Developing a living lab in ethics: Initial issues and observations

Living labs are interdisciplinary and participatory initiatives aimed at bringing research closer to practice by involving stakeholders in all stages of research. Living labs align with the principles of participatory research methods as well as recent insights about how participatory ways of generating knowledge help to change practices in concrete settings with respect to specific problems. The participatory, open, and discussion-oriented nature of living labs could be ideally suited to accompany ethical reflection and changes ensuing from reflection. To our knowledge, living labs have not been explicitly trialed and reported in ethics literature. In this discussion paper, we report and discuss four initial issues that marked the process of setting up a living lab in ethics: (1) determining the goals and expected outcomes of an ethics living lab; (2) establishing operational procedures; (3) selecting communities and defining pilot projects; and (4) adopting a lens to tackle emerging questions and challenges. We explain these four issues and present the paths taken based on the novel and specific orientation, that is, living ethics, at the basis of this project. In alignment with living ethics and É-LABO, we approach challenges as learning opportunities to ask not only "how" questions but also "why" questions. We hope that this discussion paper informed by our experience helps to clarify the theoretical, methodological, and practical approaches necessary to successfully adopt and employ living labs in ethics.

"I Had to Know About It, I Had to Find It, I Had to Know How to Access it": Experiences of Access to Rehabilitation Services Among People Living with Long COVID

Purpose

The aim of this qualitative study is to understand the need for, access to, and quality of rehabilitation services for people living with Long COVID. Little is known about the experiences of people living with Long COVID accessing rehabilitation services. Therefore, we explored health concerns leading people living with Long COVID to seek help to address functional concerns and their experiences with accessing and participating in rehabilitation.

Method

Interpretive description guided exploration of participants' experiences with Long COVID rehabilitation in Alberta, Canada. Semi-structured interviews were completed with 56 participants recruited from: three publicly funded Long COVID clinics, a specialized private physiotherapy clinic, a telephone-based rehabilitation advice line, and a Workers' Compensation Board-funded Long COVID rehabilitation program. Recruitment through mass media coverage allowed us to include people who did not access rehabilitation services. Data analysis was informed by Braun and Clarke's reflexive thematic analysis.

Results

Four themes were identified: (1) the burden of searching for guidance to address challenges with functioning and disability; (2) supportive relationships promote engagement in rehabilitation; (3) conditions for participation in safe rehabilitation; and (4) looking forward - provision of appropriate interventions at the right time.

Conclusions

Our findings highlight the experiences of accessing rehabilitation services for people living with Long COVID. Results suggest approaches to Long COVID rehabilitation should be accessible, multi-disciplinary, flexible, and person-centred.

"None of us are lying": an interpretive description of the search for legitimacy and the journey to access quality health services by individuals living with Long COVID

BACKGROUND

Understanding of Long COVID has advanced through patient-led initiatives. However, research about barriers to accessing Long COVID services is limited. This study aimed to better understand the need for, access to, and quality of, Long COVID services. We explored health needs and experiences of services, including ability of services to address needs.

METHODS

Our study was informed by the Levesque et al.'s (2013) "conceptual framework of access to health care." We used Interpretive Description, a qualitative approach partly aimed at informing clinical decisions. We recruited participants across five settings. Participants engaged in one-time, semi-structured, virtual interviews. Interviews were transcribed verbatim. We used reflexive thematic analysis. Best practice to ensure methodological rigour was employed.

RESULTS

Three key themes were generated from 56 interviews. The first theme illustrated the rollercoaster-like nature of participants' Long COVID symptoms and the resulting impact on function and health. The second theme highlighted participants' attempts to access Long COVID services. Guidance received from healthcare professionals and self-advocacy impacted initial access. When navigating Long COVID services within the broader system, participants encountered barriers to access around stigma; appointment logistics; testing and 'normal' results; and financial precarity and affordability of services. The third theme illuminated common factors participants liked and disliked about Long COVID services. We framed each sub-theme as the key lesson (stemming from all likes and dislikes) that, if acted upon, the health system can use to improve the quality of Long COVID services. This provides tangible ways to improve the system based directly on what we heard from participants.

CONCLUSION

With Long COVID services continuously evolving, our findings can inform decision makers within the health system to better understand the lived experiences of Long COVID and tailor services and policies appropriately.

Educational needs and preferences of adult patients with acute or chronic pain: a mixed methods systematic review protocol

OBJECTIVES

This review will aim to synthesize the available quantitative and qualitative evidence on the educational needs and preferences of adult patients with acute or chronic pain.

INTRODUCTION

Acute and chronic pain are prevalent problems and are associated with significant individual and societal consequences. Education is a critical component of pain management. However, the impact of educational interventions on pain outcomes remains limited. The lack of patient input--what patients want to know and how they want to be informed--is one of the main issues underlying intervention design.

INCLUSION CRITERIA

We will include qualitative, quantitative, and mixed methods studies describing the educational needs and preferences of adult patients with acute or chronic pain.

METHODS

This review will follow the JBI guidelines for mixed methods systematic reviews. We will search MEDLINE (PubMed), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ProQuest Dissertations and Theses. The search strategy will commence from the year 1990 onward and there will be no language restrictions. The retrieved titles, abstracts, and full-text reports will be screened by pairs of independent reviewers. These pairs of reviewers will also independently extract data using the JBI tools for mixed methods systematic reviews. Methodological quality will be assessed using the mixed methods appraisal tool. A convergent integrated approach to synthesis and integration of the quantitative and qualitative data will be used.

REVIEW REGISTRATION

PROSPERO CRD42022303834.

"I wanted to know what was hurting so much": a qualitative study exploring patients' expectations and experiences with primary care management

BACKGROUND

The management of shoulder pain is challenging for primary care clinicians considering that 40% of affected individuals remain symptomatic one year after initial consultation. Developing tailored knowledge mobilization interventions founded on evidence-based recommendations while also considering patients' expectations could improve primary care for shoulder pain. The aim of this qualitative study is to explore patients' expectations and experiences of their primary care consultation for shoulder pain.

METHODS

In this qualitative study, participants with shoulder pain and having consulted a primary care clinician in the past year were interviewed. All the semi-structured interviews were transcribed verbatim, and inductive thematic analysis was performed to identify themes related to the participants' expectations and experiences of primary care consultations for shoulder pain.

RESULTS

Thirteen participants with shoulder pain were interviewed (8 women, 5 men; mean age 50 ± 12 years). Eleven of them initially consulted a family physician or an emergency physician, and two participants initially consulted a physiotherapist. Four overarching themes related to patients' expectations and experiences were identified from our thematic analysis: 1) I can't sleep because of my shoulder; 2) I need to know what is happening with my shoulder; 3) But… we need to really see what is going on to help me!; and 4) Please take some time with me so I can understand what to do!. Several participants waited until they experienced a high level of shoulder pain before making an appointment since they were not confident about what their family physician could do to manage their condition. Although some participants felt that their physician took the time to listen to their concerns, many were dissatisfied with the limited assessment and education provided by the clinician.

CONCLUSIONS

Implementing evidence-based recommendations while considering patients' expectations is important as it may improve patients' satisfaction with healthcare. Several participants reported that their expectations were not met, especially when it came to the explanations provided. One unexpected finding that emerged from this study was the waiting period between the onset of shoulder pain and when patients decided to consult their primary care clinician.

Fear of Reprisal and Change Agency in the Public Health and Social Service System: Protocol for a Sequential Mixed Methods Study

BACKGROUND

 Since they are key witnesses to the systemic difficulties and social inequities experienced by vulnerable patients, health and social service (HSS) professionals and clinical managers must act as change agents. Using their expertise to achieve greater social justice, change agents employ a wide range of actions that span a continuum from the clinical (microsystem) to the societal (macrosystem) sphere and involve actors inside and outside the HSS system. Typically, however, clinical professionals and managers act in a circumscribed manner, that is, within the clinical sphere and with patients and colleagues. Among the hypotheses explaining this reduced scope of action is the fear of reprisal. Little is known about the prevalence of this fear and its complex dynamics.

OBJECTIVE

 The overall aim is to gain a better understanding of the complex dynamic process leading to clinical professionals' and managers' fear of reprisal in their change agent actions and senior administrators' and managers' determination of wrongdoing. The objectives are (1) to estimate the prevalence of fear of reprisal among clinical professionals and managers; (2) to identify the factors involved in (a) the emergence of this fear among clinical professionals and managers, and (b) the determination of wrongdoing by senior administrators and managers; (3) to describe the process of emergence of (a) the fear of reprisal among clinical professionals and managers, and (b) the determination of wrongdoing by senior administrators and managers; and (4) to document the legal and ethical issues associated with the factors identified (objective 2) and the processes described (objective 3).

METHODS

 Based on the Exit, Voice, Loyalty, Neglect model, a 3-part sequential mixed methods design will include (1) a web-based survey (objective 1), (2) a qualitative grounded theory design (objectives 2 and 3), and (3) legal and ethical analysis (objective 4). Survey: 77,794 clinical professionals or clinical managers working in the Québec public HSS system will be contacted via email. Data will be analyzed using descriptive statistics. Grounded theory design: for each of the 3 types of participants (clinical professionals, clinical managers, and senior administrators and managers), a theoretical sample of 15 to 30 people will be selected via various strategies. Data will be independently analyzed using constant comparison process. Legal and ethical analysis: situations described by participants will be analyzed using, respectively, applicable legislation and jurisprudence and 2 ethical models.

RESULTS

 This ongoing study began in June 2022 and is scheduled for completion by March 2027.

CONCLUSIONS

 Instead of acting, fear of reprisal could induce clinical professionals to tolerate situations that run counter to their social justice values. To ensure they use their capacities for serving a population that is or could become vulnerable, it is important to know the prevalence of the fear of reprisal and gain a better understanding of its complex dynamics.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48400.

Does feeling pain help prepare future clinicians to treat pain? A qualitative exploration of a novel experiential approach to teaching health professional students about pain

BACKGROUND AND INTRODUCTION

Pain is a subjective phenomenon, that is often misunderstood and invalidated. Despite recent advances in health professional training, it remains unclear how students should be taught about the subjectivity of pain. This study explored how a novel teaching activity that integrated physiotherapy students' first-hand experiences with laboratory-induced pain could address this gap.

OBJECTIVE

The study aimed to explore the experiences and perceptions of physiotherapy students in relation to a workshop where physiotherapy students experienced laboratory induced pain.

METHODS

We used a descriptive qualitative research design. Eighteen students participated in interviews. Transcripts were analyzed using an inductive conventional content analysis.

RESULTS

We identified four overarching themes: 1) First-hand pain experiences facilitated engagement in learning; 2) Reflecting on these personal and peer pain experiences helped students make sense of pain; 3) The learning activity helped students understand the inherent subjectivity and complexity of pain; and 4) Students saw benefits for clinical practice.

CONCLUSION

Integrating first-hand pain experiences within entry-level physiotherapy training appears to have novel value in helping students understand pain subjectivity. Future research should use robust and controlled designs to explore how this novel approach can be used to facilitate further understanding and empathy within clinical interactions with people living with pain.

Analysis of Private Physiotherapy Clinic Web Sites Using a Critical Perspective

Purpose

The objective of our study was to analyze visual and textual content of private physiotherapy clinic Web sites with a critical analysis framework.

Method

We analyzed 43 private physiotherapy clinics' Web sites from all regions of one Canadian province (Quebec). For each Web site, we collected and aggregated the data using a standardized extraction grid to index visual and textual content. We then conducted an analysis of the collected data using the Seven-Step Framework for Critical Analysis proposed by Nixon and colleagues.

Results

Most Web sites presented elements related to sports and active lifestyles in their names, logos, or pictures. Persons represented in the Web sites were mainly young, white, and active. Ethnic and body diversity were generally not depicted. Information encompassing manual therapy and sports injuries management largely prevailed.

Conclusions

The textual and visual content of private physiotherapy clinic Web sites was not consistent with the physiotherapy community's commitments to upholding equity principles and to serving a wide range of individuals. To fulfill the highest professional and ethical standards, the physiotherapy community should reflect on the representation of physiotherapy services and clients on Web sites to ensure that the trend towards privatization of physiotherapy services does not perpetuate the systems of inequality present in society.

Children with Disabilities in Canada during the COVID-19 Pandemic: An Analysis of COVID-19 Policies through a Disability Rights Lens

Children with disabilities were especially vulnerable during the COVID-19 pandemic, and policies designed to mitigate its effects were limited in addressing their needs. We analyzed Canadian policies related to children with disabilities and their families during the COVID-19 pandemic to identify the extent to which these policies aligned with the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) and responded to their mental health needs by conducting a systematic collection of Canadian provincial/territorial policies produced during the pandemic, building a categorization dictionary based on the UN CRPD, using text mining, and thematic analysis to identify policies' alignment with the UN CRPD and mental health supports. Mental health was addressed as a factor of importance in many policy documents, but specific interventions to promote or treat mental health were scarce. Most public health policies and recommendations are related to educational settings, demonstrating how public health for children with disabilities relies on education and community that may be out of the healthcare system and unavailable during extended periods of the pandemic. Policies often acknowledged the challenges faced by children with disabilities and their families but offered few mitigation strategies with limited considerations for human rights protection.

How Did Governments Address the Needs of People With Disabilities During the COVID-19 Pandemic? An Analysis of 14 Countries' Policies Based on the UN Convention on the Rights of Persons With Disabilities

BACKGROUND

People with disabilities have experienced heightened social risks in the context of the pandemic, resulting in higher rates of infection and mortality. They have also borne elevated burdens associated with public health measures. The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) obliges its 184 state parties to eliminate discrimination and ensure equality and inclusion for persons with disabilities, including protection and safety in situations of emergency. It remains unclear to what extent national COVID-19 policies have aligned with these commitments under the UNCRPD. Our objective in this exploratory study was to assess alignment between the UNCRPD indicators and COVID-19 policies from 14 countries with the goal of informing policy development that is inclusive of persons with disabilities and responsive to rights under the UNCRPD.

METHODS

We identified COVID-19 policy documents from 14 purposively selected countries. Country selection considered diversity based on geographic regions and national income levels, with restriction to those countries that had ratified the UNCRPD and had English or French as an official language. We used a computational text mining approach and developed a complex multilevel dictionary or categorization model based on the UNCRPD Bridging the Gap indicators proposed by the Office of the High Commissioner on Human Rights (OHCHR). This dictionary was used to assess the extent to which indicators across the entirety of the UNCRPD were represented in the selected policies. We analyzed frequency of associations with UNCRPD, as well as conducting 'key word in context' analyses to identify themes.

RESULTS

We identified 764 COVID-19 national policy documents from the period of January 2020 to June 2021. When analyzed in relation to the Articles of the UNCRPD, the most frequently identified were Articles 11 (risk and humanitarian emergencies), 23 (home and family), 24 (education), and 19 (community living). Six countries produced 27 policies that were specifically focused on disability. Common themes within these documents included continuation of services, intersectionality and equity, and disability considerations in regulations and public health measures.

CONCLUSION

Analyzing country policies in light of the UNCRPD offers important insights about how these policies do and do not align with states' commitments. As new policies are developed and existing ones revised, more comprehensive approaches to addressing the rights of persons with disabilities are urgently needed.

Gender Issues in Physiotherapy in Quebec, Canada

Purpose

This study examines gender differences in the physiotherapy (PT) profession in the province of Quebec regarding: (1) areas of practice; (2) roles associated with the advancement of the profession; (3) formal disciplinary complaints; and (4) interests and competency perceptions of PT students.

Methods

We collected data from the Canadian Institute of Health Information, the Quebec Professional Order of Physiotherapy, Quebec university public Internet sites, and PT associations. We also surveyed PT students at the Université de Montréal.

Results

The PT workforce in Quebec was 76.6% women. The presidents of the four main PT associations were men. In the five university programmes, the percentage of male and female physiotherapists in tenure track positions was 46% and 54%, respectively. There were more sanctioned complaints of sexual misconduct and not maintaining continuing education for male physiotherapists, while more women were sanctioned for problems with documentation and billing. Among students, men were more interested in becoming administrators, but neither men nor women had a strong interest in research.

Conclusions

Male physiotherapists make up 23.4% of the PT workforce in Quebec but are more involved in leadership positions in the profession than women.

Impacts of the COVID-19 Pandemic: Pan-Canadian Perspectives From Parents and Caregivers of Youth With Neurodevelopmental Disabilities

INTRODUCTION

The COVID-19 pandemic brought unprecedented challenges for youth with neurodevelopmental disabilities (NDD) and their families. Although health measures were implemented to contain the COVID-19 virus, they disrupted public service, profoundly impacting youth and their families' access to services. This study sought to better understand the perspectives and experiences of parents and caregivers of youth with NDD across Canada in accessing services and their mental health needs during the pandemic.

METHOD

The study used a qualitative research design in which we interviewed 40 parents and caregivers across Canada.

RESULTS

The results enabled us to understand the impact of service disruptions in significant areas of life, including health, education, employment, and risk mitigation.

DISCUSSION

Policymakers must consider a disability-inclusive lens during public health emergency planning and response to reduce the disproportionate impacts faced by youth with NDD and their families.

What are the perceived needs of people living with chronic pain regarding physiotherapy services? A scoping review protocol

INTRODUCTION

Chronic pain represents a major health issue, affecting the physical and mental health of approximately one in five people worldwide. It is now widely recognized that health professionals should use interventions that meet the needs of people living with chronic pain. Therefore, physiotherapists should attend to patients' perceived needs regarding physiotherapy services, i.e. the needs that are perceived by patients themselves based on their beliefs, values, preferences and expectations. However, previous reviews have mainly focused on health professionals' and experts' evaluations of patients' needs, which may result in inadequate answers to these needs. Therefore, a better understanding of patients' perceived needs could lead to more ethical and higher quality physiotherapy services.

OBJECTIVE

The aim of this scoping review is thus to explore what is known from the existing literature about the perceived needs of people living with chronic pain regarding physiotherapy services.

METHODS

This scoping review will follow Arksey and O'Malley's six-step framework. Medline, Embase, CINHAL, and APA PsycINFO will be used to search the scientific literature. The grey literature will also be searched using Google Scholar, OpenGrey and ProQuest Dissertation & Theses Global (PQDTGlobal). Studies published in English and French will only be considered. Two independent reviewers will perform the selection and extraction processes. Descriptive statistics will be performed to characterize the included studies. Quantitative, qualitative and mixed methods studies will be analyzed and synthetized using convergent qualitative meta-integration. Thereby, we will use the seven steps for convergent qualitative meta-integration proposed by Frantzen and Fetters to transform, analyze and integrate the quantitative and qualitative data.

INCLUSION CRITERIA

Included studies will describe the perceived needs of adults living with chronic pain regarding physiotherapy services. Studies focusing on the perspectives of health professionals and rehabilitation services other than physiotherapy will be excluded.

Mental health challenges during COVID-19: perspectives from parents with children with neurodevelopmental disabilities

Background

The global pandemic and subsequent denials, delays, and disruptions in essential daily activities created significant challenges for children with neurodevelopmental disorders (NDDs) and their parents. Public health restrictions during the COVID-19 pandemic limited access to supports and services required by children with NDDs to maintain their health and well-being.

Objective

This study sought to understand the impacts of these public health measures and restrictions on mental health from the perspective of parents with children with NDDs to inform pathways for public health policies responsive to the needs of this population.

Method

Interpretive descriptive design was used to guide data collection and data analysis. Forty caregivers were interviewed about their experience with pandemic restrictions.

Findings

Generic policy measures contributed to many gaps in families’ social support systems and contributed to mental health challenges for children and their parents. Four themes emerged: 1) lack of social networks and activities, 2) lack of access to health and social supports, 3) tension in the family unit, and 4) impact on mental health for children and their parents.

Recommendations

Emergency preparedness planning requires a disability inclusive approach allocating resources for family supports in the home and community. Families identified supports to minimize further pandemic disruptions and enhance recovery.

Competencies for Physiotherapists Working to Facilitate Rehabilitation, Work Participation and Return to Work for Workers with Musculoskeletal Disorders: A Scoping Review

Purpose The aim of this scoping review was to synthesize the literature addressing the competencies that physiotherapists in a clinical setting need to facilitate the rehabilitation, work participation, and return to work of workers with musculoskeletal disorders.Methods We conducted a scoping review in accordance with Arksey & O'Malley's five-step method. The following categories of keywords were used during searches in Embase, Medline and CINAHL in May 2020: (1) physiotherapy/physical therapy; (2) return to work, work participation or occupational health; and (3) education/professional competencies/guidelines. Two authors reviewed the full-text papers and agreed on the selection of articles for inclusion. The selected articles were then charted in an Excel grid and descriptively analyzed.Results Three main categories of competencies were identified: (1) Understanding and interacting with patients who are workers; (2) Planning rehabilitation with other stakeholders; and (3) Reaching out to the workplace. The fourth category named "Obstacles to the development of work-related competencies", regroups several obstacles that were identified as potentially impeding the development of work-related competencies by physiotherapists.Conclusion The findings of this scoping review inform physiotherapy clinicians, educators and regulators on the specific knowledge, skills, abilities, and attitudes that appear to play a role in facilitating the rehabilitation of workers with musculoskeletal disorders. We trust that this study will lead to new initiatives that will define, implement and evaluate the effectiveness of these competencies in practice, along with rekindling the discussions about the place of work rehabilitation in the physiotherapy profession.

"It feels like an endless fight": a qualitative study exploring healthcare utilization of persons with rheumatic conditions waiting for pain clinic admission

Background

Individuals living with a rheumatic pain condition can face delays in accessing pain clinics, which prevents them from receiving timely treatment. Little is known regarding their specific healthcare utilization in order to alleviate pain while waiting to obtain services in pain clinics. Hence, the aim of this study was to explore the perceptions and experiences of persons living with rheumatic conditions regarding healthcare utilization while waiting to access a pain clinic.

Methods

In this qualitative descriptive study, semi-structured interviews were conducted with adults living with a painful rheumatic condition that reported either being waiting for admission in a pain clinic, having been referred but then denied pain clinic services, or having received services during the previous six months, in the province of Quebec, Canada. The interviews were transcribed verbatim, and an inductive thematic analysis was performed.

Results

Twenty-six individuals were interviewed (22 women and 4 men; mean age 54 ± 10 years). Three themes were identified: 1) lacking guidance in identifying solutions to their complex and multidimensional needs, 2) struggling to obtain and maintain services due to systemic access barriers, and 3) displaying resilience through a search for accessible and sustainable self-management strategies.

Conclusions

The current approaches and structures of health services fail to adequately answer the service needs of individuals experiencing painful rheumatic conditions. Important shifts are required in pain education, in increasing access to multidisciplinary approaches at the primary care level and in breaking down barriers individuals with chronic pain face to receive appropriate and timely care.

Implementation of a biopsychosocial approach into physiotherapists' practice: a review of systematic reviews to map barriers and facilitators and identify specific behavior change techniques

PURPOSE

Our first objective was to map the barriers and facilitators to the implementation of a biopsychosocial approach into physiotherapists' practice within the Theoretical Domains Framework (TDF). Our second objective was to identify the specific behavior change techniques (BCT) that could facilitate this implementation.

MATERIALS AND METHODS

We conducted a review of systematic reviews to identify barriers and facilitators to the use of a biopsychosocial approach by physiotherapists and we mapped them within the TDF domains. We then analyzed these domains using the Theory and Techniques tool (TaTT) to identify the most appropriate BCTs for the implementation of a biopsychosocial approach into physiotherapists' practice.

RESULTS

The barriers and facilitators to the use of a biopsychosocial approach by physiotherapists were mapped to 10 domains of the TDF (Knowledge; skills; professional role; beliefs about capabilities; beliefs about consequences; intentions; memory, attention and decision processes; environmental context; social influences; emotion). The inclusion of these domains within the TaTT resulted in the identification of 33 BCTs that could foster the use of this approach by physiotherapists.

CONCLUSIONS

Investigating the implementation of a biopsychosocial approach into physiotherapists' practice from a behavior change perspective provides new strategies that can contribute to successfully implement this approach.Implications for RehabilitationThe implementation of a biopsychosocial approach into physiotherapists' practice is a complex process which involves behavior changes influenced by several barriers and facilitators.Barriers and facilitators reported by physiotherapists when implementing a biopsychosocial approach can be mapped within 10 domains of the Theoretical Domain Framework.Thirty-three behavior change techniques (e.g., verbal persuasion about capability, problem solving, restructuring the physical environment, etc.) were identified to foster the implementation of a biopsychosocial approach and specifically target barriers and facilitators.By using a behavior change perspective, this study highlights new strategies and avenues that can support current efforts to successfully implement the use of a biopsychosocial approach into physiotherapists' practice.

Framing the Care of Injured Workers: An Empirical Four-Jurisdictional Comparison of Workers' Compensation Boards' Healthcare Policies

PURPOSE

The objective of this study was to explore how workers' compensation policies related to healthcare provision for workers with musculoskeletal injuries can affect the delivery and trajectories of care for injured workers. The principal research question was: What are the different ways in which workers' compensation (WC) policies inform and transform the practices of healthcare providers (HCPs) caring for injured workers?

METHODS

We conducted a cross-jurisdictional policy analysis. We conducted qualitative interviews with 42 key informants from a variety of perspectives in the provinces of Ontario and Quebec in Canada, the state of Victoria in Australia and the state of Washington in the United States. The main methodological approach was Framework Analysis.

RESULTS

We identified two main themes: (1) Shaping HCPs' clinical practices and behaviors with injured workers. In this theme, we illustrate how clinical practice guidelines and non-economic and economic incentives were used by WCs to drive HCP's behaviours with workers; (2) Controlling workers' trajectories of care. This theme presents how WC policies achieve control of the workers' trajectory of care via different policy mechanisms, namely the standardization of care pathways and the power and autonomy vested in HCPs.

CONCLUSIONS

This policy analysis shed light on the different ways in which WC policies shape HCP's day-to-day practices and workers' trajectories. A better understanding and a nuanced portrait of these policies' impacts can help support reflections on future policy changes and inform policy development in other jurisdictions.

What is Pain-Related Suffering? Conceptual Critiques, Key Attributes, and Outstanding Questions

Suffering holds a central place within pain research, theory, and practice. However, the construct of pain-related suffering has yet to be operationalized by the International Association for the Study of Pain and is largely underdeveloped. Eric Cassell's seminal work on suffering serves as a conceptual anchor for the limited pain research that specifically addresses this construct. Yet, important critiques of Cassell's work have not been integrated within the pain literature. This Focus Article aims to take a preliminary step towards an updated operationalization of pain-related suffering by 1) presenting key attributes of pain-related suffering derived from a synthesis of the literature and 2) highlighting key challenges associated with Cassell's conceptualization of suffering. We present 4 key attributes: 1) pain and suffering are inter-related, but distinct experiences, 2) suffering is a subjective experience, 3) the experience of suffering is characterized by a negative affective valence, and 4) disruption to one's sense of self is an integral part of suffering. A key outstanding challenge is that suffering is commonly viewed as a self-reflective and future-oriented process, which fails to validate many forms of suffering and marginalizes certain populations. Future research addressing different modes of suffering - with and without self-reflection - are discussed. PERSPECTIVE: This article offers a preliminary step toward operationalizing the construct of pain-related suffering and proposes priorities for future research. A robust operationalization of this construct is essential to developing clinical strategies that aim to better recognize and alleviate suffering among people living with pain.

Strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities: A systematic literature review

Objective

Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities.

Methods

We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted.

Results

Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy ( n = 11), occupational therapy ( n = 2), prosthetics ( n = 1), exercise physiology ( n = 1) and multidisciplinary ( n = 4) services. The methodological quality varied ( n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services.

Conclusions

This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

Development of a national pain management competency profile to guide entry-level physiotherapy education in Canada

BACKGROUND

National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada.

AIMS

This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context.

METHODS

A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators.

RESULTS

Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being "very satisfied" with the process.

CONCLUSIONS

This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

Comparing ERAS-outpatient versus standard-inpatient hip and knee replacements: a mixed methods study exploring the experience of patients who underwent both

BACKGROUND

Optimizing patients' total hip and knee arthroplasty (THA/TKA) experience is as crucial for providing high quality care as improving safety and clinical effectiveness. Yet, little evidence is available on patient experience in standard-inpatient and enhanced recovery after surgery (ERAS)-outpatient programs. Therefore, this study aimed to gain a more in-depth understanding of the patient experience of ERAS-outpatient programs in comparison to standard-inpatient programs.

METHODS

We conducted a convergent mixed methods study of 48 consecutive patients who experienced both standard-inpatient and ERAS-outpatient THA/TKA contralaterally. A reflective thematic analysis was conducted based on data collected via a questionnaire. Bivariate correlations between the patient experience and patients' characteristics, clinical outcomes and care components satisfaction were performed. Then, the quantitative and qualitative data were integrated together.

RESULTS

The theme Support makes the difference for better and for worse was identified by patients as crucial to their experience in both joint replacement programs. On the other hand, patients identified 3 themes distinguishing their ERAS-outpatient from their standard-inpatient experience: 1) Minimizing inconvenience, 2) Home sweet home and 3) Returning to normal function and activities. Potential optimization expressed by patients were to receive more preoperative information, additional postoperative rehabilitation sessions, and ensuring better coherence of care between hospital and home care teams. Weak to moderate positive and statistically significant correlations were found between patients' THA/TKA experience and satisfaction with pain management, hospital stay, postoperative recovery, home care, and overall results (rs = + [0.36-0.66], p-value < 0.01).

CONCLUSION

Whatever the perioperative program, the key to improving patients' THA/TKA experience lies in improving support throughout the care episode. However, compared to standard-inpatient care, the ERAS-outpatient program improves patients' experience by providing dedicated support in postoperative care, reducing postoperative inconvenience, optimizing pain management, returning home sooner, and recovering and regaining function sooner. Patients' THA/TKA experience could further be enhanced by optimizing the information provided to the patient, the rehabilitation program and the coherence between care teams.

Acting as Change Agents: Insight Into Québec Occupational Therapists' Current Practice: Actions menées à titre d'agents de changement : aperçu des pratiques actuelles parmi les ergothérapeutes du Québec

BACKGROUND.

Change agents' actions have been studied mainly from a theoretical perspective.

PURPOSE.

This study aimed to empirically identify occupational therapists' actual change agent actions.

METHOD.

As part of a research partnership with the Canadian Association of Occupational Therapists-Québec chapter, we conducted this cross-sectional pilot study using an online survey.

FINDINGS.

The change agent practices of our 103 participants involve many types of actions but show underinvestment in mass communication. Mass communication actions are more frequent when participants have greater experience, additional academic degrees, and training in change agency. Also, occupational therapists with additional academic degrees and change agency training tend to use a wider variety of actions. Finally, our participants' actions principally target actors in the clinical context, rarely political actors.

IMPLICATIONS.

Our results suggest that occupational therapists can and will invest in the full range of change agent actions provided they can acquire the necessary knowledge and skills.

Prediction of quality of life in schizophrenia using machine learning models on data from clinical antipsychotic trials of intervention effectiveness (CATIE) schizophrenia trial

Introduction

Schizophrenia is a chronic and severe mental disorder. While research focus remains mainly on negative outcomes, it is questionable whether we are placing enough emphasis on improving their sense of well-being and functioning. This could be accessed through the study of the quality of life (QoL). To date, QoL prediction models mainly focused on neurocognition and psychotic symptoms, but their predictive power remained limited.

Objectives

The aim is to accurately predict the QoL within schizophrenia using unsupervised learning methods.

Methods

We computed variables from 952 patients from the CATIE study, a randomized, double-blind clinical trial for schizophrenia treatment. QoL was measured using the Heinrichs-Carpenter Quality of Life Scale and potential predictors included almost all available variables: symptoms, neurocognition, medication adherence, insight, adverse effects, etc. By optimizing parameters to reach optimal models, three linear regressions were calculated: (1) baseline predictors of 12-month QoL, (2) 6-month predictors of 12-month QoL, and (3) baseline predictors of 6-month QoL. Adjustments were made to ensure that included variables were not collinear nor redundant with QoL.

Results

Calculated models had adjusted R-squared of 0.918, 0.922 and 0.913, respectively. Best predictors were medication side effects, sociodemographic and neurocognitive variables. Low psychotic and depressive symptoms were also included, as well as lab values suggesting the absence of problems with chloremia and calcemia.

Conclusions

Calculated predictive models explain almost all subsequent QoL. It appears that physical health variables, generally omitted from mental health-related studies, have an important impact on patients’ QoL. Therefore, interventions should also consider these aspects.

Disclosure

No significant relationships.

Mapping first-line health care providers' roles, practices, and impacts on care for workers with compensable musculoskeletal disorders in four jurisdictions: A critical interpretive synthesis

BACKGROUND

First-line health care providers are the primary access point for workers' benefits. However, little is known about their impact on quality of care and return-to-work. Our objective was to critically compare literature on the practices of first-line providers for workers with musculoskeletal injuries in Ontario and Quebec (Canada), Washington State (United States), and Victoria (Australia).

METHODS

A critical interpretive synthesis of peer-reviewed scientific literature was conducted. The search across six databases yielded 59 relevant publications that were critically appraised.

RESULTS

Three themes emerged: 1) how policies about first-line health care providers' modulate worker access to care, 2) how these providers' roles, practices, and training shape disability management, and 3) how the quality of care and disability outcomes are evaluated.

CONCLUSIONS

First-line health care providers have a critical influence on workers' trajectories of care. A focus on their role while taking the complexity of the context into account will help orient future policy changes.

Tensions Living Out Professional Values for Physical Therapists Treating Injured Workers

Health care services provided by workers' compensation systems aim to facilitate recovery for injured workers. However, some features of these systems pose barriers to high quality care and challenge health care professionals in their everyday work. We used interpretive description methodology to explore ethical tensions experienced by physical therapists caring for patients with musculoskeletal injuries compensated by Workers' Compensation Boards. We conducted in-depth interviews with 40 physical therapists and leaders in the physical therapy and workers' compensation fields from three Canadian provinces and analyzed transcripts using concurrent and constant comparative techniques. Through our analysis, we developed inductive themes reflecting significant challenges experienced by participants in upholding three core professional values: equity, competence, and autonomy. These challenges illustrate multiple facets of physical therapists' struggles to uphold moral commitments and preserve their sense of professional integrity while providing care to injured workers within a complex health service system.

Social change agent training program tailored to occupational therapists' needs: a design-based study protocol

BACKGROUND

As social change agents (SCAs), occupational therapists (OTs) are expected to defend the rights of their clients, advocate for and with them, and try to influence organizational and political decision-makers. However, OTs do not generally feel equipped to take effective action. The overall goal of this research partnership is to support practising OTs in acquiring the knowledge and skills required to act as SCAs through a specific SCA training program and a toolkit that summarizes the key training points.

METHODS

The study will include three iterative phases (conceptualization, implementation and evaluation) and use a participatory process. The design of the training program and toolkit will draw on the expertise of the researchers (theoretical knowledge), a professional provincial partner and study participants (experiential knowledge). To evaluate the training program and toolkit, a self-administered evaluation questionnaire, facilitator observation grid and semi-structured guide designed to facilitate focus group discussions will be used. The quantitative and qualitative data will be analyzed using descriptive statistics and thematic analysis, respectively. The results of the initial implementation and evaluation phases will inform improvement of the training program and toolkit before starting the cycle with the following groups.

DISCUSSION

In addition to training about 100 OTs, this study will produce three main benefits: 1) development of two products, namely the SCA training program and toolkit, that are easy to reuse and potentially transferable to other professionals; 2) ownership of these products by the partner through its close involvement in all stages of the study; and 3) development of a sustainable partnership between a team of researchers and a recognized organization with networks across Canada and internationally. These three spin-offs will provide a solid basis for an increasing number of permanent implementation initiatives, in Québec and elsewhere in Canada, not just in occupational therapy but also in other professions.

Prioritization of Referrals in Outpatient Physiotherapy Departments in Québec and Implications for Equity in Access

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector.

Physiotherapy for injured workers in Canada: are insurers' and clinics' policies threatening good quality and equity of care? Results of a qualitative study

BACKGROUND

In recent years, significant efforts have been made to improve the provision of care for compensated injured workers internationally. However, despite increasing efforts at implementing best practices in this field, some studies show that policies overseeing the organisation of care for injured workers can have perverse influences on healthcare providers' practices and can prevent workers from receiving the best care possible. The influence of these policies on physiotherapists' practices has yet to be investigated. Our objectives were thus to explore the influence of 1) workers' compensation boards' and 2) physiotherapy clinics' policies on the care physiotherapists provide to workers with musculoskeletal injuries in three large Canadian provinces.

METHODS

The Interpretive Description framework, a qualitative methodological approach, guided this inquiry. Forty participants (30 physiotherapists and 10 leaders and administrators from physiotherapy professional groups and workers' compensation boards) were recruited in British Columbia, Ontario and Quebec to participate in an in-depth interview. Inductive analysis was conducted using constant comparative techniques.

RESULTS

Narratives from participants show that policies of workers' compensation boards and individual physiotherapy clinics have significant impacts on physiotherapists' clinical practices. Policies found at both levels often place physiotherapists in uncomfortable positions where they cannot always do what they believe to be best for their patients. Because of these policies, treatments provided to compensated injured workers markedly differ from those provided to other patients receiving physiotherapy care at the same clinic. Workers' compensation board policies such as reimbursement rates, end points for treatment and communication mechanisms, and clinic policies such as physiotherapists' remuneration schemes and restrictions on the choice of professionals had negative influences on care. Policies that were viewed as positive were board policies that recognize, promote and support physiotherapists' duties and clinics that provide organisational support for administrative tasks.

CONCLUSION

In Canada, workers' compensation play a significant role in financing physiotherapy care for people injured at work. Despite the best intentions in promoting evidence-based guidelines and procedures regarding rehabilitation care for injured workers, complex policy factors currently limit the application of these recommendations in practice. Research that targets these policies could contribute to significant changes in clinical settings.

Supporting ethics educators in Canadian occupational therapy and physical therapy programs: A national interprofessional knowledge exchange project

Ethics education is the cornerstone of professional practice, fostering knowledge and respect for core ethical values among healthcare professionals. Ethics is also a subject well-suited for interprofessional education and collaboration. However, there are few initiatives to gather experiences and share resources among ethics educators in rehabilitation. We thus undertook a knowledge exchange project to: 1) share knowledge about ethics training across Canadian occupational and physical therapy programs, and 2) build a community of educators dedicated to improving ethics education. The objectives of this paper are to describe this interprofessional knowledge exchange project involving ethics educators (with a diversity of professional and disciplinary backgrounds) from Canadian occupational and physical therapy programs as well as analyze its outcomes based on participants' experiences/perceptions. Two knowledge exchange strategies were employed: an interactive one-day workshop and a wiki platform. An immediate post-workshop questionnaire evaluated the degree to which participants' expectations were met. Structured telephone interviews 9-10 months after the workshop collected participants' perceptions on whether (and if so, how) the project influenced their teaching or led to further interprofessional collaborations. Open-ended questions from the post-workshop questionnaires and individual interviews were analyzed using qualitative methods. Of 40 ethics educators contacted, 23 participated in the workshop and 17 in the follow-up interview. Only 6 participants logged into the wiki from its launch to the end of data collection. Five themes emerged from the qualitative analysis: 1) belonging and networking; 2) sharing and collaborating; 3) changing (or not) ways of teaching ethics; 4) sustaining the network; and 5) envisioning the future of ethics education. The project attained many of its goals, despite encountering some challenges. While the wiki platform proved to be of limited benefit in advancing the project goals, the interactive format and collaborative nature of the one-day workshop were described as rewarding and effective in bringing together occupational therapy and physical therapy educators to meet, network, and share knowledge.

Fostering clinical reasoning in physiotherapy: comparing the effects of concept map study and concept map completion after example study in novice and advanced learners

BACKGROUND

Health profession learners can foster clinical reasoning by studying worked examples presenting fully worked out solutions to a clinical problem. It is possible to improve the learning effect of these worked examples by combining them with other learning activities based on concept maps. This study investigated which combinaison of activities, worked examples study with concept map completion or worked examples study with concept map study, fosters more meaningful learning of intervention knowledge in physiotherapy students. Moreover, this study compared the learning effects of these learning activity combinations between novice and advanced learners.

METHODS

Sixty-one second-year physiotherapy students participated in the study which included a pre-test phase, a 130-min guided-learning phase and a four-week self-study phase. During the guided and self-study learning sessions, participants had to study three written worked examples presenting the clinical reasoning for selecting electrotherapeutic currents to treat patients with motor deficits. After each example, participants engaged in either concept map completion or concept map study depending on which learning condition they were randomly allocated to. Students participated in an immediate post-test at the end of the guided-learning phase and a delayed post-test at the end of the self-study phase. Post-tests assessed the understanding of principles governing the domain of knowledge to be learned (conceptual knowledge) and the ability to solve new problems that have similar (i.e., near transfer) or different (i.e., far transfer) solution rationales as problems previously studied in the examples.

RESULTS

Learners engaged in concept map completion outperformed those engaged in concept map study on near transfer (p = .010) and far transfer (p < .001) performance. There was a significant interaction effect of learners' prior ability and learning condition on conceptual knowledge but not on near and far transfer performance.

CONCLUSIONS

Worked examples study combined with concept map completion led to greater transfer performance than worked examples study combined with concept map study for both novice and advanced learners. Concept map completion might give learners better insight into what they have and have not yet learned, allowing them to focus on those aspects during subsequent example study.

Ethics teaching in rehabilitation: results of a pan-Canadian workshop with occupational and physical therapy educators

PURPOSE

Ethical practice is an essential competency for occupational and physical therapists. However, rehabilitation educators have few points of reference for choosing appropriate pedagogical and evaluation methods related to ethics. The objectives of this study were to: (1) identify priority content to cover in ethics teaching in occupational therapy (OT) and physical therapy (PT) programmes and (2) explore useful and innovative teaching and evaluation methods.

METHOD

Data for this qualitative descriptive study were collected during a 1-d knowledge exchange workshop focused on ethics teaching in rehabilitation.

RESULTS

Twenty-three educators from 11 OT and 11 PT Canadian programmes participated in the workshop. They highlighted the importance of teaching foundational theoretical/philosophical approaches and grounding this teaching in concrete examples drawn from rehabilitation practice. A wide range of teaching methods was identified, such as videos, blogs, game-based simulations and role-play. For evaluation, participants used written assignments, exams, objective structured clinical examinations and reflective journals. The inclusion of opportunities for student self-evaluation was viewed as important.

CONCLUSION

The CREW Day provided ethics educators the opportunity to share knowledge and begin creating a community of practice. This space for dialogue could be expanded to international rehabilitation ethics educators, to facilitate a broader network for sharing of tacit and experiential knowledge. Implications for Rehabilitation According to the study participants, rehabilitation ethics education should include learning about foundational knowledge related to ethical theory; be grounded in examples and cases drawn from clinical rehabilitation practice; and contribute to building professional competencies such as self-knowledge and critical thinking in students. Regardless of the methods used by occupational therapy (OT) and physical therapy (PT) educators for teaching and evaluation, the value of creating spaces that support open discussion for students (e.g. protected discussion time in class, peer-discussions with the help of a facilitator, use of a web discussion forum) was consistently identified as an important facet. Educators from OT and PT programmes should work with various professionals involved in OT and PT student training across the curricula (e.g. clinical preceptors, other educators) to extend discussions of how ethics can be better integrated into the curriculum outside of sessions specifically focused on ethics. The CREW Day workshop was the first opportunity for Canadian rehabilitation ethics educators to meet and discuss their approaches to teaching and evaluating ethics for OT and PT students. Including international rehabilitation ethics educators in this dialogue could positively expand on this initial dialogue by facilitating the sharing of tacit and experiential knowledge amongst a larger and more diverse group of ethics educators.

Ethical issues raised by private practice physiotherapy are more diverse than first meets the eye: recommendations from a literature review

PURPOSE

Physiotherapy in private practice differs from physiotherapy practised in a public setting in several ways, the most evident of which is the for-profit nature of private physiotherapy clinics; these differences can generate distinct and challenging ethical issues. The objectives of this article are to identify ethical issues encountered by physiotherapists in private practice settings and to identify potential solutions and recommendations to address these issues.

METHOD

After a literature search of eight databases, 39 studies addressing ethical issues in a private practice context were analyzed.

RESULTS

A total of 25 ethical issues emerging from the included studies were classified into three main categories: (1) business and economic issues (e.g., conflicts of interests, inequity in a managed care context, lack of time affecting quality of care); (2) professional issues (e.g., professional autonomy, clinical judgment, treatment effectiveness, professional conduct); and (3) patients' rights and welfare issues (e.g., confidentiality, power asymmetries, paternalism vs. patient autonomy, informed consent). Recommendations as to how physiotherapists could better manage these issues were then identified and categorized.

CONCLUSIONS

The physiotherapy community should reflect on the challenges raised by private practice so that professionals can be supported-through education, research, and good governance-in providing the best possible care for their patients.

Example-based learning: comparing the effects of additionally providing three different integrative learning activities on physiotherapy intervention knowledge

BACKGROUND

Example-based learning using worked examples can foster clinical reasoning. Worked examples are instructional tools that learners can use to study the steps needed to solve a problem. Studying worked examples paired with completion examples promotes acquisition of problem-solving skills more than studying worked examples alone. Completion examples are worked examples in which some of the solution steps remain unsolved for learners to complete. Providing learners engaged in example-based learning with self-explanation prompts has been shown to foster increased meaningful learning compared to providing no self-explanation prompts. Concept mapping and concept map study are other instructional activities known to promote meaningful learning. This study compares the effects of self-explaining, completing a concept map and studying a concept map on conceptual knowledge and problem-solving skills among novice learners engaged in example-based learning.

METHODS

Ninety-one physiotherapy students were randomized into three conditions. They performed a pre-test and a post-test to evaluate their gains in conceptual knowledge and problem-solving skills (transfer performance) in intervention selection. They studied three pairs of worked/completion examples in a digital learning environment. Worked examples consisted of a written reasoning process for selecting an optimal physiotherapy intervention for a patient. The completion examples were partially worked out, with the last few problem-solving steps left blank for students to complete. The students then had to engage in additional self-explanation, concept map completion or model concept map study in order to synthesize and deepen their knowledge of the key concepts and problem-solving steps.

RESULTS

Pre-test performance did not differ among conditions. Post-test conceptual knowledge was higher (P < .001) in the concept map study condition (68.8 ± 21.8%) compared to the concept map completion (52.8 ± 17.0%) and self-explanation (52.2 ± 21.7%) conditions. Post-test problem-solving performance was higher (P < .05) in the self-explanation (63.2 ± 16.0%) condition compared to the concept map study (53.3 ± 16.4%) and concept map completion (51.0 ± 13.6%) conditions. Students in the self-explanation condition also invested less mental effort in the post-test.

CONCLUSIONS

Studying model concept maps led to greater conceptual knowledge, whereas self-explanation led to higher transfer performance. Self-explanation and concept map study can be combined with worked example and completion example strategies to foster intervention selection.

Theoretical frameworks used to discuss ethical issues in private physiotherapy practice and proposal of a new ethical tool

In the past, several researchers in the field of physiotherapy have asserted that physiotherapy clinicians rarely use ethical knowledge to solve ethical issues raised by their practice. Does this assertion still hold true? Do the theoretical frameworks used by researchers and clinicians allow them to analyze thoroughly the ethical issues they encounter in their everyday practice? In our quest for answers, we conducted a literature review and analyzed the ethical theoretical frameworks used by physiotherapy researchers and clinicians to discuss the ethical issues raised by private physiotherapy practice. Our final analysis corpus consisted of thirty-nine texts. Our main finding is that researchers and clinicians in physiotherapy rarely use ethical knowledge to analyze the ethical issues raised in their practice and that gaps exist in the theoretical frameworks currently used to analyze these issues. Consequently, we developed, for ethical analysis, a four-part prism which we have called the Quadripartite Ethical Tool (QET). This tool can be incorporated into existing theoretical frameworks to enable professionals to integrate ethical knowledge into their ethical analyses. The innovative particularity of the QET is that it encompasses three ethical theories (utilitarism, deontologism, and virtue ethics) and axiological ontology (professional values) and also draws on both deductive and inductive approaches. It is our hope that this new tool will help researchers and clinicians integrate ethical knowledge into their analysis of ethical issues and contribute to fostering ethical analyses that are grounded in relevant philosophical and axiological foundations.

Quality of physiotherapy services for injured workers compensated by workers' compensation in Quebec: a focus group study of physiotherapy professionals

Musculoskeletal disorders are among the leading causes of work-related physical disability in the province of Quebec in Canada. The authors conducted a focus group study with physiotherapists and physical rehabilitation therapists working with patients whose treatments are compensated by the Quebec Workers' Compensation Board with the goal of exploring quality of care and ethical issues. Three main themes were identified: (1) systemic factors, (2) complexity in treatment decisions and (3) inequality of care. Although physiotherapy professionals strive to give these patients the best possible care, patients might not always be provided with optimal or equal treatment. When compared with other patients, there appear to be differences with respect to access to care and types of services offered to injured workers, raising equity concerns. Factors that shape and constrain quality of physiotherapy services for injured workers need to be addressed to improve care for these patients.