Practitioner experiences from the structured implementation of evidence-based practice in primary care physiotherapy: A qualitative study

Physiotherapists' experiences of implementation of the BetterBack model of care for low back pain in primary care - a focus group interview study

INTRODUCTION

The BetterBack model of care (MoC), a best practice physiotherapy MoC for low back pain (LBP), was implemented in Swedish primary care to improve management of patients with LBP and provide patients with support tools to better self-manage episodes of LBP.

PURPOSE

The objective was to describe how physiotherapists in primary care experienced the implementation of the BetterBack MoC for LBP.

METHODS

Focus group interviews were conducted with physiotherapists in 2018-2019, 14-18 months after the introduction of the BetterBack MoC. Data were analyzed using qualitative content analysis.

RESULTS

Five focus group interviews with 23 (15 female and 8 male) physiotherapists, age range 24-61 years were analyzed. A supportive organization and adaptation to the local culture, combined with health care professionals' attitudes and collaboration between physiotherapists emerged as important factors for a successful implementation and for long-term sustainability of the MoC. Physiotherapists had differing opinions if the implementation led to change in clinical practice. Improved confidence in how to manage patients with LBP was expressed by physiotherapists.

CONCLUSIONS

Several barriers and facilitators influence the implementation of a best practice physiotherapy MoC for LBP in primary care, which need to be considered in future implementation and sustainability processes.

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.

Professional knowledge development and evidence-based practice in confusing vs. supportive work organizations: A grounded theory situational analysis of Swedish elderly care

BACKGROUND

This article focuses on knowledge development and health professionals' opportunities to use evidence-based practice (EBP). We studied registered physiotherapists (PT), occupational therapists (OT) and nurses (RN) in Swedish elderly-care institutions, a sector known for high turnover and shortages of competent staff.

OBJECTIVE

To examine the perspectives of healthcare providers on professional knowledge development and EBP in their organization.

METHODS

We conducted on-site qualitative interviews with a purposive sample of PTs, OTs and RNs, in six elderly care institutions. Situational analysis was used to analyze the material.

RESULTS

Three discursive professional positions were found: 1) Professional ambition in confusing work organization; 2) Professional ambition in a knowledge-promoting work organization; and 3) Professional indifference with few aspirations for knowledge development. Professional aspirations toward knowledge development were high in two of these positions, whereas the third represents a slightly different approach with fewer aspirations for knowledge development. Linked to these professional approaches to knowledge development is a continuum of aggravating or facilitating factors within the work organization, including varying degrees of support from leadership of the organization, as well as few opportunities for rewards.

DISCUSSION AND CONCLUSIONS

It is concluded that elderly care needs to develop strategies for evidence-based practice in order for the sector to become a sustainable arena for health professionals' career development, and in order to improve the quality of care for the elderly.

Continuous flow insufflation of oxygen compared with manual ventilation during out-of-hospital cardiac arrest: A survey of the paramedics

Introduction:

In 2018, a continuous flow insufflation of oxygen (CFIO) device (b-card™, Vygon (USA)) placed on a supraglottic airway (SGA) became the standard of care to ventilate patients during adult out-of-hospital cardiac arrest (OHCA) care in Quebec–Capitale-Nationale region, Canada. This study aims to assess the paramedics’ perception as well as the disadvantages and the benefits relative to the use of CFIO during OHCA management.

Methods:

An invitation to complete an online survey (Survey Monkey™) was sent to all 560 paramedics who are working in our region. The survey included 22 questions of which 9 aimed to compare the traditional manual ventilation with a bag to the CFIO using a 5-point Likert-type scale.

Results:

A total of 244 paramedics completed the survey, of which 189 (77.5%) had used the CFIO device during an OHCA at least once. Most respondents felt that the intervention was faster (70.2%) and easier (86.5%) with the CFIO device compared with manual ventilation. CFIO was also associated with perceived increased patient safety (64.4%) as well as paramedic safety during the evacuation (88.9%) and the ambulance transport (88.9%). Paramedics reported that physical (48.1%) and cognitive (52.9%) fatigue were also improved with CFIO. The main reported barriers were the bending of the external SGA tube and the loss of capnography values.

Conclusion:

The use of CFIO during adult OHCA care allows a simplified approach and was perceived as safer for the patient and the paramedics compared with manual ventilation. Its impact on patient-centred outcomes needs to be assessed.

Confidence, attitudes, beliefs and determinants of implementation behaviours among physiotherapists towards clinical management of low back pain before and after implementation of the BetterBack model of care

BACKGROUND

Implementing clinical guidelines is challenging. To facilitate uptake, we developed a model of care (BetterBack Model of Care) and an implementation strategy to support management of low back pain in primary care. The aim of this study was to evaluate physiotherapists´ confidence, attitudes and beliefs in managing patients with low back pain before and after a multifaceted implementation of the BetterBack Model of Care. A further aim was to evaluate determinants of implementation behaviours among physiotherapists.

METHODS

This clinical trial was an experimental before and after study within a hybrid type 2 effectiveness-implementation trial. The primary outcome was Practitioner Self-Confidence Scale (PCS), secondary outcomes were the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT) and Determinants of Implementation Behaviour Questionnaire (DIBQ). Data was analysed using repeated measures ANOVA and pairwise comparisons.

RESULTS

One hundred sixteen physiotherapists answered a questionnaire before, directly after, as well as 3 and 12 months after implementation of the Model of Care. PCS improved over time with a large effect size post implementation (ηp2 = 0.197, p < 0.001). Changes in PABS-PT were only significant after 12 months with higher biopsychosocial orientation, (ηp2 = 0.071, p < 0.01) and lower biomedical orientation, (ηp2 = 0.136, p < 0.001). Directly after the workshop, after 3 and 12 months, physiotherapists had high ratings on all DIBQ domains, (scores > 50) implying that all were potential facilitators of the implementation. However, after 3 months, all domains had significantly decreased except for organisation, social influence and patient expectation domains. However, after 12 months, organisation and social influence domains had significantly decreased while domains such as knowledge, skills and beliefs about capabilities returned to initial levels.

CONCLUSIONS

Physiotherapists´ confidence and biopsychosocial orientation increased after implementation and may have the potential to improve management of low back pain in primary care. The implementation behaviour showed mostly facilitating patterns but changed over time, pinpointing a need to repeatedly monitor these changes. This can inform the need for changes of implementation efforts in different phases and support sustainability strategies.

TRAIL REGISTRATION

ClinicalTrials.gov NCT03147300 3 May 2017, prospectivly registered.