The 'responsive' practitioner: physiotherapists' reflections on the 'good' in physiotherapy practice

BACKGROUND

Being 'responsive' is named as an element of ethic of care theories, yet how it is enacted is not clearly described in health professional practice. Being 'responsive' is implied within patient-centered approaches and promoted as important to health care practices, including physiotherapy. However, ways of being a responsive practitioner have not been explicitly examined. Practitioners' perspectives about how a 'good' physiotherapist enacts responsiveness have potential implications for the future practice of physiotherapy. Physiotherapists' perceptions may inform professional priorities including education curricula, professional practices, and patient interactions.

PURPOSE

The purpose of this research was to explore experienced musculoskeletal (MSK) practitioners' perceptions of 'responsiveness' in the practice of a 'good' physiotherapist.

METHODS

A secondary analysis of data arising from a hermeneutic phenomenological study into physiotherapists' perceptions of what constitutes a 'good' physiotherapist was undertaken. The secondary analysis focused on 'responsiveness,' which emerged as a major theme in the original study.

FINDINGS

Six themes were identified related to 'Being responsive' in a 'good' physiotherapist: Being person-centered, Being attentive, Being open, Being a listener, Being validating, and Being positive.

CONCLUSIONS

As a relational way of practicing, being responsive may facilitate person-centered approaches including a relational understanding of autonomy, inviting dialogue, and sharing power and decision-making with patients. Pivotal to the practice of a 'good' physiotherapist, being responsive in the ways underscored by participants suggests researchers, educators, and practitioners consider relational ways of practicing as a balance to the technical aspects of physiotherapy.

An integrative review of the qualities of a 'good' physiotherapist

INTRODUCTION

Qualities of a physiotherapist may influence the therapeutic alliance and physiotherapy outcomes. Understanding what qualities constitute a 'good' physiotherapist has yet to be systematically reviewed notwithstanding potentially profound implications for the future practice of physiotherapy.

PURPOSE

The primary purpose of this review was to critically examine how physiotherapists and their patients describe the qualities of a 'good' musculoskeletal physiotherapist as depicted in peer-reviewed literature. The secondary aim was to synthesize qualities represented in the literature, and to compare patient and physiotherapist perspectives.

METHODS

An integrative review methodology was used to undertake a comprehensive literature search, quality appraisal of studies, and thematic analysis of findings. An electronic search of CINAHL, EMBASE, Nursing and Allied Health, PsycINFO, PubMed, and Scopus databases was conducted within a time range from database inception to June 14, 2019.

RESULTS

Twenty-seven studies met the inclusion criteria. Six qualities of a 'good' musculoskeletal physiotherapist were identified as: responsive, ethical, communicative, caring, competent, and collaborative.

CONCLUSIONS

The qualities of a 'good' physiotherapist identified in the review emphasize the human interaction between physiotherapists and patients and point to the centrality of balancing technical competence with a relational way of being.

Decision-making during obstetric emergencies: A narrative approach

This study aims to explore how physicians make sense of and give meaning to their decision-making during obstetric emergencies. Childbirth is considered safe in the wealthiest parts of the world. However, variations in both intervention rates and delivery outcomes have been found between countries and between maternity units of the same country. Interventions can prevent neonatal and maternal morbidity but may cause avoidable harm if performed without medical indication. To gain insight into the possible causes of this variation, we turned to first-person perspectives, and particularly physicians’ as they hold a central role in the obstetric team. This study was conducted at four maternity units in the southern region of Sweden. Using a narrative approach, individual in-depth interviews ignited by retelling an event and supported by art images, were performed between Oct. 2018 and Feb. 2020. In total 17 obstetricians and gynecologists participated. An inductive thematic narrative analysis was used for interpreting the data. Eight themes were constructed: (a) feeling lonely, (b) awareness of time, (c) sense of responsibility, (d) keeping calm, (e) work experience, (f) attending midwife, (g) mind-set and setting, and (h) hedging. Three decision-making perspectives were constructed: (I) individual-centered strategy, (II) dialogue-distributed process, and (III) chaotic flow-orientation. This study shows how various psychological and organizational conditions synergize with physicians during decision-making. It also indicates how physicians gave decision-making meaning through individual motivations and rationales, expressed as a perspective. Finally, the study also suggests that decision-making evolves with experience, and over time. The findings have significance for teamwork, team training, patient safety and for education of trainees.

Empowering patients in the hospital as a new approach to reducing the burden of health care-associated infections: The attitudes of hospital health care workers

BACKGROUND

Any approach promoting a culture of safety and the prevention of health care-associated infections (HCAIs) should involve all stakeholders, including by definition the patients themselves. This qualitative study explored the knowledge and attitudes of health care workers toward the concept of patient empowerment focused on improving infection control practices.

METHODS

Semi-structured interviews were undertaken with 29 staff from a large hospital in Sydney, Australia.

RESULTS

There was virtually unanimous agreement among the participants that patients should be thought of as a stakeholder and should have a role in the prevention of HCAI. However, the degree of patient responsibility and level of system engagement varied. Although very few had previously been exposed to the concept of empowerment, they were accepting of the idea and were surprised that hospitals had not yet adopted the concept. However, they felt that a lack of support, busy workloads, and negative attitudes would be key barriers to the implementation of any empowerment programs.

CONCLUSION

Although the World Health Organization has recommended that patients have a role in encouraging hand hygiene as a means of preventing infection, patient engagement remains an underused method. By extending the concept of patient empowerment to a range of infection prevention opportunities, the positive impact of this intervention will not only extend to the patient but to the system itself.

Emancipatory physiotherapy practice

In physiotherapy, as with many other health-care practices, therapeutic interventions, based on scientific knowledge, may be at odds with patient experiences. Patients may understand what they need to do to improve their health condition, but feel that these requirements may be emotionally, socially, or culturally incompatible with their lifestyles, social behavior, or personal choices. To work in the best interest of their patients, physiotherapists need to engage with the tensions that exist between scientific reason and social reality to offer a meaningful and relevant service for their patients. The challenge for physiotherapists is to arrive at decisions and interventions together with their patients that enhance, for example, mobility, social function, and well-being. To achieve this, physiotherapists need to rethink their professional role and translate their technical knowledge and goals into the patient's 'lifeworld', and patients--for their part--need to engage with physiotherapy professional knowledge. Often, the most commonly used strategy for facilitating this reciprocal engagement is open dialogue between patients and therapists. Habermas, a prominent contemporary philosopher and critical theorist, has developed a communicative theory that may support physiotherapists in their efforts to arrive at more sustainable and shared decisions with their patients. In this paper, I examine what constitutes physiotherapists' practice knowledge and how Habermas's theory of knowledge, interest, and communication strengthens shared decision-making and can be used as a vehicle toward emancipatory practice. Drawing on data generated in an action research project, I examine how Habermas's ideas can be applied in emancipatory physiotherapy practice. The paper concludes that emancipatory practice is meaningful because it creates opportunities for reflection, evaluation, and choice for future physiotherapy practice.

Core components of communication of clinical reasoning: a qualitative study with experienced Australian physiotherapists

Communication is an important area in health professional education curricula, however it has been dealt with as discrete skills that can be learned and taught separate to the underlying thinking. Communication of clinical reasoning is a phenomenon that has largely been ignored in the literature. This research sought to examine how experienced physiotherapists communicate their clinical reasoning and to identify the core processes of this communication. A hermeneutic phenomenological research study was conducted using multiple methods of text construction including repeated semi-structured interviews, observation and written exercises. Hermeneutic analysis of texts involved iterative reading and interpretation of texts with the development of themes and sub-themes. Communication of clinical reasoning was perceived to be complex, dynamic and largely automatic. A key finding was that articulating reasoning (particularly during research) does not completely represent actual reasoning processes but represents a (re)construction of the more complex, rapid and multi-layered processes that operate in practice. These communications are constructed in ways that are perceived as being most relevant to the audience, context and purpose of the communication. Five core components of communicating clinical reasoning were identified: active listening, framing and presenting the message, matching the co-communicator, metacognitive aspects of communication and clinical reasoning abilities. We propose that communication of clinical reasoning is both an inherent part of reasoning as well as an essential and complementary skill based on the contextual demands of the task and situation. In this way clinical reasoning and its communication are intertwined, providing evidence for the argument that they should be learned (and explicitly taught) in synergy and in context.

Decision aid software programs in telenursing: not used as intended? Experiences of Swedish telenurses

Telenurses at call centers use decision aid software programs to offer triage recommendations and self-care advice to the general public. Decision aid programs are intended to support medical safety but were suggested by telenurses to be a hindrance to the dialogue. The aim of this study was to explore the use of decision aid software programs for telenursing, from the perspective of the users. A qualitative, descriptive approach was used. Twelve telenurses in Sweden were interviewed twice. The interviews were transcribed and analyzed thematically. Four themes were found: support for assessment but not for the decision; inconsistency between actual practice and the decision aid software; limited support for learning and information; and communication challenges and software programs. The software programs were a support for assessment, rather than decision-making, assuring the nurses that the relevant questions were asked. They were not fully adapted to current clinical practice, focusing mainly on acute conditions. Nurses worked to a large extent with self-care advice, often over-riding the recommendations made.

Evidence and expertise

This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.

Integrating Decision Making and Mental Health Interventions Research: Research Directions

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.