Dilemmas of practice in rehabilitation settings as experienced by physical therapists

Little research has explored the dilemmas of practice experienced by practitioners working with rehabilitation clients who are assimilating disabilities, resulting from injury or chronic conditions, into their lives. Consequently, there is limited literature to support educational initiatives or clinicians' decision-making in these settings. Accordingly, this qualitative study was designed to explore 'expert' physical therapists' perceptions of dilemmas of practice in rehabilitation settings. Using an ethnographic design, multiple interviews were conducted over a period of six months with each of ten participants. The researcher's theoretical background and 'insider' role were thoroughly explicated. Interpretive analysis was grounded in three overarching themes that emerged from the participants' accounts and compared with relevant theoretical constructs and research in physical therapy and other health professions. In the first theme the 'authority' of the concept of evidence-based practice as it is currently promoted within physical therapy was questioned. A need was identified to develop rigorous alternative sources of 'evidence' to support current practice that are more congruent with the multifactorial and client-centred nature of rehabilitation service provision. A second theme explored situations interpreted as causing moral distress in which the participants found themselves prevented from acting effectively on behalf of the clients, as a result of admission and discharge decisions and perceived misuse of rehabilitation resources within the organization and health system. The third theme related to the advantages and disadvantages of being involved with the interdisciplinary team. A lack of understanding of different professional philosophies of practice was perceived as a contributing factor to conflict and miscommunication. These themes are related to issues of professional accountability and suggest that physical therapy needs to develop a clearly articulated philosophy and conceptual models, including the concept of client-centred practice, that would reflect practice, serve to guide research and promote interdisciplinary collaboration. Alternative sources of 'best' evidence need to be developed that more realistically reflect complex 'practice' knowledge. In addition, the profession needs to commit to developing a comprehensive ethics curriculum offered in education programs and through interdisciplinary learning opportunities, by which physical therapists will be better prepared for the moral deliberations inherent in their professional role.Education, Faculty ofEducational Studies (EDST), Department ofGraduat