Navigating diagnostic uncertainty in musculoskeletal practice: The perspectives and experiences of new graduate physiotherapists

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Prescribing exercise therapy for the management of musculoskeletal pain: new-graduate physiotherapists' perceptions and perceived training needs

BACKGROUND

Pain management is a challenging area of practice for new-graduate physiotherapists during the transition from student to clinician. The attitudes and beliefs of new-graduate physiotherapists toward the use of exercise therapy as part of the management of musculoskeletal pain remain relatively unknown.

PURPOSE

The aim of the study was to investigate the perspectives of new-graduate physiotherapists toward prescribing exercise therapy in musculoskeletal pain management, and their perceptions of training and support needs in this area of practice.

METHODS

A qualitative study with a general inductive approach was used to investigate new-graduate physiotherapists' perspectives. Semi-structured interviews were conducted with 16 participants. Interview data was subjected to thematic analysis.

RESULTS

Four themes were generated following analysis: 1) Balancing the value of exercise with practical challenges; 2) Communication and education are inherent in exercise; 3) Influence of support and training; and 4) The benefits of direct experience.

CONCLUSION

New-graduate physiotherapists acknowledge the pivotal role of exercise in managing musculoskeletal pain. Direct learning experiences in pre-professional training that develop knowledge and skills required for delivering exercise therapy were highly valued. New-graduates recognize pain management as a skill that requires further development and identify the importance of opportunities for professional development in exercise therapy.

Identifying and navigating suspected serious pathologies: New-graduate physiotherapists' perspectives and developmental needs

BACKGROUND

Physiotherapists in Australia play a vital first-contact role in identifying suspected serious pathologies and navigating their management pathways. Current literature highlights challenges faced by physiotherapists including implications of ineffective identification and management of suspected serious pathologies, yet the perspectives of new-graduate physiotherapists related to this area of practice remain unknown.

OBJECTIVE

The aim of this study was to explore new-graduate physiotherapists' perspectives and developmental needs related to identifying suspected serious pathologies and navigating their management pathways in patients with musculoskeletal complaints.

DESIGN

and Method: A qualitative study using a reflexive thematic analytical approach was undertaken. Eighteen semi-structured interviews were conducted. Thematic analysis was utilized on the interview data.

RESULTS

Four key themes were generated: (1) Physiotherapists as advocates; (2) Navigating uncertainties and complexities; (3) Safe and accessible workplace support builds confidence; and (4) Importance of direct learning opportunities.

CONCLUSION

New-graduate physiotherapists recognize their imperative role as first-contact practitioners in identifying and navigating suspected serious pathologies yet also experience significant uncertainties. The findings highlight key developmental needs, including supportive workplaces, established referral frameworks and direct learning opportunities during pre-professional training.

The first year of private practice - new graduate physiotherapists are highly engaged and satisfied but edging toward burnout

BACKGROUND

A greater understanding of physiotherapists' work-life during their first year of work in private practice, and whether their experiences are mediated by personal traits, may provide valuable information to support their transition and retention.

OBJECTIVES

Describe the first year of practice for graduate physiotherapists in terms of employee engagement, job satisfaction, performance, and burnout, and evaluate the relationship between these measures and personal traits (resilience, grit, mind-set).

DESIGN

One-year longitudinal mixed-methods study.

METHODS

Twenty new graduate physiotherapists completed questionnaires evaluating resilience, grit, and mind-set within 1-week of commencing employment. Engagement and job satisfaction were evaluated at 3, 6 and 12-months, and burnout evaluated at 12-months. Performance data (number of patients seen, revenue) were collected throughout the year. Individual semi-structured interviews were conducted at baseline, 3, 9 and 12-months.

RESULTS

Engagement and satisfaction were high at all time points. At 12-months, burnout was at a medium level. Resilience was positively associated with job satisfaction at 6 (ρ = 0.56, p = .019) and 12-months (ρ = 0.54, p = .027). Engagement (ρ = -0.57, p = .04) and job satisfaction (ρ = -0.56, p = .03) were negatively associated with burnout at 12-months. All participants remained passionate about their work although increasing administrative burden and patient complexity contributed to feelings of burnout.

CONCLUSIONS

Resilience was positively associated with job satisfaction suggesting those with capacity to 'bounce back' were more satisfied and engaged with their job. Although moderate levels of burnout were reported at 12-months, those with higher job satisfaction and employee engagement had lower levels of burnout. Participants proposed practical strategies to help mitigate burnout.

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

AIM

The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care.

BACKGROUND

The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role.

METHOD

A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data.

FINDINGS

Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty.

CONCLUSION

This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

Uncertainty in low back pain care - insights from an ethnographic study

PURPOSE

To explore how uncertainty plays out in low back pain (LBP) care and investigate how clinicians manage accompanying emotions/tensions.

MATERIALS AND METHODS

We conducted ethnographic observations of clinical encounters in a private physiotherapy practice and a public multidisciplinary pain clinic. Our qualitative reflexive thematic analysis involved abductive thematic principles informed by Fox and Katz (medical uncertainty) and Ahmed (emotions).

RESULTS

We identified three themes. (1) Sources of uncertainty: both patients and clinicians expressed uncertainty during clinical encounters (e.g., causes of LBP, mismatch between imaging findings and presentation). Such uncertainty was often accompanied by emotions - anger, tiredness, frustration. (2) Neglecting complexity: clinicians often attempted to decrease uncertainty and associated emotions by providing narrow answers to questions about LBP. At times, clinicians' denial of uncertainty also appeared to deny patients the right to make informed decisions about treatments. (3) Attending to uncertainty?: clinicians attended to uncertainty through logical reasoning, reassurance, acknowledgement, personalising care, shifting power, adjusting language and disclosing risks.

CONCLUSIONS

Uncertainty pervades LBP care and is often accompanied by emotions, emphasising the need for a healthcare culture that recognises the emotional dimensions of patient-clinician interactions and prepares clinicians and patients to be more accepting of, and clearly communicate about, uncertainty.IMPLICATIONS FOR REHABILITATIONUncertainty pervades LBP care and is often accompanied by emotions.Neglecting complexity in LBP care may compromise person-centred care.Acknowledging uncertainty can enhance communication, balance patient-clinician relationships and address human aspects of care.

Clients and conditions encountered by final year physiotherapy students in private practice. A retrospective analysis

Currently little is known about the clients and conditions final-year physiotherapy students are exposed to in private practice settings. The aim of this study is to describe the clients and conditions encountered by final-year physiotherapy students during a six-week full-time private practice clinical placement. Client data of conditions were collected over 11 years (2008-2018) from final year physiotherapy students' client reports in a university clinic, Christchurch, New Zealand. Data for anatomical site and pathology were categorized using the Orchards Sports Injury Classification System 10 and descriptive analyses completed. Students saw a mean of 22 (SD 5) unique clients. The anatomical sites most encountered were the shoulder (97.4% of students), lumbar spine (96.3%), knee (95.8%) and ankle (91.2%). The pathologies most encountered were joint sprain (100%), muscle injury (90%), and tendon injury (88.4%). While final year physiotherapy students are exposed to a substantial number of clients encompassing major regions and condition types, this exposure is limited in scope. The findings offer a basis for discussion about what clinical exposure to clients and conditions might best support the transition from physiotherapy student to new graduate in private practice settings.