Physiotherapists as Managers: An Analysis of TasksPerformed by Head Physiotherapists

Knowledge of the activities performed bymanagers forms the basis tor managementtraining yet little is known of tasks performedby managers in the health service.. A study wasperformed to identify the managerial roleotthree physiotherapists randomly selected fromeleven physiotherapists in charge of large hos­pitaldlipartmentswho had taken part in a pre­vious study to establish a profile of perceivedtasks.

Analysis revealed that the key folesof re­source allocator, monitor and leader were sim­i/ar to other middle managers, verba/contactsweretypica/ of managers at all Jeve/sande/in­ieal work caused role ambiguity.

The study indicated areas where the headphysiotherapist's performance could possiblybe improved together with suggestions for man­agement training and the selection of futurehead physiotherapists..

MARY E.GLENDINNING

Mary Glendinning, M.App. Sc. (Phty), B.H.A. t is Sen­iorPhysiotherapistin the Lower North Shore AreaRehabilitation and Geriatric ServicetSydney, and for­merly Head Physiotherapist at Centre Industries.

In Australian health service organi­zations the day to day management ofdistinctly specialized departments suchas physiotherapy departments isgen­eraliy delegated to a member of therespective'specialized' professionalgroup. Many of these people have re­ceived no formal training in manage­ment prior to their appointment andattain their position by virtue of theirclinical expertise or seniority (Grant1976, Stevens 1974, Manez 1978,Moore 1986).

Greatly increased health costs duringthe 1970's has resulted in mare em­phasisbeingplaced on increasing theeffectiveness and efficiency afhealthservices (Commission of Inquiry intothe Efficiency and Administration ofHospitals 1980). However, improvingthe manager's performance is contin­gent on a basic understanding of thetasks each manager performs and thisknowledge forms the basis for design­ingmanagement training programmesand the selection of future managers(Mintzberg 1975, Stewart 1979).

An extensive search of the literaturehas shown that little· is known of thetasks and roles performed by physio­therapists as managers and that littleoverall importance has been placed onthe position of head physiotherapist,"despite urging by Nowell (1973, p27)for physiotherapists to acquire mana-gerial skills 'at the risk of being man­aged by professional administrators'.

The aim of this paper is to examinesome important concepts of the man­ager's role as well as the role of thephysiotherapist as a manageLParticu­lar reference will be made to a recentresearch study designed to analyse .thetasks ·performed by head physiothera­pists in selected Sydney metropolitanhospitals (Glendinning 1985).

RoleRole expectation has an important

psychological function in providing theindividual with a fairly specific modelfor interaction (Kelvin 1970) and canbe described as a set of norms whichin turn are prescriptions for behaviour

(Brown 1967). As ·head physiothera­pists frequently lack a rolernodel andhave very little knowledge of what isexpected from their performance asmanagers, a knowledge of the tasksassociated with their job will,asKatz(1974) pointed out, help to identify theparticular skills they require to be ef­fective.

The scientific examination of roleshould be approached from either thesociological or psychological point ofview (Kelvin 1970). However, Sarbinand Allen (1968) maintain that the fo­cus of attention should be on overtsocial conduct as psychological theo­rizing can only be achieved throughhuman judgmental processes whichcannot be entirely free from error. Re­cognizing that many different roles areencountered during a person'srole .per­fOfmance, Sarbin and Allen (1968)recommended that a sociological studyof role should describe the number ofroles encountered, .with a comparisonof the amount of time spent in onerole relative to another as well as a

The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987 19

Physiotherapists as Managers

comparison of the range of roles playedby the individual being studied withthat of other individuals or groups insimilar positions.

Formal Authorityand

Status

Figure 1: The manager's Joles

From: Mintzberg, H. ·(1975), The Manager's Job: Folklore andFact, Harvard Business Review, July/August.

DecisionalRoles

EntrepreneurDisturbance

HandlerResource

AllocatorNegotiator

plays a major role in the unit'sdeci­sion-making system. Decisional rolesare made up of:7. Entrepreneur , where the manag­

er's task is to initiate change;8. Disturbance Handler, responding

to pressures when the unit isthreatened;

9. Resource Allocator, with the re­sponsibility of overseeing the sys­tembywhich organizational re­sources are allocated within theunit;

10. Negotiator, which is a vital part ofthe manager's job concerned with'resource trading in real time'(Mintzberg 1973, p91).

These roles are further defined inAppendix A.

Koontz et of (1980) claimed thatMintzberg'sstudy of five chief execu­tives was too small to. make sweepingconclusions, a view refuted by Mintz­berg who cited several examples of em­pirical studies which suggested that thework of the five managers in his studywas similar to that performed by man...agers in other studies. Koontzet af(1980) also claimed that Mintzberg ig­noredsome activities not seen to beperformed by managers (such as plan-

InformationalRoles

MonitorDisseminatorSpokesman

InterpersonalRoles

FigureheadLeaderLiaison

of roles describing what the managerappears to do (see Figure 1).

The three roles arising directly fromformal authority and involving inter...personal roles are those of:

1. Figurehead, where duties are ofaformal ceremonial nature;

2. Leader,defining the manager's re­lationshipswith his subordinates- motivating, staffing, etc;

3. Liaison, interacting with peers andothers outside the organization togain favours and information.

The informational roles focus on themanager as a focal point for his or­ganizational unit's information. Thethree roles involved here are concernedwith the receiving and giving of infor­mationby virtue of the interpersonalcontacts. These are:4. Monitor, where the ~anager re­

ceivesand collects information;5. Disseminator, involving the trans­

mission ofspecial information intothe organization;

6. Spokesman, where, as 'the expert',the manager sends organizationalinformation into the environmentto outsiders.

By virtue of his formal authority andaccess to information, the manager

The Manager's RoleThere have been many approaches

to management theory over the pasttwenty five years (Koontz andO'Don­nell 1968, Drucker 1974, Fiedler 1965,­McGregor 1967, Blake and Mouton1984, Campbell et 011970, French andRaven 1967, Sayles 1964, Dale 1960)examining many areas of organiza­tional behaviour. Each approach con­tributes in its own way to the overallview of the manager in the workplace.A wide variety of managers have beenstudied ranging from company presi­dents (Carlson 1951), first line super­visors (Kelly 1969), foremen (Guest1955, Jasinski 1956), senior and mUddlelevel managers (Stewart 1967), lowerand middle level managers (Sayles 1964)and chief executive officers (Mintzberg1968). Commenting on the evidenceemerging from these studies,Hunt(1979, p126) states that the .manager'srole 'is one of .fragmented activity, in­complete tasks, interruptions, varietyand unpredictable events. Little time isspent on planning or organizing or con­trolling. Most time is spent in direct...ing'. These studies also showed thatthe functions ofmanagement originallypropounded by. Fayolconsisting ofplanning,organizing, directing andcontrolling .(Fayol 1950), failed to in­clude many of the essential purposesof the manager's activities, whichwould have contributed toa richerdefinition of the manager's role.

Mintzberg (1968) examined the workactivity of managers and was able toprovide a statement of managerial ac...tivity not previously available. Usingthe role enactment concept describedby Sarbin and Allen (1968), he wasable to draw a number of conclusionson the manager'swork characteristicsthat reinforced findings of earlier workactivity studies (Carlson 1951, Stewart1967). Mintzberg developed a typology

20 The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987

Physiotherapists as Managers

ning) but which were performed intu­itively- a fact with which Mintzbergsubsequently agreed, stating that 'whenthe manager must plan, he seems todo so implicitly in the context of dailyactions . .. the plans of chief execu­tives seemed to exist in their heads'.(Mintzberg 1975, p57).

SimilarlJy .inManager's RolesMany similarities exist between the

work of all managers, irrespective oflevel or type of organization in whichthey work. These are summarized byMintzberg (1973,p51) as follows:-Managers feel compelled to complete

great volumes of work; free time isscarce; breaks are rare.

- Activities performed are brief, var­ied and fragmented; interruptions arecommonplace. Superficiality is anoccupational hazard.

• Managers gravitate to more active,concrete activities (current, ·specific,well defined, non-routine), ratherthan the abstract. Mail is viewed asa burden. Planning is seen as im­portant but receives little attention.

• Verbal and written (mail) contactsare the basis of the manager's work,manifest by five media; mail (writ­ten), telephone (verbal), unscheduledmeetings (informal verbal, face toface) and tours (observational).Managers favour the verbal media.

-One third to one half of the man­ager's time is spent on external re­lationships, with a similar amountbeing spent with ·subordinates orothers in the organization. Relativelylittle time is spent with superiors.

Differences in Manager's RolesManagerial skills identified as tech­

nical, human and conceptual/designskills (Koontz et al 1980, Richards 1982)vary according to the level of manage­ment. The proportion of human skillin the ability to work with people iscommon to all levels of management.Supervisors are required to exercisetheir technical skills far more than highlevel managers, whereas the reverse istrue for the use of conceptual/design

skills. Middle managers use the threetypes of skills in almost equal propor­tions. Work differences also occur be­cause of the type of organization, levelof management, personality and situa­tionalvariables.Thus, the role of thechief executive officer of a hospital willdiffer in some ways to that of the headphysiotherapist in the middle manage­ment situation, with more emphasisbeing placed on negotiation by the for..mer compared to resource allocationby the latter. Drucker (1974, p447) de­fines the traditional middle manager asa 'commander of men'but the emerg­ing 'new' middle manager as essentiallya 'supplier ofknowledge' . The key rolesof a middle· manager in a·specialist unitwould be that of resource allocator,leader (to co-ordinate highly skilled ex­perts) and monitor, as the expert orhead of the specialist staff group(Mintzberg 1975).

Women as ManagersThe majority of Australian gradu­

ates in physiotherapy are female.Eighty eight per cent of physiothera­pists graduating from CumberlandCollege of Health Sciences (C.C.H.S.)between 1975 and 1982 were female(C.C.H.S. 1983), while a study ofmembers of the Australian Physio­therapy Association (Refshauge andDuckett 1976) found that, in a sampleof 86 heads of physiotherapy depart­ments in Australian hospitals, 93 percent were female.

Women are not well represented insenior management positions in healthorganizations - a study of the seniorhealth administrative workforce in NewSouth Wales (Palmer and Stevenson1982) did not include a separate male/female classification because femalerepresentation was too low at this leveLSimilarly, a Canadian study (Dixon1980) found that females were clus­tered in lower level administrative po­sitions and under represented at seniorlevels in health administration. Womenin administrative jobs have considera­ble work related pressures unique tofemale managers (Cooper .and David-

son 1982), such as the burden of eopingwith an absence of role models result­ing from the lack of women in higherpositions within the organization,strains of coping with prejudice andsex stereotyping,overtand indirect dis­crimination from fellow employees andemployers,and maintaining a familyor home. Nevertheless, several studieshave shown there is little difference inwork style between men and women(Reif eta/1978, Bartol and Wortman1975, Fogarty et 0/1972).

Very few studies have been carriedout which analyse the tasks of man...agers in health care for the purpose ofrole delineation and these areconcen­trated in the nursing field. Hunter andMays (1978) conducted a patient de­pendency study of nursing activities ina psychiatric centre, while Jones andJones (1979) studied the role of headnurses based on the method used byMintzberg (1973). In both studies,charge nurses spent from 66 per .centto 75 per cent of their time with pa­tients. Jones and Jones (1979) advo­cated a more balanced role model(divided between interpersonal, infor­mational and decisional roles) andhighlighted the need for clerical assist­ance and staff development in the man­agementrole.

Pbysiotherapists as·ManagersThe structure of physiotherapy de...

partments ·in hospitals is relatively un­complicated. Some larger departmentsare divided into sections such as out­patients, paediatrics, cardio-thoracic,rehabilitation, obstetrics and gynae­cology, with senior physiotherapists su­pervising two or more staff in eachsection and reporting directly to the.head physiotherapist. In smaller hos­pitalsall physiotherapists report di­rectly to the head physiotherapist. Staffof physiotherapy departments consistofregistered physiotherapists, aides andclinical assistants all of whom are re­sponsible ·to the head of the depart­ment. The head physiotherapist occu­pies a middle or intermediate manage­mentposition in the organization, being

The Australian Journal of Physiotherapy. Vol. 33, No. 1, 1987 21

Physiotherapists as Managers

responsible to the medical superintend­ent. Sometimes they are responsible tothe medical superintendent for clinicalmatters and the chief executive officerfor administrative matters (A.S.H.A.1976).

Little empirical research into thetasks\ performed by physiotherapists isavaila~le, although Watts (1971, p25)stated that 'the first step in the devel­opment of a system for division ofresponsibility must be an analysis ofphysiotherapy practice itself'. Tasksperformed by clinical staff have beenanalysed (Dunsford 1981, Allen 1983,Hultgren 1971) but it would appearthat no studies are available which an­alyse the tasks performed by headphysiotherapists . Nowell (1973) re­viewed some of the broad functions ofmanagement as applied to head physio­therapists, but did. not present an anal­ysisof the tasks actually performed bythem. Checklists of tasks have beencompiled by the American PhysicalTherapy Association (1977) and by theorganizers of .a management trainingcourse for District Physiotherapistsconducted by the Department of Healthand Social Security (U.K.) in 1977.

Glendinning (1985) conducted astudy to determine task performanceas perceived by head physiotherapists(Study I), using a questionnaire con­taining a checklist ·of tasks (developedfrom the two above sources and per­sonal experience)'which was distributedto eleven head physiotherapists em­ployed in Sydney metropolitan hospi­talsandwho were in charge of 15 ormore staff. A secondary aim of thestudy was to discover areas of man­agementwhich gave head physiothera­pists the most job satisfaction andcaused the most stress. Responses bythe survey group to the questionnaireare displayed in Appendix B. The groupcarried out most of the tasks listed inthe questionnaire (scheduling .patienttimetables and publishing articles beingthe only tasks not performed by anyof the group) and identified 'assessingthe department's performance' as their

most important task, whilst 'organiz­ing the department to run efficiently'gave the group the most satisfaction.However, there was little evidence thatthey received information which indi­cated the level of performance, withonly 19 per cent of departments con­ducting .staff appraisal.programmes orhaving a system for identifying prob­lems of a.managerial nature and 36 percent conducting. quality assurance pro­grammes. The greatest source of stresswas the .maintenance of an efficientservice on a restricted budget whichultimately affected staffing levels.Cop­ing with organizational structures, ne­gotiating with administrative staff anddisciplining staff members also causedconcern. The study highlighted the fre­quent failure to collect data which in­dicated the level of the department'sperformance and the various stresses,affecting the head physiotherapists intheir role as managers.

One of the limitations of this studywas that the results were based on theperceptions of the respondents ratherthan their observed performance. Inaddition, it was not possible to deter­mine from the responses the differenttypes of roles and the amount of timespent by head physiotherapists in theseroles.

A second study (Study II) was there­fore undertaken to analyse the tasks.performed by head physiotherapists inhospitals and identify their managerialrole using a structured observationmethod. The analysis of this role en­actmentwould follow that postulatedby Sarbin and Allen (1968) and usedby. Mintzberg (1973) in his study offive chief executive officers.

The research objective was to com­pare the managerial role of headphysiotherapists with the role of othermanagers as identified in past research.It was predicted that headphysiothera­pists would exhibit many of the rolepatterns demonstrated by other man­agers in similar types of middle man­agement positions. It was also pre-

dieted that head physiotherapists wouldfulfil the key roles of resource alloca­tor,monitor and leader in keeping withtheir position as middle managers re­sponsible for the internal operation oftheir departments.

The study was limited to observinghead physiotherapists' overt behav­iour. The psychological reasons foradopting this behaviour, the adequacyof their performance as managers, andthe influence of leadership styles, powerand mediating variables (such as typeof organizations, seasonal factors, per­sonality)on role were not the focus ofthis study.

The information gained from thisresearch would assist in the future se­lection of physiotherapists for mana­gerial positions and provide a basis forthe design of management educationand information programmes.

Study II: A StructuredObservation of the Role ofHead PhysiotherapistsMethod

Three head physiotherapists wererandomly selected from the eleven headphysiotherapists who responded to thequestionnaire in Study I. All agreed toparticipate. Prior to commencing theresearch, a pilot study was conductedin another hospital observing the ac­tivities of a head physiotherapist forone ·day. This gave ·the observer prac­tice in recording activities and dem­onstrated that the activities could besatisfactorily recorded and coded usingMintzberg'sstructured observationtechniques. Each physiotherapist wasinformed of the study methods beforethe observation period began and wasasked not to engage in discussion withthe observer during the day. Each wasasked to briefly introduce the observerwhen necessary, stating the reason forher presence, and to advise staff of theimpending visit, requesting them notto .alter their patterns of work or in­teraction. The researcher observed eachphysiotherapist for one working ·weekover three consecutive weeks.

22 The AustraUan Journal of Physiotherapy. Vol. 33, No.1, 1987

Physiotheraplstsas Managers

Every interaction or activity was re­corded on a worksheet developed toencompass the categories of informa­tion used by Mintzberg to provide theinformation necessary .for developingthe manager's role. Each activity wastimed to the nearest tenth of an hourand ~ctivities lasting less than threeminute~, were recorded as.02 hours.Activiti& less than one minute werealso noted.

Each activity was allocated one ofthe ten roles described by Mintzberg(1973), by matching the purpose of theactivity with the fole definition. As anactivity could represent several over­lapping roles., the main purpose waschosen as the role. For instance, indiscussing the plans for a new depart­ment with· the project planning officer,the activity could represent the role ofentrepreneur, disseminator or spokes,..man. The main purpose in this ~ase

would be that of entrepreneur. Detailsof telephone calls,mail received or sent,

were briefly described by the headphysiotherapist after the event. Uponcompletion each .day, worksheets werecollated with each activity being allo­cated one of the ten roles. A profilewas then developed for each physio­therapist and a composite score cal­culated based on the average time spentby all three in variousactivitiesw

ResultsA·summary of.the activities pertinent

to each role can be found in AppendixA.• Head physiotherapists spentapprox­

imately two thirds of their workingtime fulfilling the roles of resourceallocator, monitor and leader (seeTable 1)

The resource allocator role occupied34070 of the therapist's working timeand was conc~rned with establishingwork priorities and organizing the staff,space requirements and equipment to

achieve these. The monitor role (17f1Joof working time) involved the seekingand receiving of information whichgave head physiotherapists .an under­standing of their department's opera­tionand the health care environment.Such information was gathered throughstaff reports, personal observations andcontacts inside and outside the hospi..taL The leadership role (15f1Jo of worktime) was concerned with establishingan atmosphere within the departmentdesigned to motivate staff and improvetheir performance. The remaining onethird of the therapists' time was di­vided between the roles of figurehead(7f1Jo), liaison (4070), disseminator(7.5f1Jo), spokesman (5OJo), entrepreneur(7.5070), disturbance handler (IOJo),andnegotiator (2070) w• Head physiotherapists spent an aver­

age of 73070 of their working hoursin verbal contact with other peopleand an average of 270/0 of their timein desk work.

Table 1:Analysis of head physiotherapists' roles

Head Physiotherapists

Role Classification A B C AverageComposite

Hours/ % of Hours/ % of Hours/ % of Hours/ % ofWeek Total Week Total Week Total Week Total

Interpersonal Relations RolesFigurehead 3.94 10 2.76 8 Ow59 2 2.43 7Leader 4w11 11 6.16 19 5.48 17 5w25 15Liaison 2.82 7 0.43 1 0.88 2w5 1.38 4

Informational RolesMonitor 4.60 12 3w29 10 9.96 31 5.95 17Disseminator 1.19 3 4.30 13 2.53 8 2.67 7w5Spokesman 2.82 7 1.83 5 0.42 1 1.69 5

Decisional RolesEntrepreneurial 2.11 6 1.88 6 3w99 12 2.66 7.5Disturbance handler 0.50 1 0.1 0.5 Ow16 0.5 0.25 1Resource allocator 14.47 38 12.07 37 8.43 26 11.66 34Negotiator 1.72 5 0.1 0.5 Ow6 2

Total 38.28 100 32.92 100 32.44 100 34.54 100

The Australian Journal of Physiotherapy" Vol. 33, No.1, 1987 23

Physiotherapists as Managers

• An analysis of the activities involv...ing verbal contact (see Table 2)showed that 14070 of total work timewas spent on the telephone, 22070attending scheduled meetings, and17070 in unscheduled meetings. Theproportion of time spent on toursaway from the department to ob­serve'rctivity or deliver informationoccupi~d 4070 of time, whilst 16070 ofthe working time was spent in non...managerial activities which involvedpatient contact activities such as pa­tient treatment,organizing and at­tending clinics, ward rounds andclinical work.such as writing inmed­ieal records or relieving the clerk atthe reception desk.

• An average of 97 interactions oc­curred each day, one third of theselasting for less than one minute, and91070 lasting less than 9 minutes. Only0.5070 of interactions lasted for longerthan one hour. This pattern of 1n­teractionswas typical of managersin many other studies, who occupiedpositions at all levels in the organi­zation and who worked at an un­relenting pace with activities char­acterized by brevity, variety anddiscontinuity.

• >Head physiotherapists spent 5OJo oftotal verbal contact time with theirsuperiors,24OJo in contact with de­partment staff, 24010 in contact withothers in the hospital and 38070 withpeople outside the organization. Ofthese outside contacts, 11070 of timewas spent in contact with peers andtrade organization representatives,20070 with clients or patients, and 7070with others independent of the or­ganization.

• 'Head physiotherapists had a reason­ably accurate perception of the tasksthey performed as managers, with54 of the 69 listed tasks perceived asbeing performed in Study I actuallybeingperrformed in Study II. Noadditional tasks were performed inStudy II that had not been listed inStudy I.

e Although the head physiotherapists

in Study I saw their most importanttask as assessing departmental per­formance, there was very little evi­dence in either study of the objectivedata required to perform this func­tion.

DiscussionThe hectic nature of the job and role

ambiguity experienced in performingmanagerial and non-managerial activ­ities were a constant source of stressfor the head physiotherapists - neitherof these being·mentioned by the surveygroup participating in Study I asasource of stress.

Constant interruptions made con­centration on desk activities extremelydifficult. For example, checking paysheets in one hospital department oc­cupied the whole morning because ofinterruptions. A bank up of tasks re­sulted in the substitution of indepthefforts with superficiality in order tokeep pace with work demands, a fre­quent occurrence amongst managers.Mintzberg (1973, p35) stated that 'su­perficiality is an occupational hazardin managerial work ... iIi order tosucceed the manager must, presum­ably, become proficient at superficH...ity'.

The pattern of verbal contacts made~by head physiotherapists was typical· ofother managers at all levels in otherorganizations. Executive officers in theMintzberg (1973) study·showed almostidentical patterns .of verbal contact.This follows the trend of contact pat­terns for managers in many other stud­ies (Mintzberg J973). Managers gen­erally spend between one third and onehalf of their time with subordinates,whereas contact with superiors only ex­ceeded one eighth of their time in onestudy. Contacts external to the organ­isation always occupied a significantproportion of the manager's time. Thephysiotherapists' contact with their ownstaff involved resource allocation,re...laying 'official' communications, an­swering queries of an industrial natureand giving verbal encouragement di­rected at maintaining and improving

staff morale. Contact with heads ofother ·physiotherapy departments rein­forced role patterns and sometimes re­sulted in changes in the head physio­therapist's role enactment.

Non managerial activities (or thoseinvolving direct patient contact)occu­pied a significant proportion of totalwork time (16010). The reasons for in­volvement in patient treatment werevaried, namely the need to show staffthey were competent practitioners,helping to share the clinica1load, fillingin for staff absences, responding todoctors' demands for exclusive treat­ment of their patients, preference forclinical work over administrative du­ties . Unless the physiotherapist gavespecific instructions to avoid interrup­tions, patient treatments were the sub­ject of many interruptions by staff en­quiries and telephone calls. This roleambiguity caused stress, particularly tothe two therapists maintaining a reg­ular <clinical load. The other,with noclinicalrole,appeared to cope very wellwith the demands of the position.

Role ambiguity experienced throughrelinquishing clinical skills for mana­gerial responsibilities is a common

; source of stress to many health profes­sionals (Cartwright 1979). Itwould.ap­pear that it is quite common for middlemanagers to be involved inactivitiesrequiring technical skills which demandup to 25070 of their total work time(Koontzet 0/1980), whilst Katz (1974)recognized that all managers do somework that 1snot purely manageriaLMintzberg·(1973, pi07) found tbatchiefexecutives in smaller organizations 'stepinto non-managerial jobs in order tofill in when necessary'. Clearly, a needexists to minimize the· stress caused tohead physiotherapists from role am;,.biguity.

The role of resource allocator exhib­ited in this study is typical of middlemanagers primarily concerned with thesmooth running of their department.The monitor role is an indication ofthe need to keep up to date with eventsoccurring around them and with tech­nical information necessary for these

24 The Australian Journal of ·Physiotherapy. Vol. 33, .No. 1, 1987

Physiotherapists as Managers

Table 2:Analysis of head physiotherapists' chronological record (by activities)

Head Physiotherapists AverageActivity Composite

A B C

Total hours worked per week 38.28 32.92 (a) 32.44 34.54Total ~amount of mail (pieces) 88 90 99 92Total humber of mail activities 109 68 168 143Total number of contact activities 304 361 361 342

Desk WorkTime on desk work 6.9 hrs 7.55 hrs 13.27 hrs (b) 9.24 hrsAverage duration 5 mins 5 mins 5 mins 5 minsProportion of total time 18% 23% 41 % 27%

Telephone CallsNumber of Calls 78 120 85 94Time on telephone 5.62 hrs 6.01 hrs 3.06 hrs 4.89 hrsAverage duration of call 5 mins 3 mins 3 mins 4 minsProportion of total time 14% 18% g% 14%

Scheduled MeetingsNumber of meetings 12 9 10 10Time in meetings 11.88 hrs 6..24 hrs 4.73 hrs 7..6 hrsAverage duration 60 mins 42 mins 28 mins 43 minsProportion of total time 31 % (c) 19% 14% 22%

Unscheduled MeetingsNumber of meetings 145 128 225 166Time in meetings 6.39 hrs 4.77 hrs 6.83 hrs 6 hrsAverage duration 2 mins 2 mins 2 mins 2 minsProportion of total time 17% 14% 21% 17%

ToursNumber of tours 18 22 13Time on tours 2..97 hrs 1..34 hrs 1.4 hrsAverage duration 10 mins 4 mins 5 minsProportion of total time 9% 4% 4%

Patient ContactNumber of contacts 69 9 19 32Time in contact 7.49 hrs 5..47 hrs 3.27 hrs 5.4 hrsAverage duration 5 mins 36 mins 10 mins 17 minsProportion of total time 20% 17% 10% 16%

Proportion of activities lasting less than 9 minutes 85% 93% 94% 91 %Proportion of activities lasting less than 1 minute 30% 29% 45% 35%Proportion of activities lasting longer than 60 minutes 0.6% 1% 0.50/0Total number of activities 433 229 592 485

a) Five hours of work schedule not recorded, due to involvement of Head Physiotherapist in hospital healthpromotions event.

b) Considerable time spent preparing a brief for a new department.c) Includes time taken to attend meetings away from hospital in Community Health Centres..

The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987 25

Physiotherapists as Managers

physiotherapists as managers of aspe­cialist staff group. Variations in roleactivity between physiotherapists caninpart be accounted for by the situationalvariables occurring during the obser­vation period. No attempt was madeto assess the head physiotherapists'pers(,~alities and management styleswhich~ip1aYalso be a factor in rolevariation.

Each of the three physiotherapists(the 'samplegrollp') performed similartasks during the observation period tothose they perceived themselves as per­forming in Study I (see Appendix 2).Tasks they perceived as being per­formed but which were not observedcould possibly be attributed to the timeframe of the structured observationstudy. However, these physiotherapistsspent considerably more time per weekin scheduled meetings (7.6 hoursflver­age) than originally perceived (1.66hours average) and less actual time inoutpatients (0.82 hours average) thanperceived (4 hours average). The ques­tionnaire responses of the three partic­ipating in Study II were typical of theresponses of the remainingphysio­therapists in the 'survey group' partic­ipating in Study I.

It is expected that head physiothera-pists in smaller hospitals would have amuch·greater clinical involvement thantheir peers in larger departments. Itmight appear that identifying the rolepatterns of only three head physio­therapists would be insufficient to en­able a generalization to be made of therole of head physiotherapists in largedepartments. However, in view of thefact that the head physiotherapists inthe sample group were typical of thehead physiotherapists in the surveygroup, and that remarkable similaritieswere observed in their work activities,it is hypothesized that most headphysiotherapists have similar role pat­terns.

A limitation of the study was thatthe time of year it was carried out mayhave influenced the pattern of activitiesand one week's observation may havefailed to pick up the patterns of longer

range activities such as qualityassur­ance and research programmes neitherof which were in evidence during thestudy. Activities outside the normal de­partment working hours (such as backclasses at night, or 'bone breakfasts')were not recorded. The observer wasexclude<;t from observations on onlytwo occasions but in both cases wasinformed of the purpose of the inter-action. ~

The validity of the observations inStudy II is best supported by the sim­ilarity of the results obtained by thesample group in Study I. Although twohead physiotherapists commented thatthe observer'spresencehad not af­fected their work patterns, the otherphysiotherapist 'felt conscious of wast­ing time' and towards the end of theweek was 'mentally exhausted' having'been on my toes all week'. Thus theobserver's presence may have influ­enced the style of this head physio­therapist's work to some extent. How­ever, because it was impossible to alterscheduled meetings, incoming tele­phone calls or mail and patient contactactivities because of observer presence,it was considered that this presence didnot have a significant effect on workpatterns. Staff became less inhibited intheir interaction with the head physio­therapist after the first day of obser­vation.

Whilst acknowledging the need foranother observer to establish inter-raterreliability, this was not possible. Therewas no opportunity to have decisionsverified by another observer, particu­larly when there were 3 or 4 purposesthat related to the.one activity. In viewof the fact that the observer had prac­tisedrecording during the pilot studyand that the observations in the studyperiod were not of a global nature, itwas felt that the recording of activitiesin this study was a reasonably reliableaccount of the head physiotherapists'tasks.

ConclusionThe findings of this research support

the hypothesis that headphysiothera-

pists exhibit many of the role patternsdemonstrated by other managers insimilar types of jobs.

The key roles of resource allocator,monitor and leader fulfilled by headphysiotherapists as managers corre­sponded with those of middle man­agers in charge of internal units withinan organization.

Like other managers, physiothera­pists preferred the verbal medium todesk activities, the proportion of timeallocated to these~edia being similarto that of other managers. The relativedistribution. of tiIlJe,.allocated by headphysiotherapists\to~ontact groups wasvirtually identical with the time spentin this activity by'-chief executive of­ficers in Mintzberg's (1973) study andwas consistent :with findings reportedin other .studies (Mintzberg 1973, p45).

Head physiotherapists, in commonwith other managers, completed greatvolumes of work with their activitiesbeing brief" fragmented and varied.Most of their activities were of a cur­rent nature, involving, in the main,immediate action. Planning receivedlittle outward attention. The degreewith which head physiotherapists usedtheir technical skills appears to be con­sistent with that of most middle man­agers (Koontzet ol 1980). However,there were differences in the way eachgroup engaged in non-managerial ac­tivities . Whereas middle managers inother studies generally undertook non­managerial activities on a temporary,'fill-in' basis (Mintzberg 1973, pl07)theseacdvities formed a regular partof the head physiotherapist's job.

Recommendations for FurtherRdsearch

:It is recommended thatconsidera­tidn,~be given to assessing the effec­tiveness of head physiotherapists asmanagers, because effective manage­ment is an essential ingredient in theeffective delivery of health services(Longest 1981). As the predominantobjectives of health care managementare to improve standards of patient

26 The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987

Physiotherapists as Managers

care and to increase outputs fromhealth expenditure (Commission of In­quiry into the Efficiency and Admin­istration of Hospitals 1980, Volume 3)it is recommended that criteria be es­tablished .which measure the success oreffectiveness of head physiotherapistsin achieving these objectives throughmanagin~ their department's perform­ance.

However, McCall (1976) cautionsthat measuring leadership effectivenesshas many associated problems and can­not be reduced to .a simple index ofgroup productivity (demonstrated byincreased department output statistics)or the degree of subordinate satis­faction with leadership style. As a min..,imum, McCall suggests criteria whichmeasure the manager's ability to utilizeand disseminate knowledge, the successin interacting· with contacts outside thedepartment, the ability to develop andmotivate staff resulting in improvedperformance, the success in creatingand coping with change and the actualtask performance by the leader. McCallrecognizes that many of these areas donot lend themselves to easy measure­ment,but suggests that behaviourallyanchored measures developed by Smithand Kendall (1963) hold promise. An­other aspect of the head physiothera­pist's performance could be the extentto which managerial.style, personalityand a knowledge of managerial tech­niques influence their effectiveness as·a manager. Measures of departmentperformance which are partially influ­encedby managerial performance couldalso be· examined. These measures mayinclude staff turnover, the number ofstaff absences through illness, theamount of overtime worked and theexternal regard with which the depart­ment and head physiotherapist are held.

In view of the stressful nature of themanagerial role, andthe role ambiguityexperienced by the headphysiothera­pists in Study II, it is recommendedthat a study be undertaken to assessthe ability of head physiotherapists tocope with stress occurring in their jobs.Such a study could utilize the measures

used by Morrison (1977) who examinedthe career adaptivity of middle man­agers to changing role demands, byassessing their career maturity, self es­teem, personal autonomy, decisionstyle, means of coping with stress,physical and cognitive activity. In as­sessing their ability to cope with stress,Morrison 3lsoexamined intolerance ofambiguity and surveyed personal val­ues, orderliness, "'goal orientation, In­terpersonal values, needs satisfactionand the manager's life histories.

It is recommended that further em­pirical studies be carried out on therole of managers in other allied healthprofessions as a basis for the furthercomparison of managerial roles.. Com­parisonwith the roles of managers insimilar departments in other westerncountries would also be of interest, todiscover if they carried out similartasks, set the same priorities and ex­pressed similar frustrations concerningrole ambiguity and preparation formanagerial roles.

Implications of the StudyThis research identified the role pat­

tern currently exhibited by headphysiotherapists. The informationgained from this study has implicationsfor the head physiotherapist's presentrole as a manager, the education ofphysiotherapists and the selection ofphysiotherapists for management po­sitions.

Many factors may influence the roleenactment of head physiotherapists de­scribed in this study.. It is anticipatedthat the publication of these findingswill result in head physiotherapists be­coming more aware of their role ex­pectationsand may influence some inconforming more closely to role pat­terns revealed in this study. The dele­gation of some activities presently per­formed by head therapists to other staffmembers could influence the amountof time spent in one role relative toanother .By increasing the seniorphysiotherapist's supervisoryrespon­sibility for staff and equipment in a

specific treatment area (eg thoracics),a corresponding reduction should takeplace in the amount of time >spentbythe head physiotherapist in the re­source allocator role. Training staff indepartment procedures should reducethe number of short interactions andinterruptions to the head physiothera­pist's job process, whilst allocating themore routine administrative responsi­bilities to the physiotherapist who issecond in charge would permit the headphysiotherapist to spend more time inentrepreneurial activities such as de­signing methods to measure depart­ment performance or developing re­search programmes. However, dele­gation and job sharing do inhibit theamount of information flowingdi­recdy to the head physiotherapist, ne­cessitating the development of moreformal communication .systems (suchas regular meetings with senior staff)to counteract this tendency.

Changes in organization policy canalso affect role demands. A decisionto build a new rehabilitation unit islikely to result in more of the headphysiotherapist's time being spent inthe entrepreneurial role with conse­quent reduction of time in other roles.Similarly, changes in the person's hi­erarchical level within the organizationwill alter their legitimate (or position)power (French and Raven 1967) androle demands. It is difficult to envisagehead physiotherapists increasing theirposition power within hospitals, due tothe monopoly exerted by the medicalprofession in upper management po­sitions. However, changes· in the Of­

ganizational structure of paramedicaldepartments involving, for example,the appointment of a non-medical ad­ministrator, could significantly alter thepresent role demands of these depart­ment heads.

Although role patterns have beenidentified, it does .not mean they arenecessarily ideal. The research hasshown that there are many areas whereweaknesses in the head physiothera­pists'present role could be improved.

The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987 27

PhysiotherapistsasManagers

When viewing the head physiothera'"pist's roles in terms of classical theory,it would appear they spent most oftheir time organizing and directing.Virtually no attention was given toset­ting department objectives and devis­ingmeans to carry them through (theplanning function), nor was anyatten­tion piijd to ensuring that the depart­ment·~as actually ·achieving what itwas designed to achieve (the control­ling fp.nction).

It would appear that headphysio­therapists could make more effectiveuse of their time and management skillsby introducing changes to their workpatterns. In view of the changing healthcare system, particularly resulting inthe ·reduction in staffing numbers, anevaluation of present treatment pro­cedures.and outcomes would appear tohave high priority to establish the areasof greatest need for theallocatioh ofscarce staffing resources. The imme­diate introduction of information sys­tems which indicate the departments'performance is also required. Such sys­tems could comprise the regular mon­itoring of morbidity patterns occurringamong clients treated in the depart­ment, details on the length of treatmentfor each diagnostic category, infor-

'marton on discharge status,and therecording of problems occurring in·thedepartment together with the actiontaken to alleviate or resolve them. Theuse of personal computers or computerterminals connected to the main hos­pital computer would provide an in­terface for monitoring these aspects ofthe department's performance.Re­search projects into the efficacy ofpresent physiotherapeutic proceduresand the effectiveness of departmentpreventive health care programmesshould also be undertaken. Headphysiotherapists should also developstaff appraisal programmes for staffperformance and mechanisms to gainfeedback from staff members on theirown performance asa manager.

Additional clerical and aiding staff,carefully selected and trained by thehead physiotherapist, could perform

many of the routine non-managerialtasks presently being performed byhead physiotherapists. Clerical staff,for instance, could organize outpatientclinics, calling on theheadphysiothera­pist only when necessary. They couldalso be trained to make more decisionsthemselves and thus reduce the numberof interruptions to the head physio­therapist's work. Clerical staff couldalso be trained" to monitor telephonecalls or record messages when the ther­apistis involved in desk work that in­volvesconcentration. It may even beadvantageous for the therapist to oc­casionally carry out desk work awayfroID. the department, free from inter­ruptions.

The study showed that role ambi...guityexisted in the performance ofhead physiotherapist's work activities.One method of overcoming this prob­lem would be to define the depart­ment's objectives more clearly statingdepartment priorities (for example,clinical, research,educational), the roleof the head .physiotherapist and thatof the staff. This function is alreadyundertaken by hospital departments inpreparation for the accreditation oftheir respective hospital (A.C.H.S.1981). However, the head physiothera­pist's role or job description, in par...

," ticular, requires particular attention toclarify their participation in clinical ac­tivities.Whilstacknowledging that it iscommon practice for middle managersto 'step into non-managerial jobs tofill in when necessary' (Mintzberg .1973,pl07), it is suggested that head physio­therapists should not maintain a per...manent clinical load. It has been dem­onstrated that this aspect of thetherapist's activities causes additionalstress to an already hectic managementroutine. In addition, the constant in­terruptions experienced during the pa­tient's treatment is extremely unfair tothe patient and does not contribute toquality treatment.

Training head physiotherapists inmanagement techniques· based on theknowledge of their role and stress fac­tors within that role is also a pressing

requirement. Training should ideallyfollow the guidelines suggested byMcCall (1976) where simulations wouldbe constructed about the tasks .headphysiotherapists perform. Participantsin the programme would be ·providedwith feedback when .they returned tothe work place,either by way of video...recording or peer orobserver.rating oftheir performance.

Because head physiotherapists, likeother middle managers, spent a highpercentage of their time in the resourceallocator, .monitor and leade~ship roles,training programmes should bedi...rected at the most effective ways ofutilizing resources, establishing com...munication systems, and understand­ing leadership theory. Practise in plan­ning department goals, devising waysof achieving these and evaluating theresults is also required,as this area ofmanagerial function was found lackingin the head physiotherapist's role asidentified in this study. As much ofhead physiotherapist's time was spentin verbal contact, considerableempha­sis needs to be placed on social Inter­action (James and Jongeward 1971,Argyle 1969, 1975). Factors shown tohave caused stress amongst the headphysiotherapists such as coping withorganizational structures, staff .ration­alizationand role ambiguity should alsobe discussed, and strategies developedfor coping with stress.

A neglected aspect of physiotherapyundergraduate programmes is trainingin basic management techniques as wellas an understanding of the importanceand worth of the head physiothera­pist'smanagerial role. Trainingin theseareas would not only give undergrad­uates appropriate management skills,but ·would also make them aware ofthe difficulties experienced by headphysiotherapists in carrying a clinicalload.

This study also has implications forthe members of selection panelscharged with the task of selecting headphysiotherapists. They must try tose­lect the candidate who shows leader­ship qualities, with training andexpe-

28 The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987

Physiotherapists as Managers

rience in administration, and an abilityto interact· successfully with many dif­ferent people. The successful personmust be flexible,content to be profi­cient in a superficial manner with avariety of subjects and accept the con­stant interruptions as a part of themanager's role. Skills in oral commu­nicatioI\ are essential as is a level ofclinical~xpertisesufficient to performthe roles of leader and spokespersonfor the group. Finally, the candidateneeds to demonstrate a willingness toconstantly evaluate and improve his orher own performance through learningexperiences.

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Physiotherapists as Managers

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Appendix A

Definition and Explanation of Rolesand ~erms

The definitions of managerial roles are aprecis of those developed by Mintzberg(1973). Task examples relate to activitiesactually performed by head physiotherapistsin Study II.

1. FigureheadThe symbolic head of the unit, who, be­

cause of this position, is obliged to performa number of duties and be present at certainevents.

Task Examples: representing departmentat meetings inside and outside hospital andat social functions. Signing official staffdocuments eg passport applications.

2. LeaderResponsible for motivating .and activating

subordinates; for staffing, training .and as­sociated duties. Defines the atmosphere inwhich the organization or unit will work.

Task Examples: all aspects of staffing,engaging, dismissing, training, promoting,remuneration, transmitting information tostaff, answering requests fer authorization,probing actions of staff eg staff appraisal,problem identification.

3. LiaisonThe development and maintenance of a

network of outside contacts and informerswho provide favours and information.

Task Examples: contact with outsidephysiotherapists, doctors, other healthprofessions and outsiders for the purposeof service and advisory activities, innova­tion. Similarly, contact with trade organi­zations.

4.. MonitorThe seeking and receiving of a variety of

special information to develop a thoroughunderstanding of the organization and en­vironment.

Task Exampl€s: progress reports fromstaff on the department's operation (writ­ten, verbal), observations, contact with ex­ternal environment regarding technologicaldevelopments, politicaImoves etc achievedthrough personal contact, attending confer­ences and meetings, letters, periodicals.

5.. DisseminatorThe transmission of information received

from outsiders or from staff members tomembers of the organization and depart­ment staff.

Task Examples: reports on operation ofdepartment (eg minutes of meetings, visits,statistical summaries of activities), depart­mental procedures,. job descriptions etc asrequired by senior management.

Informing members of the organizationof changes or events occurring within thedepartment (through personal contact,memo, etc). Relaying information to staffmembers.

6. SpokesmanTransmits information to contacts about

the organization's or the department's plans,policies, actions, results etc and is viewedas an expert on the operations of the de­partment.

Task Examples: public relations activities- explaining aspects of the department's

operation to interested outsiders, compilingreports on students participating in workexperience programmes, briefing superiorson various department programmes.

7. EntrepreneurSearches the department and its environ­

ment for opportunities and initiates im­provement projects to bring about change.Supervises design of projects.

Task Examples: redesign of records,ac­tion taking to improve existing situation,design and implementation of new pro­grammes, changes to department layout.

8. Disturbance HandlerResponsible for corrective action when

the organization or department faces im­portant or unexpected disturbances.

Task Examples: resolving conflict be..tween staff, between departments, copingwith a sudden loss of resources such as areduction in staff numbers.

9. Resource AllocatorResponsible for the allocation of orga­

nizational or departmental resources of allkinds, and for the making or approval ofaU .significant organizational decisions.

Task Examples: Scheduling own time andstaff time, establishing what is to be done,who.is to do it, what type of organizationalstructure is .to be adopted, deciding budgetpriorities. Specific activities may consist ofscheduling patient appointments,staff ros­ters, space, organizing purchase and repairof equipment, listing own work priorities.

10. NegotiatorResponsible for representing the organi­

zation or department at major negotiations.Task Examples: negotiating changes to

staffing levels, design of premises.

Appendix BSummary of Tasks Performed by Head Physiotherapists as Perceived by Survey Group, as Perceived by theRandomly Selected Sample Group, and as Actually Performed by Sample Group(All results expressed as a percentage of each group).

Survey Group(N = 11)

Sample Group(N = 3)

PerceivedPerformance

PerceivedPerformance

ActualPerformance

Tasks

Question 2Representation at:a} Hospital staff meetingsb} Hospital social functionsc) Professional meetingsd) Other functions

Yes

100100100

19

No

81

Yes

10010010033.3

No

66.6

Yes

10010010033.3

No

66.6

30 The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987

Physiotherapists as Managers

Survey Group Sample Group(N = 11) (N = 3)

Perceived Perceived Actual

Tasks Performance Performance Performance

Yes No Yes No Yes No

Question 3Resp'onsible for:a) i) \recruiting staff 100 100 100

ii) 'lntroducing new staff 100 100 100iii) staff promotion 100 100 100iv) staff dismissal 72 28 100 100

b) Supervising students 9 91 33.3 66.6 100c) Supervising staff

i) personally 54 46 66.6 33.3 66.6 33.3ii) delegated supervisor 91 9 100 100iii) evaluation programmes 46 54 33.3 66.6 100iv) other methods 19 81 100 100

d) Conduct staff appraisal 19 81 33.3 66.6 33.3 66.6e) Conduct staff meetings 100 100 100f) Conduct inservice training 100 100 100g) Assign workloads 54 46 66.6 33.3 66.3 33.3h) i) Schedule patient timetables 100 100 66.6 33.3

ii) Weekend rosters 54 46 33.3 66.6 33.3 66.6iii) Holiday rosters 91 9 66.6 33.3 66.6 33.3

i) Give clinical lectures/tutorials 1 72 28 100 100j) Staff grievances 100 100 100k) Counselling staff 63 37 66.6 33.3 66.6 33.3I) Disciplining staff 100 100 100

Question 4Regular attendance in past 12 months:a) Heads of Department Meeting (hospital) 100 100 100b) Heads of Department (APA, SIG) 81 100 100c) Conferences, lectures 54 46 66.6 33.3 100d) Management lectures 54 46 100 100e) Research methods 19 81 33.3 66.6 33.3 66.6f) Other tertiary courses 19 81 33.3 66.6 33.3 66.6g) Leave granted to attend 100 100 100

Question 5a) Reports from Physiotherapy Department

Services area 72 28 100 100b) Regularly visit sections of Physiotherapy

Department 72 28 100 100c) Conduct Quality of Care Evaluation 36 64 33.3 66.6 100d) Receive or send mail to:

i) Departments in hospital 100 100 100ii) Health Commission (Regional Office) 91 9 100 100iii) Health Commission (Central

Administration) 28 72 33.3 66.6 33.3 66.6iv) Trade Organizations 72 28 66.6 33.3 100v) Professional Association 100 100 100vi) Professional Organizations 91 9 100 100vii) Patients or relatives 81 19 100 100

Question 6Most frequent method of communication:Individual contact.

The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987 31

Physiotherapists as Managers

Survey Group Sample Group(N = 11) (N = 3)

Perceived Perceived Actual

Tasks Performance Performance Performance

Yes No Yes No Yes No

Question 7a) Prepare reports on Department activities 100 100 100b) Write~ and sign requisitions 100 100 100

Question 8a) Mediate between P.T. and other hospital

departments 91 9 100 100b) Systems for identifying problems in

Physiotherapy Department 19 81 33.3 66.6 100c) Control discharge of patients 9 91 33.3 66.6 100d) Conduct research projects (in last 6 months) 36 64 66.6 33.3 100e) Allocate resources in Physiotherapy

Department 100 100 100f) Published Articles 100 100 100

Question 9Performing the following activities:a) Treating patients 72 28 100 100b) Lecturing 64 36 100 100c) Attending outpatient clinics 46 54 66.6 33.3 33.3 66.6d) Attending ward rounds 19 81 33.3 66.6 33.3 66.6e) Attending scheduled meeting_ 91 9 100 100f) Allocating patients 54 46 66.6 33.3 66.6 33.3g) Organizing physiotherapist's work 81 19 66.6 33.3 66.6 33.3h) Attending correspondence 100 100 100i) Preparing reports 100 100 100j) Preparing and overseeing budget 64 36 66.6 33.3 66.6 33.3k) Assessing department performance 81 19 100 100I) Soothing patients, families 81 19 66.6 33.3 66.6 33.3m) Pacifying doctors 81 19 100 100n) Resolving interdepartment conflict 91 9 100 1000) Negotiate for additional staff 100 100 33.3 66.6

32 The Australian Journal of Physiotherapy. Vol. 33, No.1, 1987