Musculoskeletal services in primary care in the Republic of Ireland: an insight into the perspective of physiotherapists

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Core competencies for first contact physiotherapists in a direct access model of care for adults with musculoskeletal disorders: A scoping review

INTRODUCTION

To optimise the management of Musculoskeletal disorders (MSKDs), many countries have implemented direct access to physiotherapy; however, the core competencies required for first contact physiotherapists (PTs) have not been precisely defined. The aim of this scoping review is to identify and describe the core competencies required for first contact PTs treating adults with MSKDs.

METHODS

We conducted a scoping review of the literature by searching eight databases and grey literature up to July 2023. We performed a thematic analysis of the competencies identified based on predefined themes relevant to first contact physiotherapy in direct access models in primary or emergency care settings.

RESULTS

Sixty-five articles were included. Seventeen core competencies were identified and grouped into 5 themes: (1) Assessment and examination; (2) Management and interventions; (3) Communication; (4) Cooperation and collaboration; and (5) Professionalism and leadership.

CONCLUSIONS

Our findings provide an international perspective on the core competencies required for first contact PTs.

Barriers and facilitators of integrating physiotherapy into primary health care settings: A systematic scoping review of qualitative research

Purpose

This scoping review investigated the barriers and facilitators to integrating physiotherapy into primary health care (PHC).

Materials and methods

PubMed, Scopus, Web of Science, Embase, ProQuest, and REHABDATA were searched. Two independent reviewers were involved in screening, selecting, and extracting data. Data were synthesized using thematic analysis.

Results

Of the 483 screened documents, 44 qualitative studies, primarily from high-income countries, were included. All of the studies had good methodological quality. Barriers and facilitators of integrating physiotherapy into PHC were extracted within the WHO six building blocks framework. In total, 41 items were identified as barriers to the integration process. The studies included 49 recommendations to facilitate integrating physiotherapy services into PHC.

Conclusion

Integrating physiotherapy services into PHC faces many barriers. The most commonly suggested potential barriers are poor knowledge of physicians about physiotherapy, ineffective teamwork, physiotherapists' time constraints/workload, a lack of clarity over the role and knowledge of physiotherapists, unawareness of physiotherapy users about these services, and lack of intra- and inter-professional collaborations. The most commonly suggested recommendations to facilitate the integration process include: Clarifying the role of involved professionals, strengthening teamwork, improving intra- and inter-professional collaborations, and providing comprehensive training programs for physiotherapists.

Stewardship of physiotherapy services in Iran: common pitfalls and policy solutions

Physiotherapy (PT) is a key component of the rehabilitative health strategy and an effective approach to the management and treatment of a wide range of health conditions. However, it remains underdeveloped and poorly implemented in many national health systems. Previous studies show that weak stewardship of rehabilitation services is, among others, a significant barrier to equitable access to services and supports in many parts of the world, including in Iran. This study investigated the common pitfalls and potential policy solutions to improve the stewardship of PT services in Iran from the perspective of key stakeholders. Semi-structured interviews were conducted by telephone, via the internet, and in face-to-face sessions in Iran with a purposive sample of health planners and policy decision-makers, university professors, rehabilitation managers, and physiotherapists. In total, 30 individuals agreed to participate. Participants identified several pitfalls across the six dimensions of stewardship: 1) strategy formulation; 2) inter-sectoral collaboration; 3) governance and accountability; 4) health system design; 5) policy and regulation; and 6) intelligence generation. In addition, several policy options and solutions to address critical deficiencies in the system were suggested to improve the stewardship of PT services. The study identified challenges and pitfalls affecting the stewardship of the PT sector in Iran as perceived by key stakeholders. Participants' insights can inform deliberative dialogue processes, agenda-setting, and strategy formulation to support the development, expansion, and implementation of PT services.

Organizing the flow of physiotherapy services: agreement between clinical perception and a referral protocol

Abstract Introduction: Protocols to organize the flow of treatment between primary and secondary healthcare levels help physiotherapists working in Primary Health Care (PHC) determine which cases will remain at the primary level and which should be referred to the secondary level for specialized treatment. Objective: Assess the agreement between the clinical perception of physiotherapists and the protocol in organizing the flow of physiotherapy patients. Methods: This is a methodological cross-sectional study based on the analysis of secondary data, recorded on a service spreadsheet, with respect to the clinical perception of 4 physiotherapists working in PHC and the protocol they apply to determine the urgency for referral to the secondary care level, considering physiotherapy specialties. Assessment was expressed as the percentage agreement, magnitude and significance according to the Kappa test, with > 0.80 considered perfect agreement. Analyses were conducted using SPSS 21.0 statistical software at a significance level of α = 0.05. Results: In 619 of 715 referrals, the perception of physiotherapists corroborated with the protocol in terms of patient referral to the secondary service. The percentage agreement for urgency classification in the total sample was 71% and the Weighted Kappa index 0.3710 (CI95% 0.3029-0.4391). The instrument exhibited high agreement in the areas of musculoskeletal physiotherapy (94.7%) and gerontology (98.2%), and low in urogynecology (27.6%). Conclusion: The protocol showed a high percentage of agreement and may be an important instrument in organizing the flow of physiotherapy services and could be enhanced for use in other specialties.

Physiotherapy practices in primary health care

Abstract Introduction: Physiotherapy was included in primary health care (PHC) in order to expand access and provide comprehensive care to the population. Objective: To understand the routine and tools used by physiotherapists in primary health care and analyze the determining factors in providing care in a municipality where every basic health unit (BHU) has a physiotherapist. Methods: This is a qualitative study of nineteen physiotherapists conducted in a city of Southern Brazil, using a semistructured interview and a methodological framework for discourse analysis. Results: The main tools routinely used in the physiotherapy service are individual appointments, home visits and group work. Physiotherapy practices are influenced by public health, municipal management and BHU policies, physiotherapy profile in addition to the characteristics of the coverage area and the population being treated. Introducing health promotion measures and implementing relational technologies are the main challenges for physiotherapists, and many of these professionals already recognize their importance in promoting comprehensive care. Conclusion: Physio-therapy practices and the tools used are in line with the Primary Care Family Health Support Center (NASF-AB) model of action recommended by public policies and have been effective for many health conditions. Knowing the routine of PHC physiotherapy services may help professional training and service management, with a view to producing physiotherapy care aimed at the principle of comprehensiveness and consolidating the role of physiotherapists at this level of care.

Challenges and Learning Opportunities of Pre-Registration Physiotherapy Placements in First Contact Settings: The Perspectives of Musculoskeletal First Contact Physiotherapists

OBJECTIVES

As musculoskeletal first contact physiotherapy is rolled out into primary healthcare in Britain, this could offer up new practice-based educational opportunities for pre-registration physiotherapy students. Thus, the present study sought to explore the perceived challenges and learning opportunities of pre-registration physiotherapy placements in musculoskeletal first contact physiotherapy settings from first contact physiotherapists' perspectives.

METHODS

Using a qualitative strategy, 15 musculoskeletal first contact physiotherapists from different geographical locations in Britain, participated in telephone mediated semi-structured interviews. Participants were self-selected through a Chartered Society of Physiotherapy fortnightly bulletin and online forum for first contact physiotherapists, or recruited via snowball sampling. Interview transcripts were analysed according to framework analysis - and the findings were member-checked by proxy.

RESULTS

Three core themes emerged: operational challenges, challenges for pre-registration physiotherapy students and learning opportunities for pre-registration physiotherapy students. Operational challenges included: ensuring sufficient support from first contact physiotherapy practice educators; financial cost implications of placements, and; lack of capacity within the existing first contact physiotherapy workforce to provide placements. Challenges for physiotherapy students involved: time pressures and stressors of a first contact physiotherapy placement; identifying red flags, and; complexity of patient presentations. Identified learning opportunities for physiotherapy students were: experience of a specialised physiotherapy role in a primary healthcare setting; bringing awareness of first contact physiotherapy as a potential career pathway, and; experience multidisciplinary team working in primary care.

CONCLUSIONS

By seeking the perspectives of first contact physiotherapists, this study provides the first step for the development of placements in an emerging practice area.

A profile of physiotherapy supply in Ireland

BACKGROUND

The lack of information on public and private physiotherapy supply in Ireland makes current and future resource allocation decisions difficult.

AIM

This paper estimates the supply of physiotherapists in Ireland and profiles physiotherapists across acute and non-acute sectors, and across public and private practice. It examines geographic variation in physiotherapist supply, examining the implications of controlling for healthcare need.

METHODS

Physiotherapist headcounts are estimated using Health Service Personnel Census (HSPC) and Irish Society of Chartered Physiotherapists (ISCP) Register data. Headcounts are converted to whole-time equivalents (WTEs) using the HSPC and a survey of ISCP members to account for full- and part-time working practices. Non-acute supply per 10,000 population in each county is estimated to examine geographic inequalities and the raw population is adjusted in turn for a range of need indicators.

RESULTS

An estimated 3172 physiotherapists were practising in Ireland in 2015; 6.8 physiotherapists per 10,000, providing an estimated 2620 WTEs. Females accounted for 74% of supply. Supply was greater in the non-acute sector; 1774 WTEs versus 846 WTEs in the acute sector. Physiotherapists in the acute sector were located mainly in publicly financed institutions (89%) with an even public/private split observed in the non-acute sector. Non-acute physiotherapist supply is unequally distributed across Ireland (Gini coefficient = 0.12; 95% CI 0.08-0.15), and inequalities remain after controlling for variations in healthcare needs across counties.

CONCLUSION

The supply of physiotherapists in Ireland is 30% lower than the EU-28 average. Substantial inequality in the distribution of physiotherapists across counties is observed.

Physiotherapy managers' views of musculoskeletal physiotherapy service provision in Ireland: a qualitative study

Aim Integrated multidisciplinary primary healthcare is still in a relatively early stage of development in Ireland, with significant restructuring occurring in the past decade. Musculoskeletal physiotherapy services traditionally provided in acute hospital settings have been relocated into the primary care setting where the physiotherapist works as part of the multidisciplinary team. This study aimed to explore physiotherapy managers' experiences of managing musculoskeletal physiotherapy services in primary care to gain an insight into the opportunities and challenges in service delivery, changing roles and ongoing professional development needs of staff. Participants Qualitative design using semi-structured interviews with primary care physiotherapy managers in the Republic of Ireland was employed.

RESULTS

Five interviews took in a mix of rural and urban areas nationally. The relationship with the GP was an important one in musculoskeletal physiotherapy services in primary care. Physiotherapists were well skilled but opportunities for professional and career development were restricted. Methods of optimising resources in the face of staffing restrictions were identified. Whilst there were many examples of innovations in service delivery, various barriers negatively impacted on optimal service including resource constraints and national strategy.

CONCLUSIONS

A number of factors that impact on musculoskeletal service delivery in primary care from the perspective of physiotherapy managers were identified in this study. Future research should explore the views of other stakeholders to provide a more thorough understanding of the relevant issues affecting musculoskeletal physiotherapy service provision in primary care in Ireland.