany C. Physiotherapists in emergency departments: Responsibilities, accountability and education. Physiotherapy. 2013;99(2):95-100. doi: 10.1016/j.physio.2012.05.003
  » https://doi.org/10.1016/j.physio.2012.05.003

• 5
  Study carried out in the emergency unit of the Unified Health System of a hospital in the inland region of the Rio Grande do Sul state, Brazil.
• 6
  Financing source: nothing to declare
• 8
  Approved by the Ethics Committee No. 1,876,620.

Publication Dates

• Publication in this collection
  31 July 2020
• Date of issue
  Apr-Jun 2020

History

• Received
  20 Mar 2019
• Accepted
  24 May 2019