Working as a physiotherapist in a rapid response team: ‘An emotional rollercoaster’

Figures & data

Table 1. Participant characteristics.

Characteristic	Age	Gender	Years qualified	Years of experience in RRT	Additional training
Participant
1	36	Male	14	5	Masters degree
2	35	Male	12	4	Masters degree
3	36	Male	12	4	Masters degree
4	42	Male	13	5	Masters degree
5	44	Female	9	3	Master-level module
6	48	Male	25	5	Masters degree

Table 2. Steps of the phenomenographic analysis (Larsson and Holmström, 2007).

1. Read and re-read each transcript to get a sense of the whole.

2. Divide text into meaning units (‘fragments’ of the text containing a meaning).

3. Look for ‘what’ the focus of the participants attention is on and ‘how’ they describe it.

4. Group descriptions into categories based on similarities and differences.

5. Assign a metaphor to emergent categories of description.

6. Develop and find a structure in the outcome space.

7. Identify ‘non-dominant’ ways of understanding.

Figure 1. The outcome space.

Table 3. Descriptive categories.

	Descriptive category (metaphor) of working in a rapid response team
	An emotional roller coaster
Varying perceptions of working in a rapid response team	The Detective	The Guru	The Lone Ranger	The Team Player	The Bricoleur

Table A1. Data analysis example from participant 2. Exploring what was the focus of their attention and how they described it (analysis steps 2 and 3).

Transcript	What was the focus of attention	How he/she described their understanding	Category of description
I: So, can you tell me a little bit about your experience as a physiotherapist working in a rapid response team and what that means to you?
P2: Well. err, I have been working in the rapid response team for the last four years, our team is called ‘xxx,’ we are integrated professionals, we have physio’s, doctors, nurses, GPs, healthcare workers, a handy man. It is like, you know, our integrated team is a whole, we support a lot of patients, right from the complex patient and we do support patients from hospital as an early supported discharge patient we will facilitate their functioning such as their ability to achieve baseline goals. We do support the patient from the community to try and prevent any hospital admissions. We support GPs, erm, early discharges, any rapid responses. We do also support the London Ambulance Service to avoid any hospital admissions, where the patient can be treated at home with the support of different multi-professionals.	Background to his time with the team Focuses on that they are integrated (integrated MDT) Describes the makeup of the team members Focuses on the types of patients seen Focuses on the remit of the team ‘supporting discharged patients … and preventing admissions' Focuses on RRs and working with the LAS The environment where the patient care is – the home Supported by the MDT	Considers the team to be a team of integrated professionals (MDT members) A joined-up team? Perceives the team to treat and care for complex patients Role and remit referred to Describes the remit of the team, the understanding of the care pathways and aims of the team Other services are also worked with – close working with LAS The team prevents admissions	MDT working – working in a team Complex cases Role/remit
I: OK
P2: It has been great working with different people learning and sharing all the knowledge with all inter disciplines, a really positive experience.	A positive experience working with various people	This way of working is about sharing knowledge	Knowledge (teaching and learning from others?)
I: OK so maybe we could touch on that. So, as a physiotherapist what’s your experience of working with those different professionals?
P2: It, erm, I have been quite amazed, a real opportunity, liaising with GPs, knowing erm learning the medical stuff, working with the nurses, knowing more about learning more about wound care and pressure care and working with occupational professionals, health professionals, to know more about wash and dress, functional independence, different equipment, erm, as a, being a physiotherapist, we share our knowledge on this team, share with other professionals, teach others about our own clinical knowledge, such as healing and repair of tissue for example, so it has been, erm a great erm, err, I’d say it has very knowledge sharing this job	Feelings focused on Focuses on the other professionals worked with and the knowledge gained	Amazed at this experience/ an opportunity to work with various MDT members Describes new knowledge and skill that has been learnt, describes what has been learnt LEARNING from others EDUCATION Also sharing knowledge in this role	Emotions – opportunity New skills Knowledge and learning Education and sharing
I: Can you give me a clinical case example of perhaps who you might see, as a physiotherapist working in this team?
P2: Oh yeah, erm so examples, we see patients who have got admitted to hospital with poor mobility, urinary tract infection, chest infections, any surgical patients, a patient that has been in ITU, HDU, neuro patients, ortho patients, a different diagnosis, for example where the patient needs facilitation of therapy input when they are going to be discharged home, say for example if patient has fallen and fractured NOF, which is neck of femur fracture when the hospital can only provide a certain number of erm days service and that patient is discharged home and being a physio you go there and assess the patient, the transfers, mobility and gradually and progress this patient, you may give them a different walking aid and try and maximize the patients environment and requirements to get them back to baseline, erm, … . NOF, for example total knee, total knee replacements, hip replacements, any issues with the mobility like following urinary tract infections, leg injuries, cellulitis erm any other various medical condition where the patient needs an intervention and physio plays a major role.	Focuses on the types of patients that are seen in the team Wide range of clinical cases seen Experience and knowledge is illustrated in these example What the physio in the team does Refers to case examples and what physio role may be in these cases Knowledge also illustrated	Way of working: sees a variety of cases The team will see a wide spectrum of clinical cases Specifically talks about how/ when therapy (physio) may be needed Wide range of experience and knowledge illustrated Scenarios given of when physiotherapy may be needed for a patient who has bene discharged The way of working is discussed: physio specific skills shown – what the physio does Physio will make: Problem lists Interventions/ treatment and GOALS Issues: problem lists Considers physiotherapy to be key in helping with a wide range of patients Physio plays a major role	Multiple and new knowledge needed BUT Still an expert as a physio Core physio skills Problem list (part of being a detective?) Working out the solution, detective work?
I: Thanks very much. So, my next question is erm, about the term rapid response, erm, what does rapid response mean to you?
P2: Well, acting asap, as soon as possible to attend the patient needs, where erm, the patient can be treated at home, rather than sending them to hospital, like err, sort of a rapid, you got an interdisciplinary team where you can straight away you can act, hmm, rapid, where you can, they are a priority where you can see the patient within 2 hours or 4 hours, where you can assess the patient and do next day observations and analyze the situation and see if you feel that the patient is safe to be treated at home, that can facilitate the patient at home rather than sending them back to the hospital you know, that is why we are rapid, where you see the patient asap within a two hour slot.	Explains/ focuses on the RR meaning Seeing the patient immediately Time frame of response What is undertaken is responding to a RR	Explains/ describes the understanding of RR So, speed is referred to, to attend to their needs (Person centered) A rapid interdisciplinary team Being able to act/respond straightaway (immediately) Prioritizing the patient Describes the process of seeing the patient quickly and what happens Time frame Assessment, analyzing, monitoring etc Decision making if the patient can stay at home or not Rapid: seeing the patient within 2 hours	Rapid response understanding/meaning- speed and urgency Rapid response is team work Using expert clinical skill Team work and autonomy
I: That’s great thank you. So, as a physiotherapist in a rapid response team, could you give me a specific clinical case example that you have recently been involved in, which has been a rapid response. Can you tell me what was that experience like and what you did?
P2: Erm, well recently we saw a patient, elderly day, 90 years old, not drinking or eating, very drowsy, difficulty standing up. and, we got a call from the GP asking the patient, because she lives in a care home and the carers are not able to cope any more, and they are literally struggling with manual handling and they’re more worried in terms of her general health, and we got a call from the GP asking that an urgent intervention is needed, in terms of both nursing and physio-wise, me and my colleagues went in, we took the observations, where patient observations, err, not up to the mark, her blood pressure was very high, and temperature, there could be an underlying infection that was going on, and we did check the urine, urine dip, all the ketones and nitrates and we did not notice an underlying infection, but the patient was presenting with symptoms like confusion and drowsiness, unable to stand and she was literally off the legs, so we had to send her into the hospital for further investigations to see what exactly the underlying illness turned out to be, she was not able to cope.	Provides an example of a case and the details Gives the issue Referrals come from GPs and response needs to be urgent Details of clinical skills undertaken Clinical assessment and reasoning and knowledge Outcome and result – the team could not keep them at home as further tests needed	Detailed knowledge of case is given An example of referral pathways in the team and types of patients seen Urgent response provided An example of joint professional working Clinical skills illustrated but also explanation of thinking, so clinical reasoning Detective? Differential diagnosing examples given An example of full assessment joint working and the clinical result – sent to hospital, further investigations needed so beyond remit of the team?	Referral pathways/remit of rapid response Advanced skills? (part of skills category – core and advanced) Being a detective Joint working, MDT working

Table A2. Initial descriptions of understanding from meaning units for participant 2 (analysis step 4).

Considers it to be a unique new role, not seen before

Describes the role as challenging if have not had sufficient previous experience

A role that is constantly developing (learning all the time)

Being a problem solver

This job is different, a move away from old traditional roles – not just the job itself but also the environment/clinical setting

Detail is required, assessments are very thorough – nothing is left unturned

Crossing of professional boundaries by upskilling in different clinical areas without losing physio specialist skill

Greater responsibility required

Yes, make autonomous decisions but MDT is also important

Important to recognize that experience develops further competence

Knowledge is obtained on the job

Important to be aware of own limitations

Considers rapid response to be beyond the scope of traditional physio practice

Experience and education needed for the role

Role is not met without apprehension and hesitation, there are risks – daunting

A responsible role with high risk taking

A role that is dynamic and complex, you never know what you will get – faced with the unknown

A LOT To juggle all at once

An expectation for speed that makes it more challenging

Education and advice forms part of the role

Working beyond physio skills

These notes were generated for each participant and then compared and contrasted between participants to generate thecategories of description.

Table A3. Data analysis compiling quotes across participants. Example of category of descriptions of the Lone Ranger (analysis step 4).

Participant number	Quote
P2	“ … you need to be competent, especially as you are often on your own … so you need to be competent enough to take blood pressure or competent enough to do blood glucose levels … and make decisions etc … ”
P3	“I do work alone, but you know, I am able to think right, take the necessary steps, and that is because, because of the experience that comes with time … ”
P5	“In this job, you know you have to undertake many skills on your own, even skills that you would think might be more of a nurses skill set or occupational therapist … ”
P1	“ … you know I work alone at times, and I am able to because of the experience and the knowledge and skill I have, but the knowledge required may sometimes extend beyond the scope of physiotherapy, so it’s being aware … ”
P6	“ … you need to make sure, especially if you are assessing alone, is that your clinical skills and knowledge is all up to date … ”
P4	“I have to make the decision on my own … is the patient to stay in the community or go back to the hospital … so here, in this team, I have to think about everything myself, each and every aspect of the patients err situation, their clinical care … .”
P1	“ … it wasn’t nerve racking for me to make that decision on my own, I do consider that, apart from a couple of junior staff that rotate into the team … members of staff are very experienced, they’re happy to make autonomous decisions … ” (P1)
P4	“ … if you are alone and the last person to see that person … if anything goes wrong with the patient overnight then … as a health professional, I might be in danger … you might get in trouble” (P4)
P6	“It’s actually … it’s very challenging, especially as we often work alone … It is a challenge, but again at the same time, how do I put it? I am confident … ” (P6)

Quotes reflecting how the category of description was present in the data were compiled for each category of description.

Figure A1. Early development the metaphors and outcome space.

This figure represents an early development of the metaphors and outcome space. The final outcome space (Figure 1 in the main article) was refined by moving backward and forward between the quotes in each category of description, mind maps, and diagrams and with dialogic discussion between the authors (analysis steps 5 and 6).

Larsson J, Holmström I 2007 Phenomenographic or phenomenological analysis: Does it matter? Examples from a study on anaesthesiologists’ work. International Journal of Qualitative Studies on Health and Well-Being 2: 55–64. doi:10.1080/17482620601068105.

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