What is collaborative reasoning?

When worlds collide: Experiences of physiotherapists, chiropractors, and osteopaths working together

BACKGROUND

In Australia, people with musculoskeletal conditions frequently seek care from chiropractors, osteopaths, and physiotherapists. Intertwined histories, distinct philosophies and practical tensions characterise relationships between these three professions, yet little is known about contact or collaboration between individual clinicians.

OBJECTIVES

To explore the experiences of osteopaths, physiotherapists and chiropractors who work together in the same clinic location and explore their attitudes towards each other.

METHODS

Utilising a predominantly inductive qualitative research design, semi-structured interviews were undertaken with a total of 13 clinicians (physiotherapists [n=6], chiropractors [n=2], osteopaths [n=4], dual-qualified chiropractor and physiotherapist [n=1]) who work with at least one clinician from the other two professions. Interviews were analysed using reflexive thematic analysis.

RESULTS

Data analysis produced two main themes and five sub-themes that characterised clinicians' experiences and attitudes: collaboration (collaborative practices; benefits of collaboration) and resisting tension (accepting similarities and differences to work towards shared goals; clinic culture; alignment with evidence-based practice). These findings can be understood in the context of the concepts of professional boundary-work and intergroup contact theory.

CONCLUSIONS

The findings from this study suggest that physiotherapists, chiropractors and osteopaths that work together in the same clinic may collaborate while simultaneously navigating blurred professional lines. These results suggest that working together in the same clinic is a meaningful form of contact, which in turn allows for collaborative practices that may reduce intergroup tension between professions.

Musculoskeletal physiotherapists' perceptions of health promotion

BACKGROUND

Non-communicable diseases from unhealthy lifestyles account for most preventable deaths in the UK. Physiotherapy training now includes Health Promotion (HP) for the reduction of unhealthy lifestyles such as obesity, smoking, alcohol and inactivity. However, physiotherapists' perceptions of HP in the context of musculoskeletal care in the UK have not been explored.

OBJECTIVES

To explore musculoskeletal physiotherapists' perceptions of HP.

DESIGN

Phenomenographic qualitative research.

METHOD

semi-structured interviews with 7 musculoskeletal physiotherapists.

RESULTS/FINDINGS

Physiotherapist conceptions of HP were analysed using phenomenographic analysis and three main categories emerged. These were the concepts of physiotherapists' self, education in the therapeutic alliance and persons' agency for change. Each category contained a variety of perceptions which were sometimes conflicting, and each category had scope for influencing the others.

CONCLUSIONS

Participants' (physiotherapists) perceptions of their personal and professional self were entwined with perceptions of persons' agency when describing health promotion in their practice. Within the therapeutic alliance concepts of health coaching were discussed but these conceptualisations sometimes contradicted descriptions of experiences. This research may encourage physiotherapists to reflect on their perceptions of, and role in HP.

"Selling" chronic pain: physiotherapists' lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients

Introduction: Chronic nonspecific lower back pain (CNSLBP) is a common musculoskeletal condition which can be a source of significant distress and disability for patients. Approaches to managing CNSLBP have been explored in healthcare literature, as has the importance of communication in physiotherapy practice. However, no previous studies have explored clinicians' experiences of communicating their understanding of this diagnosis to their patients.Methods: A qualitative research design, using hermeneutic phenomenological methodology, was employed. Five participants were purposively recruited for the research and data collected via semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Emergent, super-ordinate and master themes were developed to help convey the qualitative significant meanings of the lived-through experiences.Findings: Three master themes were identified, with each comprising two sub-themes. These were: 1) Patient-centeredness (1a. Understanding the patient; and 1b. emotional awareness and adaptability); 2) Getting patients "on board" (2a. the "selling" process; and 2b. paternalism and the clinician's perspective); and 3) Dealing with conflict and uncertainty (3a. fear of interpersonal conflict; and 3b. personal doubts and uncertainty).Conclusions: Personal conflicts were identified between clinicians' descriptions of their wishes to "sell" their own perspectives to patients while simultaneously wanting to demonstrate a patient-focused approach and avoid the interpersonal conflicts which arose from clashes with patients' beliefs. Building a good initial rapport, showing empathy and adapting approaches in response to perceptions of patients' reactions were perceived as strategies to help mitigate the risks of failed communication, but this was something for which participants felt unprepared by their prior training.

Predictors of Clinical Reasoning Using the Reasoning 4 Change Instrument With Physical Therapist Students

BACKGROUND

Although physical therapist students must be well prepared to integrate biopsychosocial and behavioral perspectives into their clinical reasoning, there is a lack of knowledge regarding factors that influence such competence.

OBJECTIVE

This study explored the associations among the independent variables-knowledge, cognition, metacognition, psychological factors, contextual factors, and curriculum orientation vis-à-vis behavioral medicine competencies-and the dependent variables-outcomes of input from client (IC), functional behavioral analysis (FBA), and strategies for behavior change (SBC) as levels in physical therapist students' clinical reasoning processes.

DESIGN

This study used an exploratory cross-sectional design.

METHODS

The Reasoning 4 Change instrument was completed by 151 final-semester physical therapist students. Hierarchical multiple regression analyses for IC, FBA, and SBC were conducted. In the first step, curriculum orientation was inserted into the model; in the second step, self-rated knowledge, cognition, and metacognition; and in the third step, psychological factors.

RESULTS

All independent variables except contextual factors explained 37% of the variance in the outcome of IC. Curriculum orientation explained 3%, cognitive and metacognitive factors an additional 22%, and attitudes another 15%. Variance in the outcomes of FBA and SBC were explained by curriculum orientation only (FBA change in R2 = 0.04; SBC change in R2 = 0.05). Higher scores of the dependent variables were associated with a curriculum having behavioral medicine competencies.

LIMITATIONS

The limitations of this study are that it was cross-sectional.

CONCLUSIONS

Cognitive and metacognitive capabilities and skills and positive attitudes are important predictors of physical therapist students' clinical reasoning focused on behavior change at the IC level. Curricula with behavioral medicine competencies are associated with positive outcomes at all clinical reasoning levels.

The investigation of the educational needs on the job competence for physical therapist assistant in the students of Quang Tri medical college in Vietnam

[Purpose] The purpose of this study was to investigate the educational needs on the job competence for physical therapist assistant in the students of Quang Tri medical college in Vietnam. [Participants and Methods] Participants consisted of 17 individuals in the educational program for physical therapist assistant in Quang Tri medical college. The importance recognition ranking and current levels were measured by self-assessment for job competence of physical therapist assistant using a questionnaire. The educational needs were calculated by importance recognition ranking and current level by a self-assessment of job competence. [Results] The importance recognition ranking of job competence appeared to show a ‘system checkup’ as the top ranked category. The rank of current levels of competencies was determined by self-assessment of job competence and results showed that ‘cooperation, communication, and documentation’ was the highest category of the current levels. The highest rank of the educational needs was ‘counseling and education’. [Conclusion] The educational needs rank of job competence appeared to be ‘counseling and education’ foremost. Counseling and education with the patient is a fundamental component of effective healthcare. Therefore, it should be considered a priority for the educational curriculum of physical therapist assistant.

Exploring reasoning mechanisms in ward rounds: a critical realist multiple case study

BACKGROUND

Ward rounds are an important and ubiquitous element of hospital care with a history extending well over a century. Although originally intended as a means of educating medical trainees and junior doctors, over time they have become focused on supporting clinical practice. Surprisingly, given their ubiquity and importance, they are under-researched and inadequately understood. This study aims to contribute knowledge in human reasoning within medical teams, meeting a pressing need for research concerning the reasoning occurring in rounds.

METHODS

The research reported here aimed to improve the understanding of ward round reasoning by conducting a critical realist case study exploring the collaborative group reasoning mechanisms in the ward rounds of two hospitals in Victoria, Australia. The data collection involved observing rounds, interviewing medical practitioners and holding focus group meetings.

RESULTS

Nine group reasoning mechanisms concerning sharing, agreeing and recording information in the categories of information accumulation, sense-making and decision-making were identified, together forming a program theory of ward round reasoning. In addition, themes spanning across mechanisms were identified, further explaining ward round reasoning and suggesting avenues for future exploration. Themes included the use of various criteria, tensions involving mechanisms, time factors, medical roles and hierarchies.

CONCLUSIONS

This paper contributes to the literature by representing rounds in a manner that strengthens understanding of the form of the group reasoning occurring within, thus supporting theory-based evaluation strategies, redesigned practices and training enhancements.

Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors

RATIONALE, AIMS, AND OBJECTIVES

Clinical reasoning is an essential aspect of clinical practice, however is largely ignored in the current rehabilitation sciences evidence base. Literature related to clinical reasoning and clinical expertise has evolved concurrently although rehabilitation reasoning frameworks remain relatively generic. The purpose of this study was to explicate the clinical reasoning process of Bobath instructors of a widely used neuro-rehabilitation approach, the Bobath concept.

METHODS

A qualitative interpretive description approach consisting of stimulated recall using video-recorded treatment sessions and in-depth interviews. Purposive sampling was used to recruit members of the International Bobath Instructors Training Association (IBITA). Interview transcripts were transcribed verbatim providing the raw data. Data analysis was progressive, iterative, and inductive.

RESULTS

Twenty-two IBITA instructors from 7 different countries participated. Ranging in clinical experience from 12 to 40 years, and instructor experience from 1 to 35 years. Three themes were developed, (a) a Bobath clinical framework, (b) person-centered, and (c) a Bobath reasoning approach, highlighting the role of practical wisdom, phronesis in the clinical reasoning process. In particular the role of visuospatial-kinesthetic perception, an element of technical expertise, was illuminated as an integral aspect of clinical reasoning in this expert group.

CONCLUSIONS

This study provides an interpretive understanding of the clinical reasoning process used by IBITA instructors illustrating an inactive embodied view of clinical reasoning, specifically the role of phronesis, requiring further investigation in nonexpert Bobath therapists, as well as in novice and experienced therapists in other specialty areas.

The investigation of the effectiveness on the educational procedure development for physical therapist assistant in Quang Tri province of Vietnam

[Purpose] The purpose of the present study was to investigate the effectiveness on the educational procedure development for physical therapist assistant in Quang Tri province of Vietnam. [Subjects and Methods] The subjects consisted of 10 lecturers for the education of physical therapist assistant in Quang Tri medical college. To compare with satisfaction and educational effectiveness according to the participation of educational procedure, the lecturers conducted the survey research. [Results] In the descriptive values of participant satisfaction in educational procedure, most of the scored were higher than 4. There was no significance in the difference between the satisfaction in educational procedure according to gender and degree. However, there was some significance in class according to major. To investigate the educational effectiveness, 5 domains about knowledge of physical therapist assistant included 4 questions each were evaluated the understanding level before and after the education. In all domains, the understanding level after education was notably higher than before. [Conclusion] The present study was to the satisfaction and effectiveness of the educational procedure for physical therapist assistant reflecting the regional specialty in this area. The development of educational procedure for physical therapist assistant helps to improve the situation where the medical specialists for rehabilitation are insufficient.

Exploring barriers to accessing physiotherapy services for stroke patients at Tema general hospital, Ghana

Background

Physiotherapy has been shown to reduce the risk of disability among stroke patients. Poor adherence to physiotherapy can negatively affect outcomes and healthcare cost. However, very little is known about barriers especially to physiotherapy services in Ghana. The objective of this study was to assess the barriers to physiotherapy services for stroke patients at Tema General Hospital (TGH). The individual/personal and health system barriers to physiotherapy services at TGH were determined.

Method

A cross-sectional study design was employed. A simple random sampling technique was used to recruit 207 respondents for a face-to-face interview. Interviewer-administered questionnaires were used to collect data on individual/personal barriers of respondents to physiotherapy services and were described using the Likert’s scale. Health system barriers were assessed using a self-structured questionnaire which had section under the following heading: human factors, physiotherapy modalities, physical barriers and material/equipment factors. The time spent waiting for physiotherapy and attitude of physiotherapist towards patients; physiotherapy modality such as electrotherapy, exercise therapy and massage therapy among others were some of the indices measured. Respondents’ adherence to Medication was assessed with the Morisky 8-item medication adherence questionnaire. Data were entered and analysed using Epi info 7 and STATA 12.0. Associations between the variables were determined using a chi-square test and logistic regression model was used to test the strength of associations between the independent and the dependent variables. The level of statistical significance was set at p < 0.05.

Results

The results showed that majority (76.3%) of the respondents had economic barrier as their main individual/personal barrier to physiotherapy services. For medication adherence level, patients with low medication adherence level were about 21 times the odds of defaulting on accessing physiotherapy services five times or more as compared to those with medium adherence level (OR 20.63, 95% CI 8.96, 42.97). It was concluded in the study that individual/personal barriers of stroke patients were the significant barriers to accessing physiotherapy services at Tema General Hospital.

Electronic supplementary material

The online version of this article (doi:10.1186/s40945-017-0037-5) contains supplementary material, which is available to authorized users.

Patterns of Clinical Reasoning in Physical Therapist Students

BACKGROUND AND PURPOSE

Clinical reasoning is a complex, nonlinear problem-solving process that is influenced by models of practice. The development of physical therapists' clinical reasoning abilities is a crucial yet underresearched aspect of entry-level (professional) physical therapist education.

OBJECTIVES

The purpose of this qualitative study was to examine the types of clinical reasoning strategies physical therapist students engage in during a patient encounter.

METHODS

A qualitative descriptive case study design involving within and across case analysis was used. Eight second-year, professional physical therapist students from 2 different programs completed an evaluation and initial intervention for a standardized patient followed by a retrospective think-aloud interview to explicate their reasoning processes. Participants' clinical reasoning strategies were examined using a 2-stage qualitative method of thematic analysis.

RESULTS

Participants demonstrated consistent signs of development of physical therapy-specific reasoning processes, yet varied in their approach to the case and use of reflection. Participants who gave greater attention to patient education and empowerment also demonstrated greater use of reflection-in-action during the patient encounter. One negative case illustrates the variability in the rate at which students may develop these abilities.

CONCLUSIONS

Participants demonstrated development toward physical therapist--specific clinical reasoning, yet demonstrated qualitatively different approaches to the patient encounter. Multiple factors, including the use of reflection-in-action, may enable students to develop greater flexibility in their reasoning processes.

Physical Therapists' Ways of Talking About Overweight and Obesity: Clinical Implications

BACKGROUND

How people think and talk about weight is important because it can influence their behavior toward people who are overweight. One study has shown that physical therapists have negative attitudes toward people who are overweight. However, how this finding translates into clinical practice is not well understood. Investigating physical therapists' ways of thinking and speaking about overweight and obesity in the context of their work can provide insight into this underresearched area.

OBJECTIVES

The purpose of this study was to investigate physical therapists' ways of talking about overweight individuals and discuss clinical implications.

DESIGN

An interpretive qualitative design was used.

METHODS

The research team used discourse analysis, a type of inductive qualitative methodology, to guide data collection and analysis. The data came from 6 focus groups of 4 to 6 physical therapists in Queensland, Australia, who discussed weight in a physical therapy environment. Participants (N=27) represented a variety of physical therapy subdisciplines.

RESULTS

Data analysis identified 4 main weight discourses (ways of thinking and speaking about weight). Participants described patients who are overweight as little affected by stigma and difficult to treat. Furthermore, participants portrayed weight as having simple causes and being important in physical therapy. Alternate weight discourses were less frequent in these data.

CONCLUSIONS

The results indicated that some physical therapists' understandings of weight might lead to negative interactions with patients who are overweight. The findings suggest physical therapists require more nuanced understandings of: how patients who are overweight might feel in a physical therapy setting, the complexity of causes of weight, and possible benefits and disadvantages of introducing weight-management discussions with patients. Therefore, education should encourage complex understandings of working with patients of all sizes, including knowledge of weight stigma.

The potential of critical social theory as an educational framework for people with epilepsy

Effective education can support people with epilepsy to develop the attributes and skills required to function as equal partners with clinical service providers, make informed decisions, and competently self-manage their healthcare. However, despite knowledge deficits, unmet information needs, and a poor sense of empowerment, the study of education for people with epilepsy is often neglected and is a poorly understood component of holistic practice within epilepsy healthcare. Historically, the only debate with regard to education and people with epilepsy has been guided either within a positivist or within a constructivist philosophy. We argue that new pedagogies are warranted, recognizing the views of people with epilepsy regarding their illness. Therefore, this paper explores the potential of an educational framework for people with epilepsy based upon critical social theory (CST). By utilizing a CST approach for education, people with epilepsy are engaged with as active 'participants'. This is a key difference that distinguishes CST from other metatheoretical frameworks. It has the potential to support people with epilepsy to acquire the skills and confidence to manage the biopsychosocial challenges associated with their condition.

Opening clinical encounters in an adult musculoskeletal setting

Effective communication between healthcare professionals and their patients is crucial for successful consultations, and can profoundly affect patients' adherence to treatment. Despite this evidence, communication within the physiotherapy profession is still underexplored, in particular, how 'best' to open clinical encounters. This study explores the issue by seeking the preferences of physiotherapists for opening encounters in the adult musculoskeletal outpatient setting. Initially, 42 consultations and 17 first follow-up encounters were observed between qualified physiotherapists and patients with back pain. These encounters were audio-recorded, analysed and used to develop a questionnaire to determine clinicians' preferences for opening encounters. From these findings, a synopsis of the questionnaire was posted on the four most-relevant professional networks of the national, interactive Chartered Society of Physiotherapy (iCSP) website, to canvass opinion more widely. Among the 43 physiotherapists who responded, the preferred 'key clinical question' for an initial encounter was: "Do you want to just tell me a little bit about [your 'problem presentation'] first of all?"; and for follow-up encounters: 'How have you been since I last saw you?' These results provide an important and novel contribution to the profession, as debate on this issue has not previously been published. Although the sample size in this study is small, the aim of this paper is to generate reflection and debate among clinicians on their preferences for opening patient encounters and optimising the non-specific treatment effects.

A spinal triage programme delivered by physiotherapists in collaboration with orthopaedic surgeons

PURPOSE

To describe the characteristics of participants in a physiotherapist spinal triage programme, compare the profiles of patients for whom surgery was and was not recommended by a surgeon, and determine the surgical yield among those referred to surgeons.

METHODS

Data were collected retrospectively by reviewing charts of people who used the service over a 3-year period (2003-2006). Data from up to1,096 people were used in the analysis; complete data were available for 299 people. Descriptive statistics were used to summarize demographics, clinical features, and management recommendations. Characteristics of those who were and were not recommended for surgery were examined using Pearson's chi-square or Fisher's Exact tests.

RESULTS

The majority of 746 participants were classified as "mechanical spine" (92.5%), 2.9% were "other body part," 2.5% were "medical/other," and only 2% were classified as "surgical spine." Recommendations for surgery (by a surgeon) were independent of patients' age, sex, duration of symptoms, residence (urban/rural), source of health care funding, and diagnosis. The surgical yield was 80%.

CONCLUSIONS

Most people were not considered candidates for surgery. Triage assessment by physiotherapists can increase the efficiency of an orthopaedic surgeon's caseload by reducing the number of non-surgical referrals and can thus help to ensure more timely access to appropriate health care.

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.

Enhancing Professional Reasoning through the Use of Evidence-Based Assessments, Robust Case Formulations and Measurable Goals

The value of therapists documenting their clinical reasoning and negotiating specific and measurable goals is widely acknowledged. However, the literature suggests that practitioners often encounter barriers when implementing best practice.

This article details how occupational therapists in Derbyshire Healthcare NHS Foundation Trust entered an academic partnership, which transformed their communication of clinical and professional reasoning. Having adopted a conceptual model of practice, they established clearly defined processes for assessment, case formulation and goal setting. Service users, carers and team members confirmed that these initiatives enhanced person-centred practice, highlighted occupational issues and made treatment planning more effective for the whole team.

Patients' experiences of telerehabilitation at home after shoulder joint replacement

We investigated the experience of ten patients who received video-based physiotherapy at home for two months after a shoulder joint replacement. Videoconferencing took place via the patient's home broadband connection at a bandwidth of 256–768 kbit/s. Qualitative interviews were carried out, transcribed and analysed. Through qualitative content analysis six categories were identified: (1) a different reinforced communication; (2) pain-free exercising as an effective routine; (3) from a dependent patient to a strengthened person at home; (4) closeness at a distance; (5) facilitated daily living; and (6) continuous physiotherapy chain. The access to bodily knowledge, continuity, collaboration and being at home were all aspects that contributed to the patients' recovery. The patients described experiences of safety, and strengthening during their daily exercise routine at home. The frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgement about each patient; this could be one reason for the positive findings. Home video-based physiotherapy may be useful in other kinds of physiotherapy.

Goal-setting in paediatric rehabilitation: perceptions of parents and professional

BACKGROUND

In paediatric rehabilitation, there is a belief in goal-setting as a fundamental component of decision-making that encourages collaboration and motivation, and improves outcomes. This study aimed to explore parents' and professionals' perceptions of setting and implementing goals within a family centred rehabilitation programme for preschoolers with cerebral palsy (CP).

METHODS

Parents and service providers of 13 preschoolers with CP, classified in Gross Motor Function Classification System level I-III, participated in two-step focus group interviews.

RESULTS

Three major themes emerged, each with two subthemes: (1) 'Goals enhance competence' with the subthemes 'parents as drivers', and 'awareness through observation'; (2) 'Goals direct attention' with the subthemes 'goals as valuable means' and 'collaboration through participation', and (3) 'Goals enter everyday life' with the subthemes 'goals as activities' and 'training vs. everyday practise'. A fourth theme 'child perspective' with the subthemes 'follow-up initiative', 'capture mastery', and 'create learning opportunities' was both an exclusive theme and integrated in the other three main themes.

CONCLUSIONS

Active involvement of parents throughout the process of setting and implementing goals seemed to increase their feeling of competency and partnership with professionals. Concrete goals based on families' preferences and concerns, participatory observation, and discussions with professionals, came out as valuable means for practice of functional tasks within home environments.

'We got the whole story all at once': physiotherapists' use of key questions when meeting patients with long-standing pain

Long-standing musculoskeletal pain has many dimensions. Physiotherapy lacks a tested method of dialogue with which physiotherapists and patients can together explore pain in all its complexity. The present aim was to find out how physiotherapists experienced the influence of systematically prepared key questioning on their relation to, and understanding of, patients with long-standing pain. A group of six physiotherapists with long experience of pain rehabilitation used such questions in their encounters with their patients. Two periods of work with the questions were followed by discussions in which the physiotherapists shared their experience in a joint focus group. Verbatim transcripts of the discussions constitute the data of the study. A phenomenographic method was used for the analysis. The responses to the key questions gave the physiotherapists an insight into the patient as a person. The questions started a process of change in the patient, and changed the physiotherapist's relation to her or him. The patient expressed feelings and experience, and this also seemed to encourage a change in chosen coping strategies. This new content of the interaction challenged the physiotherapist's role, thus raising questions about her professional mandate.

Clinical reasoning in musculoskeletal practice: students' conceptualizations

BACKGROUND

Qualitative research on physical therapist students' conceptualizations of clinical reasoning (CR) is sparse.

OBJECTIVES

The purpose of this study was to explore CR from students' perspectives.

DESIGN

For this study, a qualitative, cross-sectional design was used.

METHODS

Thirty-one students were randomly selected from years 2, 3, and 4 of an undergraduate physical therapist program in New Zealand. Students were interviewed about their understanding of CR and how they used it in practice in a recent musculoskeletal placement. Interviews were recorded and transcribed verbatim. A 3-stage analysis included the categorization of students' conceptualizations on the basis of the meaning and the structure of each experience and the identification of cross-category themes.

RESULTS

Five qualitatively different categories were identified: A--applying knowledge and experience to the problem, patient, or situation; B--analyzing and reanalyzing to deduce the problem and treatment; C--rationalizing or justifying what and why; D-combining knowledge to reach a conclusion; and E--problem solving and pattern building. Cross-category analysis revealed 5 general themes: forms of CR, spatiotemporal aspects, the degree of focus on the patient, attributions of confidence, and the role of clinical experience.

CONCLUSIONS

Categories formed a continuum of CR from less to more sophistication and complexity. Students were distributed evenly across categories, except for category E, which included only students from years 3 and 4. Each category comprised a logical, coherent experiential field. The general themes as critical dimensions suggest a new way of exploring CR and suggest a possible pathway of development, but further research is required. These findings have implications for teaching and the development of physical therapy curricula.

An ethnographic study of physiotherapists' perceptions of their interactions with patients on a chronic pain unit

Changes in health care brought about by the increased incidence of chronic conditions have resulted in an increased focus on patient self-directed care. This ethnographic study explores from the therapists' perspectives how therapist/patient interactions influence success or contribute to meeting the patients' goals on a pain management program. A team of physiotherapists were observed individually with their patients over a period of 6 months. Their interactions were audiotaped, transcribed, analysed, and cross-referenced to the field notes and the follow-up interviews with the therapists after each observation. The analysis was iterative, guided by questions and contextualised. Codes, categories, and evolving patterns of behaviour were documented, and three major themes were identified. The therapist/patient interactions demonstrated certain consistent standpoints toward the purpose of the program. The team judged those who achieved positive outcomes, as having entered into interactions typified by assertiveness, negotiation, and critical reflection. However, even the most able team of therapists will not be able to create a collaborative framework unless their patients are willing to grasp the opportunity offered to them, and they judged their least successful patients as having adopted unwilling and unrealistic interactions. Interactions of resistance or an inability to carry over problem solving skills into their lives resulted in a negative outcome for the patients and a stunting of the team's potential.

A survey to e xplore the negative social evaluation of patients by physiotherapists

There is a paucity in the physiotherapy literature about the specific characteristics and circumstances which lead to the negative social evaluation of patients as 'problems'. The aim of this survey was to explore further the 'problem patient' categories defined by Thomson (2000) in a group of physiotherapists in four London NHS hospitals.

Results showed that the majority of problem patient categories were generalizable to a wider population of therapists although the agreement was relatively weak. Patients with multiple healthcare and psychosocial needs were seen the most often and 15 out of the 17 categories were seen regularly.

The lack of extremes of opinion suggests these physiotherapists are reluctant to label patients negatively. The differences between the junior grades (juniors and senior IIs) and senior grades (senior I and above) suggested that inexperience and lack of time management skills underpinned the juniors' understanding of problem patients. The context, daily practice and the type of patients seen reflected the disparity between the clinical settings. A biopsychosocial approach in which patients are enabled to contribute their perspective to increase and possibly change the therapists' understanding are crucial to the management of problem patients.

Nurses’ responses to expert patients: The rhetoric and reality of self-management in long-term conditions: A grounded theory study

BACKGROUND

Against the backdrop in the western world of increasing prevalence of chronic disease, active and informed patients and a policy emphasis on self-management, this English study explored health professionals' responses to expert patients.

OBJECTIVES

To:

DESIGN

A grounded theory approach was utilised with two concurrent data strands.

SETTING

A relatively affluent English county including community, primary and secondary care settings.

PARTICIPANTS

Via purposeful and theoretical sampling 100 health professionals (nurses, doctors, physiotherapists) and 100 adults affected by chronic disease participated.

METHODS

Focus groups, interviews and observation.

RESULTS

Nurses were found to be most anxious about expert patients when compared to other professionals, which appeared to be linked with a lack of professional confidence and unfounded fears regarding litigation. However, nurse specialists often provided a negative case for this. As a whole, nurses were most able to meet the emotional needs of patients, but apart from nurse specialists did not articulate this as a skill.

CONCLUSION

Apart from nurse specialists the majority of nurses appeared limited in appropriately facilitating self-management. It is suggested that this is linked to an ongoing nursing culture of patient as passive, an over-emphasis on empirical knowledge and a feeling of vulnerability on the nurses' part towards expert patients. The findings also indicate a rhetoric rather than reality of autonomous nursing roles within the chronic disease management agenda.