Experiences of physical therapists during the COVID-19 pandemic: an interpretive phenomenological analysis

ABSTRACT

Introduction

The COVID-19 pandemic is the most fundamental challenge to the healthcare system in current generations. Physical therapists (PTs), as essential members of the healthcare team, were impacted substantially. Understanding their experiences during this unique and challenging time would help PTs manage the pandemic and future crises in healthcare. It may also reveal professional changes that may persist through the pandemic and beyond.

Purpose

To describe the experiences of PTs in the New York metropolitan area during the initial wave of the pandemic.

Methods

This was an interpretive phenomenological study. Data were collected during 8 focus groups of 2–3 PTs each in August and September 2020 via videoconference. Audio recordings of the groups were transcribed, and data were coded in 3 rounds.

Results

Twenty-two PTs from a range of settings participated. Four themes were identified: (1) Everything was disrupted; (2) It was not safe; (3) It was overwhelming; and (4) There was a professional transformation. In hospitals, participants described chaos, poor communication, and unsafe working environments. In outpatient settings, participants described job instability and challenges adapting to telehealth. As the pandemic progressed inpatient PTs felt safer, gained confidence, and became critical members of interdisciplinary care teams. Outpatient therapists adapted to telehealth and experienced rising caseloads as patients returned to therapy.

Conclusion

Physical therapists experienced a variety of challenges during the initial phases of the pandemic. As the pandemic progressed, they redefined practice.

KEYWORDS:

• Physical therapists
• coronavirus
• occupational health
• rehabilitation

Introduction

The COVID-19 virus is the most fundamental challenge to the healthcare system in generations. As of the writing of this paper, there have been over 630,000 deaths in the US and over 4.3 million deaths worldwide (Centers for Disease Control, 2020; World Health Organization, 2020). During the early phases of the COVID-19 pandemic, one of the hardest hit locations in the US was the New York metropolitan area. Hospitals, health systems, and private clinics were ill prepared and ill equipped to manage the volume and acuity of patients with COVID-19. Little was known about the virus and relatively high proportions of patients were admitted to hospitals and mechanically ventilated (Cummings et al., 2020; Petrilli et al., 2020).

The COVID-19 pandemic has continued throughout the world, and variants have added to the challenge. However, healthcare procedures and safety have improved since the initial phase, and effective vaccines are available (Harder et al., 2021; Sommerstein et al., 2020). Throughout history, pandemics that emerge in the absence of effective treatments or vaccines have resulted in chaos (Munnoli, Nabapure, and Yeshavanth, 2020). The environment in the New York metropolitan area during the Spring of 2020 was highly chaotic because so little was known about the virus at the time and because effective treatments and vaccines were not available. As essential members of the healthcare system, physical therapists (PTs) were impacted substantially by this chaos. Understanding their experiences during this unique and challenging time would be instructive to PTs more broadly as the pandemic continues. Some of the initial, adverse effects on both therapists and patients may be avoided if other PTs know what they can expect when case rates rise dramatically. These experiences may also reveal directions for the profession through the pandemic and beyond. Previous pandemics, such as polio, have had dramatic and lasting effects on the profession of physical therapy (Neumann, 2004). The purpose of this study was to describe the lived experiences of PTs in the initial wave of the COVID-19 pandemic in one of the areas where the pandemic was initially very intense. An interpretive phenomenological approach was used to understand what it was like to be a PT, in that place, at that time in history.

Methods

Study design

This was a qualitative study with an interpretive phenomenological analysis (IPA) (Cassidy, Reynolds, Naylor, and De Souza, 2011). Shaw and Connelly (2012) described a variety of phenomenological philosophies with varying degrees of overlap. The primary distinction has been between Transcendental (descriptive) and Hermeneutic (interpretive) phenomenology. In IPA, it is accepted that the researchers are not free from bias and interpret the world through their own contexts and environments (Neubauer, Witkop, and Varpio, 2019).

Sampling strategy

We recruited participants from our clinical contacts in the NY metro area via e-mail. A purposive sampling strategy was used along with snowball sampling to identify additional participants. To be included, participants had to be licensed PTs, have worked in facilities in the NY metro area at the onset of the pandemic (March 1, 2020), and their positions had to have included direct patient-care responsibilities. We sought participants from a diversity of practice settings including acute care hospital departments, inpatient rehabilitation, homecare, outpatient clinics, school systems, and skilled nursing facilities. Because the pandemic affected racial and ethnic populations differently, we attempted to ensure representation from diverse racial and ethnic groups. We did not invite PTs who worked at the same unit of a hospital or the same outpatient clinic. Sampling continued until saturation was reached.

Data collection

Data were collected during 8 focus groups of 2–3 physical therapists each (n = 22). The number of participants was chosen to allow for different experiences and settings within groups, while allowing participants time to explore and share sensitive, and in some cases, traumatic events. Focus groups were conducted in August and September 2020. None of the participants were aware of the study goals or purposes prior to recruitment.

Each group lasted between 45 to 90 minutes and was conducted via video conference (Archibald, Ambagtsheer, Casey, and Lawless, 2019). Prior to each focus group, participants were sent a brief survey to collect background and demographic information via Research Electronic Data Capture (REDCap) (Harris et al., 2009). All participants signed informed consent through the REDCap e-consent framework. The methods of this study were approved by the Institutional Review Board of Mercy College and all participants received a $100 gift card as an incentive to participate.

The focus groups were facilitated by the primary investigator who was experienced in qualitative research and focus group data collection. Questions for the focus groups were developed through discussions between the investigators after considering their perspectives and biases. Four open-ended questions were used (Table 1). A second investigator, also experienced in focus group data collection, served as facilitator and scribe. Focus group audio recordings were transcribed and checked for accuracy. All 3 investigators participated in the qualitative analysis.

Table 1. Focus group questions.

1. Describe your experiences as a physical therapist during the COVID-19 pandemic.

2. How did you feel?

3. How has this changed your perspective as a physical therapist?

4. How will the profession change?

Qualitative data analysis

The coding unit of meaning was a phrase, sentence, or group of sentences that was thought to capture the essence of something important related to the purpose of the study. We identified units of meaning independently for the first 2 round of coding. For the final round, the primary investigator identified excerpts so that all investigators could code the same units and responses could be compared.

The coding process is summarized in Appendix A. Initially we read through the transcripts and took notes to immerse ourselves in the data and we discussed our impressions. The transcripts were then coded in three rounds starting with an inductive, open coding strategy (Saldaña, 2015). In the first round, we selected units and coded the transcripts independently and developed our own initial codebooks. We then met to reach consensus on the initial codebook. In the next round, we coded the units independently again, grouping similar codes together, and collapsing, categorizing, and revising codes as needed. We then met to reach consensus and further merge codes and categories. In the final round of coding, we independently re-coded the data looking only at the excerpted units of meaning and we continued to refine and reconsider the code list. All codes and categories were then reviewed and discussed to reach a final consensus on coding. Themes were identified through additional discussions.

Strategies to improve trustworthiness

Several strategies were used to improve the trustworthiness of the analysis. Prior to recruitment, question development, and data collection, we considered our personal perspectives and bracketed our biases by discussing and documenting how they could play a role in the interpretation of the data. We used analytic memos and notes, and we maintained an audit trail. We took notes during each meeting, and we debriefed after each focus group to review the discussion and to determine if saturation had been reached. Triangulation of analysts (3 coders) provided a range of experience during interpretation. We calculated coding reliability (Krippendorff’s alpha = 0.76) to examine the consistency of our coding process (O’Connor and Joffe, 2020). Coding reliability was analyzed after the third round of coding, prior to the consensus discussion. Qualitative coding processes should allow for varied interpretations and perspectives, so reliability should not be seen as a validation of the process (O’Connor and Joffe, 2020). With 3 coders however, reliability allowed us to determine if the coding frame was developed enough for us to apply the same codes to more straightforward units and whether there were systematic differences in our interpretations. Member checking is not recommended in IPA (McConnell-Henry, Chapman, and Francis, 2011). Qualitative data were coded using Dedoose v 8 (Dedoose, Hermosa Beach, CA) and Excel for Office 365 (Microsoft Corp., Redmond, WA). Quantitative data and coding reliability were analyzed using STATA IC v 15 (StataCorp, College Station, TX, USA).

Results

Participants

Participant characteristics are summarized in Table 2. Participants practiced in a broad range of settings, and each was working as a PT at the time of the focus groups and as of March 1, 2020, at the start of the pandemic intensification.

Table 2. Participant characteristics.

Characteristic
	Mean (SD)
Age (years)	37.4 (8.5)
Experience (years)	9.2 (7.7)
Gender	N (%)
Male	6 (27%)
Female	16 (73%)
Race/Ethnicity*
White	16 (73%)
Asian	2 (9%)
Black/African American	2 (9%)
Hispanic or Latino	2 (9%)
Native American/Hawaiian	1 (5%)
Middle Eastern or North African	1 (5%)
	As of March 1, 2020 Mean (SD)	At time of Focus Group Mean (SD)
Work Hours per Week	38.9 (5.7)	38.0 (6.2)
Work Settings	N (%)	N (%)
Acute Care	9 (41%)	7 (31%)
Outpatient	7 (31%)	8 (36%)
SNF	1 (5%)	1 (5%)
Home Care	1 (5%)	1 (5%)
School System	2 (9%)	2 (9%)
Inpatient Rehabilitation	2 (9%)	3 (14%)
Effects of COVID
Reduced Hours	4 (18%)
Furloughed	3 (14%)
Changed Settings	6 (27%)
Used Telehealth	10 (45%)
Worked in non-PT Capacity	3 (14%)
Other	15 (68%)

*Participants could indicate more than one category.

Themes

We identified 4 themes that ran through the data: 1) Everything was disrupted; 2) It was not safe; 3) It was overwhelming; and 4) There was a professional transformation. Excerpts have been edited to remove filler words such as ‘um’ or ‘ah,’ and they have been edited for brevity. Gender pronouns have been changed to neutral. Excerpts are identified by focus group and participant number. Code descriptions and additional excerpts are included Appendix B.

Theme 1: everything was disrupted

The pandemic resulted in the most rapid and profound changes in the careers of the participants. In hospitals, the initial weeks were characterized by confusion and chaos:

“ … it was extremely chaotic … I felt like everyone was running around like a chicken without their head on … ” (group 2-participant 6)

Communication was inconsistent:

“The hardest part was all the changing policies … day to day, hour to hour, I would say.” (3-9)

“ … there were so many changes happening so fast that I think they even didn’t feel that it was worth communicating to the whole building. Which then, kind of made people panic.” (2-4)

Chaos resulted, in part, from the inability to determine which patients had COVID-19:

“I come in one day to a patient who is admitted who apparently was kept on the COVID unit at [another hospital] … and there was mass confusion about if this patient actually had COVID … there was no actual plan in place yet … the whole unit had that acute fear of all the sudden the virus is here and all this planning felt like it was for nothing because once that person ended up on our floor, it felt like nobody actually knew what to do.” (2-4)

Some facilities initially thought masks were only needed in specific COVID-19 rooms and units and there was little state or federal guidance available. It also was not clear if patients outside of those units had been infected:

“An email came from higher-ups saying if you are found to be wearing a mask inappropriately … it could be … disciplinary action … or get fired … it quickly became everyone wears a surgical mask at all times, whether you’re in a hallway, whether you’re in a patient’s room, or not … ” (3-9)

Another participant said a coworker was told to come to work while positive:

“ … they said in our meeting, ‘I tested positive and [human resources] told me to come to work the next day’ … and then like 15 minutes later we got an email … saying if you tested positive you have to stay home for 7 days, so there was so much conflicting information coming from our management.” (2-6)

Disruption was also evident in the struggle to accommodate the influx of patients with COVID-19. Hospitals made dramatic and rapid changes to improve capacity. New units were created, and resources were re-allocated. Some facilities converted entire units to COVID-19 only and some entire facilities were shifted to COVID-19-only care:

“So, our hospital, in a matter of like 2 weeks, expanded from about 800 beds to I think somewhere around 15 or 16 hundred beds.” (4-11)

“ … my patients on one floor having tested positive, eventually the entire hospital was patients that had tested positive. And they had opened different floors of that hospital that were previously meant for outpatient treatment, outpatient procedures, they became inpatient.” (6-16)

“they actually did major construction and turned OR’s into ICU rooms.” (4-12)

The volume of patients was not the only issue. Acuity was a factor as well:

“I think we had 160 patients that were on vents. So, that’s a lot of vents, a lot of IC units, and a lot of really sick people … it was definitely an experience … my entire day was filled for two months straight just treating COVID patients.” (4-11)

Participants in outpatient facilities experienced disruption as well. Caseloads dropped dramatically and some facilities closed. For the first time in their careers, PTs had to grapple with job instability.

“I work in [outpatient facility], and we got a last-minute notification that we were closing on March 20th, which was a Friday … and we were actually given that message probably about three days before we actually closed the office.” (2-5)

Theme 2: it was not safe

Safety was something that came up repeatedly, from all participants, in all groups. It was the most frequently coded excerpt. Initially, there was a lack of personal protective equipment (PPE), and policies were inadequate to keep PTs and patients safe:

“…actually, we didn’t have anything in the beginning because no one really knew” (7-20).

“there was just really limited resources in regard to PPE … we only got an N-95 once at the beginning of the week.” (4-11)

“ … they supplied me with a packet of masks, I think it was maybe 10 … it was the k-n95? I don’t even know … I would use it but then I realized that they weren’t replenishing it, so I said oh my god let me not throw it away … and then I had makeshift masks from friends that were making them and donating them to the hospitals. So, I had a couple of those.” (3-8)

Participants were lacking key protective equipment like gowns, masks, and face shields. In some cases, it was prioritized for other professionals:

“there was such a focus on medical stability with these patients … they didn’t feel we were necessary and there was definitely that concern of if therapy isn’t necessary, don’t waste the PPE with the therapists, make sure it was going to the doctors and the nursing staff and the aides.” (2-4)

Some hospitals, however, either were effective from the beginning, or they improved quickly..

“ … we had infectious disease involved from the start. We had a lot of support. I think our hospital did an incredible job at making sure we had the PPE … ” (7-20)

Even when PPE was adequate, the participants reported being too scared to take their masks off. One homecare PT described working all day without touching the mask:

“I would always have my N-95 mask on at the beginning of the day. I sealed it up, pinched it tight, and I didn’t touch it until I finished. I didn’t drink any water, I didn’t eat any food.” (3-7)

Participants from outpatient settings had their own issues with safety. Clinics faced challenges establishing protocols, determining if it was safe to return, and figuring out staffing and distancing. One participant described reluctance by patients to wear masks:

“I found it challenging in enforcing … the mask rule. There were patients who would come in who would not want to wear a mask.” (2-5)

Safety precautions were inadequate to protect PTs. Participants described colleagues who got sick or told us that they contracted the virus themselves:

“ … we had 10 of our therapists catch the virus.” (2-6)

“ … we called ourselves the magnificent 8 when everybody got sick. So, I understand. Even I got sick … ” (8-22)

Some participants tested positive for antibodies but were never symptomatic:

“ … personally, I didn’t have any symptoms, but I did test positive for antibodies … ” (4-11)

Some cases, however, were more severe:

“ … I think 5 of my department staff got COVID … one of which almost lost their life, and it was that part that was really devastating for me.” (8-21)

The same participant recalled an especially traumatic experience with another colleague:

“And then I went to the next room and then I was shocked because it was one of my coworkers that I didn’t know was admitted … they said, ‘I’m so afraid I’m gonna die.’ I said ‘no - don’t say that’ … [my colleague] died after three days.” (8-21)

Theme 3: it was overwhelming

The participants described their emotional responses to the pandemic in detail. In some cases, the responses were extreme. The most frequent emotion was fear:

“Walking into a positive COVID room for the first time … felt like being thrown into a lion’s cage and waiting to see if you’re gonna be eaten or not.” (7-18)

This resulted, in part, from little being know about COVID at the time:

“ … it was scary in the sense that it was so much unknown … ” (8-22)

Participants were not only scared for their own safety, but they feared passing the disease on to partners and family members:

“I was like [expletive] I can bring this home and my husband can die. It was surreal.” (8-21)

Participants described difficulty processing everything that was going on around them, and described heightened anxiety, stress, and/or sadness:

“I was having a hard time sleeping … ” (3-9)

“I cried many days driving home.” (8-22)

This was exacerbated by conditions outside of work:

“ ….you couldn’t go see your friends … I didn’t see my family for about 6 months.” (6-16)

Part of being overwhelmed was related to emotions around death and dying. As PTs, the participants had not experienced high rates of mortality at work. With the pandemic however, this changed dramatically:

“ … They were calling codes after codes. It was like a warzone.” (8-21)

“ … I wasn’t used to seeing my patients die … every day you were checking to see how many of your patients had passed away and it was just a very depressing feeling.” (5-13)

Theme 4: there was a professional transformation

The focus groups revealed a pattern of transformation. After an initial period characterized by disruption, emotions, and safety concerns, they described a transformational process. The participants created new clinical paradigms to work with patients with COVID-19. Initially little was known about the disease, so they had to ‘learn on the fly’ and search for intervention strategies. They eventually figured out how to work effectively:

“ … my brain was going in different directions and any spare minute I had trying to educate myself … learn whatever I could” (4-12)

Previous clinical decision making based on vital signs such as oxygen saturation was different for patients with COVID-19..

“you’d be in a room with 4 patients … all on high flow and now all de-sating to … video game numbers … ” (6-16)

Guidance was lacking so the participants described doing whatever they could to learn.

“ … you feel like you’re on your own because you aren’t quite sure if you’re doing the right thing and it was hard to get really confident answers … you were just hoping whoever you talked to gave you the right information and you went in and you treated … ” (2-4)

Part of the transformation related to changes in job tasks and responsibilities. Some PTs were redeployed (fully or partially):

“ … we had therapists that had come from the outpatient site to come help us on acute care … ” (3-9)

“And then the PACU became our step-down unit. So, I got redeployed 3 days a week because I had critical care experience … so I went up to help lead the … the COVID critical care team.” (4-12)

Participants described having to perform in different capacities as a PT or being asked to perform non-traditional tasks. One of the more extreme examples included a PT who was reassigned to the morgue:

“So, the hospital wound up renting refrigerator trailers … my team with two other therapists who were normally outpatient therapists at [hospital] … we had to go through the WHO guidelines on how to stack people appropriately and respectfully, how to transport them optimally without PTs getting injured.” (5-15)

One specific transformation was the development of ‘prone teams.’ These were groups of PTs who were responsible for transferring ventilated patients to a prone position and then back again. The patients and procedures were complex:

“ … we’ve proned patients that were 400 pounds, 500 pounds … you gotta watch your body mechanics and you gotta do well because you only get one shot at this and if you pull something out, you could literally just really kill them.” (4-11).

Initially the sessions took a long time, but efficiency increased:

“ … in the beginning, the proning sessions took about an hour … we got it down to like 15 to 20 minutes.” (2-6)

And PTs took on a leadership role in terms of the process:

“ … we were the most consistent members of the proning team, and they really looked to us to lead them.” (5-13)

The transformation also involved increased interprofessional collaboration. Some participants recalled helping nurses:

“ … we definitely took on a ton of new roles just to help out nursing. Nursing was completely overrun.” (4-11)

There was a wide range of collaboration:

“I had an opportunity to work with a lot of people that I wouldn’t have been able to have the opportunity of working with, had it not been a pandemic. I was working side by side with people from dietary, people from cancer center, people from security, wound care center, pediatrics.” (8-21)

These changes were lasting:

“ … we don’t have any COVID patients in the hospital right now … there’s still a much better rapport and dynamic with the doctors … ” (2-4)

As transformation occurred, participants described a heightened sense of professional identity and pride:

“I think when a lot of people go to school for therapy, it’s because they know they wanna help people … but I don’t think anyone really pictured it on a level of an essential worker … in reality, when the lever met the load, we were, and we are. So, I think that’s something people can take pride in.” (6-16)

Reflecting on the full experience, one participant said:

“ … I think it’s like a badge of honor. I went through COVID-19. In an acute care hospital.” (8-21)

Another commented:

“I think it made me have a greater appreciation for our profession because I felt like we were able to be a little more versatile.” (5-13)

For participants in outpatient settings and school systems, the major transformation was telehealth. The change was abrupt and there were initial challenges:

“ … the front desk people, they were very, very hectic trying to get all the patients to convert them to telehealth and explaining to them how that was working.” (3-8)

“I find myself sometimes working till midnight, 1 am, sending emails out figuring stuff out, trying to get everyone on board and figuring out … how I was gonna do this via the internet?” (7-19)

After adapting to telehealth however, participants reported some success. A pediatric PT noted:

“I don’t think I’ve ever been this creative in my entire life. I think it made me a better therapist … ” (6-17)

Participants who discussed telehealth were optimistic about the future of telehealth in physical therapy..

“ … it’s definitely gonna be here to stay … it’s not only with patients when they discharge home and we can’t be in contact with them, I think it’s gonna open a whole new chapter in regard to therapy in general.” (4-11)

Another change occurred in outpatient facilities. Several participants noted that because of reduced capacity, they were seeing fewer patients and spending more time with each patient.

“ … in my facility we’re not seeing patients every fifteen minutes the way that we were pre-pandemic. I’m kind of enjoying being in the outpatient setting now I feel like I’m … able to work one on one with patients for forty-five minutes … ” (3-9)

The transformations that resulted from the pandemic shifted their views of the profession and its potential role in public health:

“ … some of the main comorbidities that exacerbated people’s conditions with this virus with you know hypertension, obesity, and hopefully we can develop prevention or mediation programs.” (6-16)

Another advocated for broadening our outlook:

“I’ve long held a belief that we need to have more of a public health perspective to help advance PT.” (5-14)

Discussion

The impacts of the initial phase of the COVID-19 pandemic on PTs were profound. Participants experienced disruption, they were scared, and they were anxious. Safety was a major concern, and PPE and safety procedures were lacking. In hospitals, there were no protocols for COVID-19 rehabilitation. Previous norms related to perceived exertion, blood oxygen saturation, and heart rate no longer applied. Though gaps remain, guidance has evolved and improved (Candan, Elibol, and Abdullahi, 2020; Felten-Barentsz et al., 2020; Wang et al., 2020). At the time however, there was little. These conditions led to anxiety and feelings of being overwhelmed. These feelings were not unique to PTs. Other professionals such as physicians, nurses, and respiratory therapists have all confronted high levels of danger, stress, and anxiety (Bennett et al., 2020; Salari et al., 2020).

Palacios-Ceña et al. (2020) performed a qualitative study of the emotional experiences of PTs in rehabilitation departments in Madrid hospitals during first COVID-19 outbreak in Spain. The participants reported a range of intense positive and negative emotional experiences. They experienced conflicted feelings because the profession grew into new opportunities, but these occurred at a time of immense suffering. There were similar emotional responses from hospital-based PTs in our focus groups, but the experiences varied depending on the environment. Not all hospitals faced the same challenges. Some had access to greater resources and what appeared to be better planning, safety, and communication.

In a national survey of PTs conducted by the American Physical Therapy Association (2020), the majority of respondents (85%) reported access to adequate PPE. These findings contrast with the experiences described in the current study and highlight the unique circumstances of the very earliest phases of the pandemic. Most regions did not experience a surge in patients at a time when they were least prepared.

The participants who worked in outpatient settings also had problems with safety, but they also described challenges such as job instability and the adaptation to telehealth. Similar findings were noted by the American Physical Therapy Association (2020) survey. Other settings, such as skilled nursing faced their own unique challenges. A lack of safety and adequate PPE have been documented in SNFs, and the experiences described in the current study were consistent with what has been reported (Gibson and Greene, 2020). To prepare PTs for the ongoing pandemic and for future challenges, one size will not fit all, and different measures will be needed in different environments and health systems.

What came across in all settings and groups was the need for flexibility and adaptability. Initially there was confusion about the role of physical therapy during an acute pandemic. As they established roles for PT in COVID-19 rehabilitation, the participants engaged in clinical decision-making processes that were much more complex and urgent than what they had been trained for. But the participants rapidly adjusted, gained confidence, and initiated change. They also collaborated more often, and more effectively with other disciplines. This process led to a growing sense of pride and accomplishment and a reconsideration of professional roles. The American Physical Therapy Association (2020) survey also noted some increases in professional pride.

Training for complex clinical decision making, in crisis situations, would help to prepare PTs to manage future crises and may encourage the flexibility that is needed to thrive in situations like COVID-19. Some of the strategies described by participants such as prone teams were only possible with much higher levels of collaboration between disciplines such as nursing and medicine. In some cases, participants described performing tasks that were normally performed by other professionals. The emphasis on interprofessional experiences (IPE) in PT education has increased, but an even greater focus may be needed considering the demands of the current and future pandemics. Research indicates that IPE can improve attitudes toward collaboration, teamwork, and other healthcare disciplines (Dyess et al., 2019). Experiences based on care of patients during a pandemic would be ideal for IPE moving forward.

Another shift in training may occur around public health. The pandemic prompted the participants to reconsider the role of physical therapy in public health. They witnessed the impact of comorbidities on mortality, and they wondered if their profession could play a role in prevention of some of the most important comorbidities such as obesity and hypertension. Dean et al. (2020) suggested that PTs could play a larger role in the mitigation of non-communicable diseases such as type 2 diabetes mellitus, atherosclerosis, hypertension, and obesity through noninvasive means with a focus on patient education. Improved management of these conditions could reduce susceptibility to the acute and chronic effects of COVID-19 while improving public health more broadly. This broader, community-based focus and the clinical reasoning process necessary to support it, have received attention in recent years, and the pandemic may accelerate efforts in these areas. To make progress in public health however, the profession will need to develop a clinical reasoning process to support community-based care (Edwards and Richardson, 2008). Further, entry-level physical therapist educational curricula will have to include competencies related to health promotion and the prevention of non-communicable diseases (Dean et al., 2019).

Telehealth was a transformation that is likely to outlast the pandemic. The lack of experience led to initial challenges, but the impressions were eventually positive. Much of the research on telehealth in physical therapy occurred prior to the pandemic with favorable impressions noted (Cottrell and Russell, 2020). Patients have reported high levels of satisfaction with telehealth during the pandemic as well (Tenforde et al., 2020). The focus on telehealth has been heightened by the pandemic and it is likely to continue but the transformation to digital health offers both opportunities and challenges. Lee (2020) described recommendations from an international task force on digital physical therapist practice. The report highlighted the potential for digital practice to improve access, but also highlighted a broad variety of requirements that would ensure safe, effective, and accessible services. The move toward digital practice should be considered within the larger context of healthcare. Digital services, such as triage screening, clinical visits, home monitoring, and remote mental healthcare have all increased because of the pandemic (Jazieh and Kozlakidis, 2020).

Limitations

The participants volunteered for this study and as such, may have had extreme experiences either positive or negative. The results may not be transferrable to PTs in the NY metropolitan area, or other PTs worldwide during the pandemic. We recommend larger, quantitative studies to examine the full range of experiences related to COVID-19 in physical therapy.

Conclusion

The purpose of this study was to describe the lived experiences of PTs who worked through the initial wave of the COVID-19 pandemic in an area where it was very intense. For PTs, the initial phases of the pandemic were characterized by fear, danger, confusion, and chaos. As the crisis progressed, they adapted and transformed practice to meet the demands of the pandemic. Physical therapists in hospitals became essential members of multi-disciplinary critical care teams, and PTs in school systems and outpatient settings adapted to new technologies to provide care. Larger, quantitative studies would help to determine whether these changes have persisted. The participants also described a range of effects on their emotional and professional well-being. Longitudinal studies would help to determine the long-term impact of the pandemic on the profession.

Acknowledgments

The authors thank Nicole O’Brien SPT and Laurilyn Gelardi SPT for their help with focus group transcription.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Mercy College [Faculty Development Grant].

Appendix A.

Coding process

Appendix B.

Code descriptions

Theme 1: Everything was Disrupted

Confusion and chaos

The early days of the pandemic were characterized by confusion and chaos. Communication was contradictory, not clear, or lacking altogether. Initially it was hard to determine who had COVID-19 and who did not. This created problems for front-line staff.

“I come in one day to a patient who is admitted who apparently was kept on the COVID unit at [another hospital] … there was mass confusion about if this patient actually had COVID, or just happened to be coming from that unit and there was no actual plan in place yet … it felt like nobody actually knew what to do.” (group 2, participant 4).

“We ended up bringing in someone from the military … he would like walk up and down the unit … he would literally say like be motivated by fear not panic. Do not panic.” (group 4, participant 12).

“I remember being in a room with a resident and she’s hacking away, and at this point were still weren’t wearing a mask. And I’m feeding her, and I said to the speech therapist … listen, I think you need to do a swallow eval on her, not even knowing that she was sick. And she was one of the first … to pass away. And I’m like how many of the staff went in that room and fed that patient? (group 8, participant 22)

Capacity

In hospitals, there was a desperate effort to accommodate the influx of COVID-19. Facilities either created separate units or converted completely to COVID-19 care. In outpatient facilities, capacity was greatly reduced, and participants had to determine a triage process to see patients that really needed in-person therapy.

“at first there was a lot of fear amongst staff about who should be coming in and who shouldn’t … we made a decision to restrict patients only to those we deemed critical, meaning if they didn’t get care, they would suffer some form of long-term infirmity.” (group 1, participant 1).

“I would hear conversations like … ’we only have one high flow machine right now. There’s an 87- year-old woman who is sating at 76 versus this man who needs it, he’s 45 years old and he’s sating at the same time and the doctors will have to make a decision.’” (group 8, participant 21)

“ … we got hit pretty early and when it came it hit really fast.” (group 4, participant 11)

Furloughs, layoffs, and job security

Participants experienced furloughs, losing jobs or cuts in salary or hours. Not all instances were involuntary. Some clinics closed completely. Participants also described colleagues who volunteered for furloughs or stopped working deliberately. References to job security (both positive and negative) were also noted in the groups. This was more of an issue in outpatient settings. Some participants from inpatient settings felt fortunate to be working while others were losing their jobs.

“the homecare census went way down, so we got two days’ notice that all the fee for service therapists had to hand over our caseload to the staff therapists.” (group 3, participant 7)

“ … we were furloughed … because we just had a significant drop off in patients coming in, and at the time, telehealth was still up in the air. So, we were all furloughed mid-March.” (group 5, participant 14)

“ … the outpatient setting was completely shut down.” (group 2, participant 4)

Theme 2: It was not safe

PPE and policies

Personal protective equipment and safety policies were the most cited issues, particularly for hospitals and skilled nursing. For most participants, PPE was initially lacking and there were few policies governing its use. Eventually, most facilities secured enough PPE for staff to work safely. Therapists who used PPE struggled to adjust to it in some cases and reported not wanting to touch their masks for the full workday. In outpatient facilities, there were issues related to cleaning, distance, and how many patients could be safely accommodated.

“We had a little issue with the PPE in the beginning where we did re-wear our masks, even our surgical masks we had to re-wear for a week. But then all of the sudden it was, we could go in pretty much every day, and get the PPE we needed.” (group 3, participant 7)

“we didn’t want to have our masks off for that amount of time eating … so we would just work through the day and go home and eat when we got home” (group 2, participant 4)

“I found it very difficult … working alone in a clinic and trying to maintain cleanliness and six feet apart … making people wait in the cars and call, just the whole thing that all the doctors are going through. I find it challenging in the outpatient setting to provide the level of care that you strive to provide while adhering to some of these guidelines … ” (group 2, participant 5)

Therapists with COVID

Some of the participants (or their colleagues) contracted COVID-19. Severity levels varied widely. The descriptions ranged from cases that were asymptomatic to cases that were fatal.

“unfortunately … the clinicians within our clinic, a few of them tested positive, luckily everybody was okay. I think that just heightened everybody else’s sense that knowing that somebody that they interacted with maybe a few days ago, tested positive, and that added to their anxiety.” (group 1, participant 2)

“in the beginning I wasn’t frightened at all … I felt like its being a little blown out of proportion … it’s going to be like the Swine Flu … and then as I started seeing more and more incidents of people getting sick, and then of course when I contracted it myself, I was like ‘wow this is really much more serious than we believe’ … then returning back from all of that, very grateful to be okay that I could return to work. (group 2, participant 5)

“I did test positive for antibodies. I never got the COVID test because I never was symptomatic.” (group 3, participant 9)

Theme 3: It was overwhelming

Fear of COVID

Fear was the most frequently described emotion. Most of the participants feared contracting the disease though there were a few that felt relatively safe, even in the early phases. Some participants described a progression from extreme fear to growing confidence and security.

“Everybody was truly so scared, but we just tried to do everything we could to be safe, even when we didn’t know what the heck it even was … ” (group 4, participant 10)

My first experience, it was scary. It was at a point where I didn’t even know if I wanted to go to work.” (group 8, participant 21)

“that first eval … that real panic of, this might be someone with this virus … it hit you a lot harder than you thought it would. But … almost like jumping in the pool … after you get passed that one person, and you try and do everything the right way, the acute fear I think left us … but it was exhausting … ” (group 2, participant 4)

I Didn’t Want to Bring this Home

Another source of fear was the potential to spread COVID-19 to family members, partners, and friends.

“I live with my parents … I was scared I was gonna get it, but I can probably fight it … but my parents … ” (group 4, participant 10)

“and that’s when it kind of hit me, I’m like ‘oh man, um, what about my health?’ I immediately texted my wife and said ‘I’m going to set up a bed in the other room and don’t touch me, don’t come near me cause if I’m symptomatic and I bring it home to you, … I can’t, I won’t be able to forgive myself.’” (group 5, participant 15)

And even then, I would come home and still take a shower and change my clothes because there was always a fear that something could be on my clothes … I could give it to my kids … I could give it to the rest of my family members. (group 7, participant 18)

Anxiety, Stress, and Sadness

Participants described feeling anxious, stressed, or being overwhelmed. Some of these feelings resulted from having so many patients who were so acute.

“ … a lot of times I guess it was just my anxiety. I was going to bed at night, and I would just feel like I couldn’t breathe … I’d come home, and I would still hear the beeping of all the machines … ” (group 5, participant 13)

“Especially when you’re treating … intubated patients … you’re dealing with exactly what they tell you to stay away from and you’re spending 45 minutes plus in a room with that, so definitely a lot of tears. There was definitely a lot of stress.” (group 7, participant 20)

“my entire day was filled for two months straight just treating COVID patients … it was stressful, a lot of tears, a lot of hugs and … we worked through it together.” (group 4, participant 11)

Compassion and Empathy

Compassion and empathy were reactions to patient suffering. The participants reported doing what they could to help patients who were in difficult situations. Some patients, for example, did not come to the hospital with a phone charger and were unable to contact their families.

“ … I think part of what got me through those times was a lot of the patients were so thankful to just have somebody face to face to talk to.” (group 4, participant 10)

“ … and there’s this gentleman 97 years old and he has COVID and he was DNR and DNI so I was expecting somebody who’s almost dead … he was alert, oriented, and he said “I’m just really hungry.” So, I fed him … I said you know what, if, if I didn’t work today, that man wouldn’t have eaten … because we don’t have any CNAs to feed him.” (group 8, participant 21)

“So, we called from my cell phone, she was finally able to talk to her son for like 20 minutes … I stayed in the room the whole time.” (group 4, participant 11)

Death and Dying

The pandemic resulted in much higher levels of mortality than participants were used to. They had to adjust to having so many patients who died. These excerpts describe the related emotions.

“it was just depressing and sad everyday … we had 30-year-old guys and they would have pictures of their 2-month-old infants on the hospital door ….it was just so depressing every single day … we had, in total, proned 30 people and 20 of them died so it was just so depressing … and sad.” (group 2, participant 6)

“hearing all the codes that were going on, and how many people were dying during your shift, and feeling almost helpless.” (group 3, participant 9)

“ … these therapists who have never experienced like death at work or these like scary diagnosis’s that they don’t really understand … how to help them cope, and to keep coming back to work, honestly.” (group 7, participant 20)

Theme 4: There was a professional transformation

A New Clinical Paradigm

Working with patients with COVID-19 required a new clinical paradigm. Without any guidance, therapists attempted to ‘learn on the fly.’ These patients were much more acute and at much higher risk of death that the participants were used to. Clinical reasoning related to exertion and vital signs was reconsidered. Participants also described working with patients who had recovered from COVID-19 but who were still struggling.

“You try to get them bed to chair and just see what kind of plummet the O2 would take and then talk to the respiratory therapist about how to adjust oxygen, talk to care teams, try to get up to date stuff.” (group 5, participant 15)

“we weren’t really used to working with vent patients … so we were watching [internet] videos and trying to learn as much as we could to like keep ourselves like safe working with these patients.” (group 2, participant 6)

“It was an eye opener, as far as for physical therapists, because we tend to push them along … But you really couldn’t do that … with this population … there were not any textbook symptoms … the main thing was deconditioning. A lot of them lost a lot of weight, so walking ten feet was a big deal.” (group 3, participant 7)

Collaboration and Teamwork

The participants described an expanded role working within the healthcare team. This included higher degrees of inter-professional collaboration. Participants noted instances of PTs volunteering to work with patients with COVID-19 when they did not have to. Most discussions were positive. However, there were a few descriptions of coworkers who refused to work with patients with COVID-19 or who stopped working altogether during the pandemic.

“ … they asked for volunteers … Overwhelming, I think I would say like 70% or 80% of the department said that they would go ahead and treat those patients.” (group 6, participant 16)

“I’m doing the screening and I said to myself, no you know what this is a nursing job, why am I doing this? No, you’re doing this because you’re part of management … So the staff could feel comfortable.” (group 8, participant 21)

“ … I actually have a set of skills that could be used to like help people during this … that was like really my motivation to go up and like start working on the units. I know I could help my colleagues who are like some of my closest friends.” (group 4, participant 12)

Redeployment and Workload

Physical therapists were re-assigned or moved within their facilities. In some cases, PTs performed non-traditional job tasks to assist nursing and other providers. Examples included working as a screener or arranging bodies in morgue. The workload also changed for some of the participants and required longer days.

“I never really thought like during my career as a physical therapist that I will be bringing bodies to the morgue.” (group 8, participant 21)

“I was like a high paid intern, wipe down the nurses’ station, and just help out any way I can. But I didn’t, at that point, have to treat directly … I didn’t go into the rooms, and I really liked it. It, it was a really cool job … ” (group 3, participant 7)

“We’re all in acute care and we weren’t getting any orders they were redeploying all of our therapists who were older who didn’t wanna be around COVID” (group 2, participant 6)

The Prone Team

In hospitals, teams of therapists would be responsible for transferring patients on mechanical ventilation prone and then back to supine every day. This was a new experience for everyone involved. Protocols and procedures had to be developed.

“The patients that we were working with proning … they were the sickest patients … in the world … they were so young, and the people we were proning were younger because they had the greatest chance of surviving.” (group 2, participant 6)

“I was in a smaller group, that was chosen to be a part of the proning team, so we weren’t treating patients on the acute care floors, like most other physical therapists would be doing … we were basically called to the different ICUs that they had set up, and had to prone, the patients that they had identified … in the morning, we returned all the patients to supine and then the afternoon was spent putting them back in prone because they had to stay in prone for 16–18 hours. (group 5, participant 13)

“ … me and a few therapists were identified for the ICU for proning and mobility and moving intubated patients … we would come in, get the lists of who needs to be seen, determine who was appropriate … based on an algorithm we came up.” (group 7, participant 20)

Telehealth

There were discussions of telehealth by participants in outpatient clinics and the school system. These included the adaptation process, and the challenges and benefits of telehealth. For most, the process was challenging initially, but ultimately rewarding.

“I mentioned just my creativity level just it just allowed me to continue to self-educate and learn more because there’s just so much more that’s in there that you know sometimes, I feel like if I wasn’t pushed to this level … I don’t know if I would be able to pull so many things and realize that oh my God, you’re so creative.” (group 6, participant 17)

“I guess initially, chaotic. Trying to learn new media and a new way to um perform therapy via teletherapy … and getting the parents on board … yeah, chaotic initially.” (group 7, participant 19)

“I think it’s difficult for post-op rotator cuff repairs to have telehealth when they are passive motion, and you can’t get your hands on them.” (2–5)

Pride and Value

Participants indicated they were proud to be physical therapists. There were descriptions of increased stature and greater perceptions of the value of physical therapy by other healthcare providers and the public.

“we really … took a lot more initiative in that setting as opposed to just being one small part of a very large team.” (group 2, participant 4)

“I’m glad I chose this, and I wouldn’t … I wouldn’t change it, not even for a minute.” (group 8, participant 22)

“I love working in the hospital, so I feel like even still after this I won’t change.” (group 2, participant 6)

Leadership

Some of the participants had supervisory positions. They discussed the challenges and stress of having to lead during the crisis. They referred to both positive and negative aspects of their administrative roles and performance.

“I think that’s where you know, I felt a lot of responsibility as a leader to, to make sure that I was calm, cool, and collected to … communicate the information that we had, and our plans … sometimes it was received well, and sometimes it was not.” (group 1, participant 2)

“ … then it’s just kind of rallying the troops. I had to put my, my fears aside and just try to get everyone through it. We added in a morning huddle … where we talked about the changing policies or … the changes that had happened in the last 12 hours, the last 8 hours, the last 24 hours, and make sure that everybody’s on the same page.” (group 3, participant 9)

“So, I felt really the burden of responsibility for my therapists and for my patients … ” (group, 1 participant 1)

Public Health

The pandemic caused some participants to reconsider the role of physical therapy in public health. They felt that PTs could have a broader role in prevention and dealing with diseases that were major co-morbidities for patients with COVID-19.

“the comorbidities that people had, taking a more fine approach for preventative and prophylactic purposes and I think that we’re gonna be dealing with a lot of the complications after the fact of the survivors.” (group 5, participant 15)

“ … unfortunately, it seems like what were some of the main comorbidities that exacerbated people’s conditions with this virus … hypertension, obesity, and hopefully we can develop prevention programs, or mediation programs where we kind of stop things … ” (group 6, participant 16)

“ … obviously we have our specific role and that’s really important to keep in mind, but I think that this should kind of show the profession that we need to be a little more broad-minded, and maybe look outside our little circle … once we’re out in the community, looking to how we can and manage overall health, like general health and wellness, so I think just kind of taking a broader look at our role in public health.” (group 5, participant 14)

Quality of Care

Participants in some of the outpatient clinics discussed their caseloads which were coming back to normal, but still lower than pre-pandemic levels at the time of the focus groups. They felt the quality of care improved as they spent more time with patients. They hoped the trend would continue beyond the pandemic.

“I like this system’s pace, and I feel like my care is better. I feel like from the billing standpoint, yes now I can bill these 4 units to maximize what I’m doing with this patient to try to keep the revenue coming in at a volume … at a point that will support the office still. I’d like to see that continue.” (group 2, participant 5)

“In the outpatient setting where you’re one of four in the gym at the same time, you know, or, maybe it should force the profession to give a little bit more quality over quantity for now, but we’ll see.” (group 3, participant 9)

“We were doing 15-minute slots before. And we actually me and my co-workers were looking at the numbers … with the 15-minute slots, no one was billing as much because they weren’t spending the time with the patients. Whereas now they’re billing for the full 45 minutes because they’re spending the full 45 minutes with the patients.” (group 2, participant 6)

Abbreviations used in excerpts:

CNA: Certified nursing assistant, DNI: Do not intubate, DNR: Do not resuscitate, ICU: Intensive care unit, IPE: inter-professional education, PACU: Post-anesthesia care unit, PPE: Personal protective equipment, WHO: World Health Organization.