Journal of Physiotherapy 64 (2018) 229–236

Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys

Research

Staff and patients have mostly positive perceptions of physiotherapists working in

emergency departments: a systematic review
Giovanni E Ferreira, Adrian C Traeger, Mary O’Keeffe, Chris G Maher
School of Public Health, Faculty of Medicine and Health, The University of Sydney, Australia

K E Y W O R D S A B S T R A C T

Emergency department Question: What are staff and patients’ perceptions of physiotherapists working in the emergency
Physical therapy specialty department (ED)? Design: Systematic review of qualitative studies. Participants: Staff working in EDs
Emergency medicine and patients presenting to the ED and managed by ED physiotherapists. Outcome measures: Perceptions
Primary contact physical therapy
of ED staff and patients were synthesised using a three-stage thematic analysis consisting of extraction,
Musculoskeletal pain
grouping (codes), and abstraction of findings. Results: Eight studies, which had sought the perceptions of
138 patients and 122 ED staff members, were included. Three main themes emerged: role of
physiotherapists in the ED, positive perceptions of ED physiotherapists, and concerns about
physiotherapists in the ED. Patients and ED staff both considered physiotherapists to be experts in
musculoskeletal care. The role of ED physiotherapists was seen as providing thorough patient education,
non-pharmacological pain management and activity resumption, especially through exercise therapy.
Having broad knowledge to assess and treat different health conditions was seen as facilitating the work
of physiotherapists in the ED. Patients and ED staff felt that ED physiotherapists had good interpersonal
communication skills. ED staff expressed concerns regarding the additional time that physiotherapists
spent with patients. Some patients felt that performing exercises in the ED was inappropriate and
painful. Conclusions: ED physiotherapists were mostly well accepted by patients and ED staff, and their
work was perceived to improve the ED. Concerns included restricted availability, lack of awareness of the
role undertaken by physiotherapists in the ED, and increased treatment time in some settings. [Ferreira
GE, Traeger AC, O’Keeffe M, Maher CG (2018) Staff and patients have mostly positive perceptions of
physiotherapists working in emergency departments: a systematic review. Journal of Physiotherapy
64: 229–236]
© 2018 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction It is complex to introduce a new profession into a setting with a

Physiotherapists first extended their roles to work in emergen-
cy departments (ED) in the United Kingdom (UK) in the mid-1990s.
Since then, physiotherapists have undertaken roles in the ED acting
both as primary and secondary contact clinicians.1 The main
difference between these two models of care is that physiothera-
pists working as primary contact clinicians are able to assess and
manage patients after the initial ED triage, while secondary contact
physiotherapists only manage patients upon referral from other ED
staff.2,3 Even in models of care where physiotherapists are primary
contact clinicians there is still a wide variation in practice patterns
due to legislative requirements. For instance, ED physiotherapists
in the UK with appropriate training levels are allowed to prescribe
some medicines, whereas the right to prescribe medicines is still
under debate in Australia.2,4 This model of care has spread to other
developed countries, including Denmark, Australia and the United
States.1 Advocacy for the role of ED physiotherapists has been
justified by an increase in ED presentations,5 many of which are
musculoskeletal conditions, which are historically managed by
physiotherapists in other settings.6
well-established organisational structure such as the ED. For
example, other ED staff may be concerned about how the new
profession will affect their role and patient care.7 While it is
expected that physiotherapists will contribute to the ED with their
particular set of knowledge and skills, the potential overlap of
competencies with other professions can create confusion about
practice boundaries and resistance to organisational change.8,9 An
understanding of how the ED staff perceive physiotherapists
undertaking a new role in the ED could inform the implementation
of this model of care.7
The relative novelty of physiotherapists working in EDs can also
impact patients’ perceptions and expectations.6 Physiotherapists
have long been recognised by the general population for their role
in the rehabilitation of musculoskeletal and orthopaedic condi-
tions.10 However, patients’ acceptance of being managed by
physiotherapists in the ED has not yet been sufficiently explored.
A recent scoping review2 found that despite pain management
being part of the tasks and roles undertaken by ED physiothera-
pists, the three most commonly reported roles of ED physiothera-
pists were ordering of imaging, patient education and review of

https://doi.org/10.1016/j.jphys.2018.08.001
1836-9553/© 2018 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
230 Ferreira et al: Physiotherapists in the emergency department
medication. This potential discrepancy between patients’ expec-
tations and the care provided in the ED may create confusion and
negative perceptions of the role. Given this, there is a need for a
better understanding of how patients perceive the treatment
provided by physiotherapists in the ED.
Despite growing interest in this model of care,11 there has been
little evaluation of its acceptance by both patients and ED staff.
Primary qualitative studies have addressed different models of
care (eg, primary or secondary contact physiotherapists) and most
of them have focused on ED staff or patients’ perceptions
separately.6,7,12–16 Synthesising evidence from individual qualita-
tive studies has the potential to help display similarities and
differences in the perceptions of ED staff and patients. The aim of
this study was to systematically review staff and patients’
perceptions of physiotherapists working in the ED.
Therefore, the research question for this systematic review was:
What are staff and patients’ perceptions of physiotherapists
working in the emergency department?
Methods
This review is reported in accordance with the Enhancing
transparency in reporting the synthesis of qualitative research
(ENTREQ) guidelines.17
Identification and selection of studies
This review included qualitative studies using any design (eg,
phenomenological, grounded theory, ethnography), written in
English, and published in peer-reviewed journals. No restriction
was placed on the profession of ED staff, the type of patient
included (eg, musculoskeletal or cardiopulmonary conditions) or
the method used to collect staff and patients’ perceptions (eg,
interview, semi-structured interview, survey with free text).
Mixed-methods studies were included if the qualitative data
could be extracted and analysed independent of the quantitative
data.
A search strategy was used that was comprehensive rather than
purposive. The following were searched from their inception to
18th September 2017: MEDLINE (PubMed), EMBASE, CINAHL and
Cochrane CENTRAL. Searches on PubMed were updated on 12
February 2018. The search terms used for the PubMed search
(Appendix 1, on the eAddenda) were adapted for use on the other
databases. Working independently, two reviewers (GF and CM)
initially screened the search results by title and abstract, and then
by full text. Disagreements were resolved by discussion between
the two reviewers. The reference lists of all included studies were
screened.
Quality appraisal
Two reviewers (GF and MOK) independently assessed the
quality of individual studies using the Critical Appraisal Skills
Programme (CASP) qualitative assessment tool,18 with disagree-
ments resolved by discussion (Appendix 2, on the eAddenda). The
CASP is a 10-item tool designed to assess the quality of the research
design, adequacy of sampling methods used, appropriateness of
data collection methods, researcher reflexivity, ethical issues, data
analysis, findings, and value of the research. The CASP tool is the
most commonly used instrument in qualitative evidence synthe-
sis.19
Data extraction and synthesis
Two reviewers (GF and MOK) independently extracted data for
study details (author, year of publication), study design (qualita-
tive), participants (demographic characteristics, number of indi-
viduals enrolled, ED staff professions), setting (eg, ED within a
trauma centre), role of the physiotherapist (primary or secondary
contact), and findings of each individual study.
Data were synthesised from qualitative studies using a thematic
synthesis approach. The inductive method20,21 was used to: extract
the findings and develop a set of codes; group the codes according
to their topical similarity; and abstract the findings. Free
line-by-line coding was used, a process in which sentences or
fragments of sentences are given a label or ‘code’ that more broadly
describes what a study participant or study author was saying. For
example, if a participant said [The physio] was gentle, and she
explained everything to me . . . I just wanted all of my queries
answered, and she answered them . . . I felt she was probably more
informative and extremely helpful,13 this would be coded as patient
education. When a pattern emerged from the combination of two
or more codes, these were grouped into subthemes. Related
subthemes were then grouped into themes.22 To abstract the
findings, codes were analysed for consistency and pattern
recognition, and concise statements that captured the content of
findings were drawn. All steps were independently conducted by
two reviewers, and consensus on codes and themes was reached
after three rounds.
Results
Flow of studies through the review
The database search retrieved 2012 records. After removal of
624 duplicates, 1388 titles and abstracts were screened and
1355 were excluded. The remaining 33 articles were read in full
text and eight of them met the inclusion criteria. The flow of
studies through the review is displayed in Figure 1.
Characteristics of the included studies
Seven studies used a phenomenological design to describe
patient and staff perceptions of ED physiotherapists.3,6,7,13–16 One
study used a thematic survey design.12 Six of those studies were
conducted in Australia3,6,7,13,15,16 and two in the United States.12,14
Records identified through databases (n = 2012)
Duplicates removed (n = 624)
Records screened by title and abstract (n = 1388)
Excluded after screening (n = 1355)
Full-text articles assessed for eligibility (n = 33)
Excluded after evaluation of full text (n = 25)
conference abstract (n = 7)
quantitative outcomes only (n = 4)
editorial or correspondence (n = 4)
review article (n = 3)
not published in English (n = 2)
primary care physiotherapy (n = 2)
no separate data for physiotherapy (n = 2)
management of a single case (n = 1)
Studies included in the thematic synthesis (n = 8)
Figure 1. Flow of studies through the review.
 Research
Physiotherapists had primary contact roles in five studies,3,6,7,13,15
and secondary contact roles in three studies.12,14,16 Four
studies3,6,13,16 interviewed patients and four studies interviewed
ED staff.7,12,14,15 Study characteristics are displayed in Table 1.
Quality
Six studies did not adequately describe the relationship
between researchers and study participants.3,7,12,13,15,16 One study
was judged as having an inappropriate methodology to adequately
explore the richness of data on perceptions.12 Two studies had
insufficient sample sizes and the rationale for the reduced sample
size was not discussed.3,15 One study was judged to have problems
with addressing the research question with the data collected.13
One study did not mention ethics approval.12 Three studies did not
analyse data appropriately because of the over-simplistic approach
to data12 or because of a lack of adequate description of how codes
and themes emerged.3,14 Overall, the quality of the included
studies was of concern due to issues with data collection, research
reflexivity and insufficient sample size. No study was excluded
based on its methodological quality. Quality appraisal results are
displayed in Table 2.
Themes identified from thematic synthesis
Table 3 provides an overview of the identified themes and
subthemes and the total number of times each subtheme appeared
across studies.
Theme 1: Role of physiotherapists in the emergency department
Management of musculoskeletal conditions
ED physiotherapists were mainly recognised by patients6,13 and
staff3,7,14,15 for their expertise in managing musculoskeletal
conditions.6 Patients6,13 and staff3,7,14 suggested that physiothera-
pists were better trained than ED physicians to manage such
conditions. ED staff felt that having a physiotherapist working in
the ED enabled patients presenting with musculoskeletal condi-
tions to start receiving appropriate treatments earlier in the ED,
rather than just being referred back to their general practitioners.3
[ED physiotherapists] see people with sports injuries or strained
muscles because they are specifically trained in that area.6
(Patient)
At the end of the day [physiotherapists] probably know more of the
sort of anatomy . . . bone structures and stuff like that . . . than a
general GP would, so to me it’s the right person for the role. That’s
kind of their speciality.13 (Patient)
ED staff felt that the most useful aspect of having an ED
physiotherapist was to manage low back pain.3,6,7,13 This was
highlighted not only because of its high prevalence, but also
because of the perceived effective management strategies adopted
by the ED physiotherapists.3,7
I have seen so many matters approaching the physiotherapists. Not
necessarily in the extended scope of practice physios but even the
other like back pain, you find doctors don’t really have that
confidence in treating, which the physiotherapists have.3 (ED Staff)
Movement and return to function
Movement and exercise were considered by some patients and
ED staff to be an important means to re-acquire function.6 Patients
believed that exercises were helpful for a diverse range of
conditions – from rehabilitation of traumatic injuries to prevention
of recurrence of pain conditions.6 ED staff considered exercise as
an important part of the ‘treatment package’ delivered by ED
physiotherapists, due to the high value attributed to this
intervention by patients.15
231
[They manage] people that really need care – people that can’t
manage to walk, use their arms, need to exercise to get better . . . 6
(Patient)
The benefits of movement assessment were considered to be
important components of elderly care.14,15 Mobility assessment
was conducted to appraise the risk of falls and to help determine
discharge planning.14
One of the things that I think is really valuable to have down in the
emergency department is the gait assessments that we do for the
elderly patients. Often that’s one of the big determinants of
whether or not somebody’s safe and able to go home or not. And I
think we just get a much more valuable assessment if it’s being
done by the physical therapist as opposed to either the physicians
or the tech, or the nurses in the emergency department doing it.14
(ED staff)
Some patients provided a contrasting viewpoint about the role
of exercise therapy prescription in the ED environment. Interest-
ingly, patients in one study found that exercises prescribed by a
physiotherapist were painful and difficult to perform,16 and
patients from another study6 felt that exercises were unnecessary
in the ED environment.
Patient education
ED physiotherapists were recognised by patients and the ED
staff as health providers greatly involved in the provision of patient
education.6,7,13–15 This educational role was important to patients
in terms of explaining their current condition,3,6,13 as well as
informing them about possible treatment options after
discharge.3,13 ED staff12,14 highlighted how thorough ED phy-
siotherapists were in providing relevant information to patients
about their current condition, treatment and prognosis. Patients
also recognised that the benefits of education and advice extended
beyond the episode managed at the ED consultation, stating that
the information provided could be helpful for prevention.
I just liked the fact [that he] followed through with it and yeah, he
made sure that I knew exactly what was going on and everything
and advised – you had the results of the x-rays, the best treatment
option, what my other options were.3 (Patient)
There is education that we don’t provide as in-depth as a physical
therapist does.14 (ED staff)
Improve patient flow
Patients and the ED staff considered ED physiotherapists to be
efficient. This was reflected by an overall improvement in patient
flow,3,12–14 which was valued by patients, especially for those in pain
waiting to be seen.13 The efficiency of ED physiotherapists was valued
by the ED staff as well, as they helped ease the pressure created by the
standards for ED performance.7 ED staff perceived that having
physiotherapists in the ED efficiently managing patients allowed
them to manage patients with more serious conditions.14
I brought a book to read, so I only probably got through about 20 or
30 pages, over the whole time I was there. I was pretty impressed.
Was a good emergency experience, which you don’t often get.13
(Patient)
The ED doctors are supportive of the advanced scope of practice
physiotherapy (ASoP) role as it provides an alternative, effective
and time-efficient management option for musculoskeletal
presentations to the ED. This has been particularly noticeable as
the ASoP physiotherapist has become competent in more advanced
skills such as independently reviewing x-rays.3 (ED staff)
Referral and discharge
Patients and ED staff perceived that ED physiotherapists liaised
with other ED health professionals to suggest different treatments,
or to facilitate referral for further investigation when deemed
 232
Table 1
Study characteristics (n = 8).

Study Design Participants Therapist role Data collection procedures Main findings
Setting

Anaf (2010)4 Thematic survey Convenience sample of 80 ED patients Primary contact Questionnaire with open-ended Patients’ perceptions
1 metro and 1 regional Australian hospital questions, during the ED consultation,  Management of musculoskeletal
over 1 week conditions
 Management of orthopaedic conditions
 Management of cardiothoracic conditions
 Non-pharmacological pain management
 Patient education
 Movement and return to function
 Referral and discharge
Coyle (2017)5 Phenomenological Purposeful sample of 42 ED staff Primary contact Interview and focus groups, in the ED, Staff perceptions
Australian tertiary hospital (17 nurses, 10 medical staff, 9 PT, over two waves 1 year apart  Good interpersonal communication skills
6 other)  Being good team workers
 Reduced working hours was perceived as
negative

Ferreira et al: Physiotherapists in the emergency department

Fruth (2016)11 Topical survey Convenience sample of 61 ED staff Secondary contact Online or hard-copy surveys, collected in Staff perceptions
USA tertiary hospital (physicians and residents) two waves 7 years apart  ED physiotherapists are valuable assets
 Additional time spent with patients
Harding (2015)12 Phenomenological Convenience sample of 25 ED patients Primary contact One-to-one, semi-structured interviews Patients’ perceptions
1 metro and 1 remote Australian hospital by telephone, days after discharge from  Improve efficiency
the ED, in two waves 7 years apart  Good interpersonal communications skills
Lebec (2010)13 Phenomenological Samplea of 11 ED physicians Secondary contact Face-to-face interviews Staff perceptions
USA trauma centre  Patient education
 Mobility assessments
 Referral and discharge planning
 Additional time spent with patients
Lefmann (2014)14 Phenomenological Convenience sample of 6 ED staff Primary contact Semi-structured interviews, in the ED, Staff perceptions
Australian hospital (2 doctors, 2 nurses and 2 PT) over 1 week  Organising discharge planning
 Involved in a broader spectrum of care,
such as wound care and vestibular
assessment
Morris (2015)1 Phenomenological 2 ED nurses and 11 ED patients Primary contact Semi-structured interviews by phone Patients’ perceptions
Australian tertiary teaching hospital (patients) or face-to-face (ED staff), after  Improve efficiency
ED discharge  Referral and discharge
 Patient education
 Staff perceptions
 Management of musculoskeletal
conditions
 Improve efficiency
Sheppard (2010)15 Phenomenological Samplea of 22 ED patients Secondary contact Semi-structured interviews and follow- Patients’ perceptions
Australian hospital up telephone interviews, in the ED (face-  Lack of awareness of role of ED
to-face) and after ED discharge physiotherapists
(telephone), over 1 week  Management of musculoskeletal
conditions
 Management of orthopaedic conditions
 Good interpersonal communication skills

ED = emergency department, metro = metropolitan, PT = physiotherapist, USA = United States of America.

a
Mixture of convenience and purposeful.
 Research 233

Table 2
Critical Appraisal Skills Programme (CASP) criteria summary for each included study (n = 8).

Study (year) Clear Qualitative Appropriate Sampling Data Researcher Ethical Appropriate Clear Research
statement methodology research collection reflexivity issues data statement value
of aim appropriate design analysis of
findings

Anaf (2010)4 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Coyle (2017)5 Yes Yes Yes Yes Yes No Yes Yes Yes Yes
Fruth (2016)11 Yes No Yes Yes Yes No No No Yes Yes
Harding (2015)12 Yes Yes Yes Yes No No Yes Yes No Yes
Lebec (2010)13 Yes Yes Yes Yes Yes Yes Yes No Yes Yes
Lefmann (2014)14 Yes Yes Yes No Yes No Yes Yes Yes Yes
Morris (2015)1 Yes Yes Yes No Yes No Yes No Yes Yes
Sheppard (2010)15 Yes Yes Yes Yes Yes No Yes Yes Yes Yes

Table 3
Themes, subthemes and number of quotations supporting each subtheme.

Themes Subthemes Supportive quotations (n)

Patients Staff

Role of ED physiotherapists in the ED Management of musculoskeletal conditions 21 9

Movement return and function 16 6
Patient education 9 9
Improve patient flow 5 13
Referral and discharge 8 5
Non-pharmacological pain management 5 2
Cardiorespiratory management 3 0
Positive perceptions of physiotherapists in the ED Knowledge and expertise 3 17
Good interpersonal communication skills 8 5
Good team worker 0 9
Concerns about physiotherapists in the ED Lack of awareness of the role of ED physiotherapists 1 2
Restricted availability 0 3
Additional time spent with patients 0 2

ED = emergency department.

appropriate.6,7 Patients felt confident that the ED physiotherapist
would refer them if necessary.3,13 Besides improving patient flow
in the ED, physiotherapists organised community services for
patients to attend after discharge from the ED.15
[They] encourage me, liaise with my general practitioner, suggest
different treatments [and are] sympathetic.6 (Patient)
. . . it’s really good to have the physiotherapist and they can
organise services and get them on track and stuff in the
community, which we don’t necessarily have time to or we don’t
have those contacts.15 (ED staff)
Non-pharmacological pain management
Patients highlighted that non-pharmacological interventions,
such as exercises and hands-on treatments, were a core compo-
nent of the work of ED physiotherapists.6 Physicians also valued ED
physiotherapists for providing interventions that were alternatives
to pharmacological management.12
[They] could massage, help the pain; [it’s] someone who knows the
ins and outs of pain.6 (Patient)
Cardiorespiratory management
Management of cardiorespiratory conditions was perceived by
patients as a relevant, yet small, role of ED physiotherapists.6 ED
physiotherapists provided assessment and treatment techniques
aimed at removing secretions, improving breathing, and prevent-
ing infections.6
[ED physiotherapists treat] chest infections and asthma6 (Patient)
important for physiotherapists to be more accepted as part of the
team. Patients and ED staff noted the involvement of ED
physiotherapists in a broader spectrum of care such as: wound
care, minor trauma management, vestibular assessment, neuro-
logical conditions, and geriatric care.6,15
The level of expertise . . . has really improved our treatment of
both wound care patients and orthopedic patients.14 (ED staff)
ED staff noted the importance of the continued learning process
of specific tasks and routines within the ED. This was perceived as a
necessary condition for physiotherapists to be more accepted as
part of the team, and contributed to the perception that
physiotherapists were committed to the team.7
I think they [physiotherapists] get better at it, they get more
confident, their knowledge base, their expertise in reading x-rays
and all that sort of stuff, it improves, and I think they just get
accepted as being more part of the team.7 (ED staff)
Good interpersonal communication skills
Patients perceived ED physiotherapists as having good inter-
personal communication skills. Patients felt that ED physiothera-
pists were sympathetic,6 encouraging,6 gentle13 and friendly.16
Being supportive facilitated patient education16 about their
condition and prognosis.
And it came from an authoritative, but very pleasant, bed friendly
manner if you like, but factual way in which he imparts, he’s a good
communicator.16 (Patient)

The ED staff identified that ED physiotherapists needed to have

Theme 2: Positive perceptions of physiotherapists in the
emergency department
Knowledge and expertise
ED staff considered that having broad knowledge and expertise
on assessment and management of different health conditions was
good communication skills to be successful in their roles, as well as
have the ability to multi-task, work under stressful situations7,14
and deal with distressed patients in a calm way.14 ED staff
recognised the ability of ED physiotherapists to educate patients
about their condition using lay terms. ED physiotherapists were
also acknowledged for having the ability to communicate
234 Ferreira et al: Physiotherapists in the emergency department
effectively with other ED staff, tailoring communication to other
professionals whenever needed.7,14
It can be the most basic education, because people soak up
education here so easily. [Teaching others] doesn’t have to be
something you spend hours doing hard work on, it can be fitting
slings, fitting splints on legs, really boring basic stuff that
[physiotherapists] can do off the cuff like that and not have to
do any study for it.7 (Patient)
Good team worker
According to the ED staff, ED physiotherapists displayed a set of
characteristics that made them good team workers.7,15 ED
physiotherapists were flexible in helping other ED staff members,
understood their role within the team, acknowledged their
boundaries, and worked to build trust with their colleagues. The
ability to work in a multidisciplinary setting, seeking help from
more senior ED staff members and seeing a reasonable number of
patients in a timely manner, meant that physiotherapists were
considered valuable assets to EDs.
We have an understanding of peoples’ abilities and, I suppose, you
can trust them a little bit more, like knowing that this person is going
to get the right x-ray that they need or the right kind of care. For
example, with the physiotherapist I would be like, “oh this [patient’s]
a good one for you” and I probably won’t need to say anything more
than that. I know it would be sorted out. So I suppose it’s the trusting
as well. There’s a lot of trusting in this job.7 (ED staff)
Theme 3: Concerns about physiotherapists in the emergency
department
Lack of awareness of the role of ED physiotherapists
ED staff were initially unaware of the contribution that
physiotherapists could make to the ED.14 ED physicians expressed
their concerns on how introducing physiotherapists in the ED
would alter the organisation of care in this setting, where all
interventions are provided within one visit and not across a longer
period of time. Furthermore, the lack of awareness of what roles
physiotherapists would actually undertake in the ED created
concerns related to limitations in the physical environment of the
ED, as it was thought that ED physiotherapists would require larger
spaces to treat patients. However, awareness of the role of
physiotherapists increased when ED staff observed the tasks
undertaken by physiotherapists, as well as their interpersonal
characteristics. Their commitment to the ED team and the
improvement in the quality of care were noticed by the ED staff.7
Those aspects helped to reshape staff members’ perceptions
towards accepting a new profession working in the ED.7
I think (that the services are) an unrecognised need. I certainly never
would have sought out physiotherapy services for the department,
and I’m the medical director . . . But now that they’re here I can’t
imagine working in a department without them.14 (ED staff)
I myself was very skeptical when I heard that physical therapists
were coming to the department. I didn’t really have a good
understanding of how it might aid my practice. And it has greatly
aided my practice.14 (ED staff)
Restricted availability of physiotherapy service
The working hours of ED physiotherapists were seen as
detrimental to the ED service organisation.7,12 ED staff were
critical that physiotherapists only worked during business hours7
and suggested that the ED physiotherapy service be expanded to
cover the busiest shifts like night and weekend shifts.12 The
reduced workload of some physiotherapists was also seen as a
concern.7 Physiotherapists who worked occasionally were consid-
ered to lack competence in all the procedures, and were constantly
asking for assistance, which was viewed as a barrier to efficiency.7
There’s something that [the physiotherapy service is] inflexible
with, and that is [the] roster. It’s probably the only thing that
they’re inflexible with. But we’re working in a public hospital
emergency department with needs that don’t necessarily fit in with
family life.7 (ED staff)
Additional time spent with patients
Where physiotherapists worked as secondary contact practi-
tioners, ED staff raised concerns about physiotherapists increasing
total treatment times in the ED.12,14 In both studies, physicians
noted that patients seen by ED physiotherapists had greater
treatment times, which hampered patient throughput.
(The service is a) double-edged sword in terms of patient flow. It
allows them to move from patient to patient faster, and they do a
great job informing the patients about their injury. They are the
experts. However, the patient and the physiotherapist tie up the
bed for another 30 minutes, and prevented another patient from
being admitted.14 (ED staff)
Contrasts in patients and staff perceptions between primary and
secondary contact ED physiotherapists
The emerging themes were very similar across studies on
primary and secondary physiotherapists working in the ED, except
for the subtheme ‘Additional time spent with patients’ within
Theme 3. The staff of EDs where physiotherapists acted as
secondary contact practitioners expressed concerns about in-
creased treatment times.12,14 Nevertheless, staff from these studies
also noted that having physiotherapists in the ED was helpful as it
enabled them to focus on patients with more serious conditions.
When physiotherapists acted as primary contacts, the concern
with increased treatment times was not highlighted by either
patients or staff.
Discussion
Patients and ED staff recognised ED physiotherapists as experts
in the management of musculoskeletal conditions. Physiothera-
pists provided education, exercises and encouragement aiming at
improving patients’ function. Patients and ED staff recognised the
value of ED physiotherapists in providing a non-pharmacological
alternative to pain medicines in the ED. Characteristics that
facilitated their role in the ED were having good interpersonal
communication skills and being good team workers. Despite an
overall perception that adding physiotherapists to the ED staff
improved efficiency, there were some concerns regarding the
additional time physiotherapists spent with patients, where their
role was of a secondary contact clinician. Restricted availability (ie,
not being available during weekends or only during certain shifts
on weekdays) was perceived as a negative aspect, preventing the
effective integration of the physiotherapist into the ED staff. We
identified contrasting views about the role of movement and
exercise by patients. While some felt this was an important part of
the care plan, others felt this approach to be painful, unproductive,
and that it should only be used in the later stages of care.
This review had a number of strengths. Although the grey
literature was not searched, which could have revealed more
studies, the sensitive search strategy was designed to capture all
published qualitative research on this topic from several databases.
Two independent reviewers were involved in all processes, from
screening titles and abstracts, to the creation of themes, and
synthesis of findings. This review appraised the methodological
quality of the included studies using a widely employed tool.18
The quality appraisal revealed that most studies did not provide
sufficient information on researchers’ reflexivity through data
collection (CASP tool item 6). This may have biased the results
because the researchers’ assumptions, agendas, personal beliefs
and emotions can impact the content of the investigation, the
 Research
methods used, and which findings were considered more
relevant.23,24 Another limitation in terms of the quality assessment
of the included studies was that because the CASP tool does not
produce an overall score, it was not simple to compare quality
between studies. Despite the richness with which some of the
subthemes were described by patients and clinicians, some studies
contributed with more extensive findings than others.6,7 Those
studies inevitably had a larger influence upon some of the
emergent themes of this review, such as the perception of patients
showing that physiotherapists were mostly recognised for
managing musculoskeletal conditions.6 Furthermore, most of the
included studies did not clearly state whether data saturation was
achieved, potentially increasing the risk that some themes may
have been missed.24 Some included studies were conducted in a
single setting, collected data over a short period of time, and
involved the perceptions of patients about a limited number of
physiotherapists.
By conducting a systematic review, perceptions of both ED staff
and patients were able to be summarised and contrasted, which
had been performed by only one primary qualitative study.3
Furthermore, the current review was also able to explore
perceptions across different models of care. Even though none
of the primary studies evaluated differences in perceptions of ED
staff and patients in EDs where physiotherapists had undertaken
both primary and secondary contact roles, evidence from the
current review suggests that this warrants further investigation.
Evidence was found that perceptions of these two roles may differ,
especially with regard to the improvement of patient flow, as
concerns about increased time spent with patients emerged only
from studies where physiotherapists had secondary contact
roles.12,14 It must be noted that all studies included in this review
were conducted either in Australia or in the United States. No
qualitative studies conducted in the UK were found,25 where the
scope of practice of physiotherapists is well established and
slightly different from Australia and the United States. For example,
the extended scope in the UK includes prescription of medicines.26
Nevertheless, this limitation was considered to be inherent to the
primary studies, rather than a limitation of the current review. The
current review therefore identified key areas for future research in
this topic.
Introducing a new profession in a well-established model of
care is a significant change for health organisations. Such a change
may affect other professional roles, put some staff under excessive
pressure, or increase redundancy. This may in turn negatively
impact the acceptance of the new profession.9 The restricted
availability of physiotherapists working in ED was a concern for the
ED staff.7,12 This may influence the success of this model of care and
deserves more attention in future studies. This review showed that
both patients and ED staff generally accepted physiotherapists as
part of the team. Importantly, for the ED staff the integration
process occurred gradually7 after physiotherapists had proven to
have sufficient expertise7,14 to undertake the role. Being perceived
as a good team worker also facilitated the acceptance, especially
when physiotherapists acted collaboratively, helping other ED staff
with some of their tasks.
Physiotherapists were perceived by some ED patients6,13 as
having comparable or better skills at assessing and treating
musculoskeletal conditions than physicians. A similar finding was
described for physiotherapists working in primary care, where
patients recognised physiotherapists as being as good as or better
than general practitioners at treating musculoskeletal disorders.27
However, some patients expressed concern that some treatments
proposed by physiotherapists in the ED, such as exercise therapy,
were not helpful on some occasions.6,16
There was consensus among patients and ED staff on the
abilities of ED physiotherapists as professionals greatly involved in
providing thorough patient education. A recent scoping review2
showed that patient education was the second most commonly
reported role of physiotherapists in the ED. Patient education
appears to be a useful strategy to reduce fear and apprehension in
235
other settings;28 this may also be the case for patients with
musculoskeletal pain in ED, who are known for presenting with
increased levels of psychological distress.29
The perception of some patients that the exercises prescribed
by physiotherapists in the ED were painful, hard to execute, and
pointless given the medical environment they were in, deserves
attention. To date, the safety of introducing physiotherapists has
not been adequately evaluated.2 This perception may indicate that
some patients presenting with musculoskeletal conditions may
not be suitable to be prescribed exercises in the ED environment.
While exercise is unlikely to have major negative consequences to
the patient, safety and acceptability of exercise therapy in the ED
should be further investigated. In the meantime, clinicians should
appreciate that such an approach may not make sense to some
patients, and effective communication is likely to be essential.
It is important to point out that, despite the findings of the
current review indicating that physiotherapists are accepted by
patients and ED staff, current evidence on efficiency, and safety of
this model of care has not yet been thoroughly evaluated.2 This has
implications for the broad implementation of this model of care, as
a new model of care would ideally be implemented in the presence
of sound evidence to justify the costs and alterations in staffing.
Although the findings of this review should be interpreted in this
context, evidence from a large-scale observational study has
revealed promising estimates in terms of improved efficiency
when primary contact physiotherapists were added to the ED.4
Six out of eight studies failed to adequately describe the
interaction between researchers and participants. Future studies
should describe what strategies, if any, were used to reduce the
influence of researcher bias in the primary studies. Furthermore,
none of the included studies were conducted alongside random-
ised controlled trials evaluating the effectiveness of physiothera-
pists in the ED.25,26,30 Nesting qualitative research into randomised
controlled trials designed to evaluate the performance of this
model of care can provide relevant insights to better understand
the process underlying the success or failure of its implementation.
None of the included studies have evaluated the perceptions of
ED staff and patients in EDs without physiotherapists as part of the
staff. That is particularly important, given the relative novelty of
this area of knowledge and research for the physiotherapy
profession. Understanding anticipated barriers and facilitators
can contribute to the creation of implementation strategies to
address these factors. In addition, future research should look at
how work organisational factors (eg, staffing characteristics,
physical environment) and clinical features (eg, patient profile)
may facilitate or impose barriers to the effective implementation of
physiotherapists in the ED.
ED physiotherapists were mostly well accepted by patients and
ED staff, and their work was perceived to improve the ED. Concerns
included restricted availability, lack of awareness of the role
undertaken by physiotherapists in the ED, and increased treatment
time in some settings. More investigation into the usefulness of
interventions provided by physiotherapists in the ED (such as
exercise therapy) is needed, given that some patients felt this
approach had little value in the ED context.
What was already known on this topic: Interest is growing
in the ED model of care where physiotherapists undertake
either a primary contact (assess and manage patients after the
initial ED triage) or secondary contact (only manage patients
upon referral from other ED staff) role.
What this study adds: Emergency department physiothera-
pists should communicate well with the ED team to ensure that
their role is understood. Emergency department physiothera-
pists should expect management of musculoskeletal condi-
tions and patient education to be key aspects of their role.
Exercises may not make sense to some patients in the ED;
physiotherapists prescribing this treatment should communi-
cate clearly about predicted benefits and harms for the patient.
236 Ferreira et al: Physiotherapists in the emergency department
eAddenda: Appendices 1 and 2 can be found online at
https://doi.org/10.1016/j.jphys.2018.08.001
Ethics approval: Nil.
Competing interest: Nil.
Source of support: GF is supported by CAPES (Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior), Brazil with a PhD
scholarship. AT is supported by an NHMRC Early Career Fellowship
(APP1144026). MOK is supported by a European Commission
Horizon 2020 Marie Skłodowska Curie post-doctoral fellowship.
CM is supported by an NHMRC Principal Research Fellowship
(APP1103022) and NHMRC Program Grant (ID APP1113532).
Acknowledgements: Nil.
Provenance: Not invited. Peer reviewed.
Correspondence: Giovanni Ferreira, School of Public Health,
Faculty of Medicine and Health, The University of Sydney, Australia.
Email: giovanni.ferreira@sydney.edu.au
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