Physical therapists are a key stakeholder in primary health care systems. We play a significant role in the health and wellbeing of persons with a wide array of (often challenging) physical complaints. Yet the industry itself is confronted with its own challenges – notably, early workforce attrition. Data from national surveys (e.g. Australia, England) indicate that the distribution of physical therapists peaks in the younger age groups, and declines considerably in the older age groups.1,2 If we consider age as a (somewhat crude) proxy measure of clinical experience, evidence suggests that those with the skills, experience, and clinical reasoning ability required to provide high-level physical therapy services are exiting the profession prematurely. With the demand for physical therapy services expected to increase against the backdrop of aging populations, concerns exist regarding the capacity of physical therapy workforces to respond to this need.3 We posit that this systemic or ‘macro-level’ issue is relevant to our ability to respond to this need; and is an impediment to high-level care delivery.
Attrition in physical therapyAttrition amongst physical therapists is to an extent related to high burnout rates, characterised by feelings of detachment, lack of personal achievement, and emotional fatigue.4 A recent investigation from Spain found that 30% of physical therapists experienced high levels of occupational stress, a predictor of burnout.5 Recent data from Australia show that the distribution of physical therapists peaks between 25 and 29 years with a considerable decline in numbers across subsequent age groups.1 Amongst those with general registration, a 35% decline is observed between the 25–29 and 35–39 year age categories. This is remarkably similar to an earlier Australian report (2012), suggesting this issue is endemic; and is an impediment to the recruitment and retention of senior and specialist staff.6 Data from England (2017) illustrate a similar issue – as the age distribution of physical therapists in the National Health Service peaks in the 30–34 year age group.2 Furthermore, a 2018 report from New Zealand (NZ) also notes that the greatest proportion of physical therapists are aged 34 years or less (with numbers of both males and females steadily declining in subsequent aged groups).7 The average clinical career length of NZ physical therapists is less than seven years, with practitioners leaving primarily within two years, or between four and six years.7
Experience underpins advanced clinical reasoningClinical experience is an important and necessary aspect of optimizing physical therapy management. Prior research demonstrates that experienced clinicians display advanced clinical reasoning - founded on a highly organised base of knowledge, and clinical pattern recognition.8-10 Experience also underpins knowledge of one's craft (i.e. non-propositional knowledge, also known as ‘professional artistry’) which is inextricably linked to expert clinical reasoning.11 Reflection is another fundamental element of advanced clinical reasoning and decision making; and comprises “active engagement in intellectual processes, exploration of problems or experiences, and a subsequent changed perspective or new insights”.12(p76) Experienced physical therapists engage in more frequent ‘reflection-in-action’, which informs advanced clinical decision making in real-time.12 The implications of attrition therefore, likely influence the capability of the workforce in terms of advanced clinical reasoning and high-level care.
Moving forwardsThe issue of workforce attrition warrants further exploration and importantly, discussion at an industry and policy-making level. Addressing this trend across the industry would clearly be a complex undertaking, given that influences on attrition and burnout are many and varied.13 However, perhaps within this lies an opportunity to “kill two birds with one stone”, as the saying goes. Optimizing clinical care, and creating a culture of retention within the profession, may not be mutually exclusive. Do health systems need greater investment in the development of specialized physical therapy positions, distinct from administration, with an overarching remit of enhancing physical therapy care? For example, such roles could encompass advanced training in contemporary and evidenced-based care models, education (e.g. colleagues and community), research activities and translation, the development of systems and processes that support the provision of high-level care, and mentoring. Regarding the latter, there is evidence that mentoring from experienced physical therapists can improve patient outcomes.14 Roles akin to this have been trialed in the United Kingdom's National Health Service (NHS) – to good effect, by way of ‘Physical Therapy Research Facilitator’ positions.15 It is recognized that these multi-faceted roles have facilitated greater research dissemination and engagement from clinical physical therapists, advanced implementation of evidence, and ultimately improved patient care.15 Greater availability of these roles could not only contribute to the strategic uplift of service provision, but also create opportunities for experienced physical therapists to remain engaged in the profession. Such an investment in the ‘front end’ could yield improved health outcomes for patients, and greater retention of clinicians in the profession, at the ‘back end’.