Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient
Introduction
References to patient-centred care are abundant in recent literature, particularly in relation to chronic conditions, with policy documents for the UK National Health Service (NHS) stating that care should be patient-centred [1]. In addition, several authors have suggested that physiotherapy should be patient-centred [2], [3]. Despite this, research has shown that ‘the concept of patient-centred care is complex and contested’ [4], and it remains unclear precisely what is meant or understood by the term with regard to physiotherapy.
Chronic low back pain (CLBP) is a condition commonly seen by physiotherapists in primary care [5], and it is suggested that CLBP patients will benefit from a patient-centred approach [6]. However, it is impossible to demonstrate the extent to which physiotherapy is patient-centred, and therefore to assess the possible benefits of such an approach, in the absence of a clear definition.
Several other professional groups, such as nursing, occupational therapy and medicine, have proposed models of patient-centredness; three examples are discussed below. In nursing, Gerteis et al. [7] developed a model in an acute medical and surgical context. Important differences between this setting and outpatient physiotherapy departments make the extent to which the model can be applied in the latter questionable. In occupational therapy, Law et al. [8] developed a model from the literature rather than practice, with a key emphasis on decision-making. In medicine, the model proposed by Mead and Bower [9] was also developed from the literature, mainly in the context of primary care. It is possible that these theoretical models relate fairly well to physiotherapy in primary care. However, there are several differences between the three models described, suggesting that different professional groups and contexts result in different focuses on aspects of patient-centred care [4], and that a specific model for physiotherapy may be required. Patients’ views on some of the dimensions of patient-centredness proposed in nursing, occupational therapy and medicine have been explored. These include involvement in goal setting, treatment planning and outcome evaluation [10], decision-making [11], [12], the patient–therapist relationship [13] and communication [2], [3]. However, it is not clear how these will apply to CLBP patients.
If patient-centred care has the patient at its centre, patients’ views are paramount to the development of a model of patient-centredness. This is in keeping with the current drive to involve patients in the design and evaluation of healthcare services [14]. In physiotherapy, patient-centredness has been discussed from the professional's perspective [15], but patients’ views on patient-centredness appear to be lacking.
A definition of patient-centredness will provide a common language, enable assessment of the extent to which physiotherapy is achieving patient-centredness, and inform the development of strategies to optimise patient-centred physiotherapy. Therefore, the aim of this study was to define patient-centredness, in the context of physiotherapy for CLBP, from the patient's perspective.
Section snippets
Methods
Participants were recruited from seven physiotherapy departments in the Grampian region of Scotland. A purposive sampling frame was developed to ensure representation from the wide range of CLBP patients typically seen in this region [16]. Sampling criteria were: location of physiotherapy, defined as urban or semi-rural [17]; gender; whether or not participants completed their course of physiotherapy; age; and management style (group, one-to-one or mixed). Participants who had attended at least
Results
In total, 140 letters were sent to prospective participants. As they were sent out in batches, it was possible to monitor sampling criteria and target the next batch appropriately. Twenty-five participants provided informed consent and were subsequently interviewed; their characteristics are displayed in Table 1.
Two broad dimensions relating to patient-centredness emerged during data analysis: the physiotherapy experience; and the process of physiotherapy. There were 11 themes within these two
Discussion
Patient-centredness, from the perspective of these CLBP patients, is a complex combination of the following six dimensions: communication; individual care; decision-making; information sharing; the physiotherapist; and organisation of care. Effective communication is common to all dimensions, emphasising its importance. The results of this study revealed a number of dimensions of patient-centredness that may assist physiotherapists to better understand and manage CLBP patients. However, a
Generalisation
It is not the purpose of qualitative research to generalise to the wider population, but to demonstrate that findings ‘can be transferred and may have meaning if applied to other individuals, contexts and situations’ [28]. Therefore, it is intended that the current research has been presented in a sufficiently detailed manner for the reader to judge to what extent the findings apply in similar settings [29]. The views of a small group can never represent the ‘truth’, and further research is
Implications
An evidence-based model of patient-centred physiotherapy is presented for the first time. Addressing these dimensions of patient-centredness should enhance the experience of physiotherapy for CLBP patients. Physiotherapists should be aware of the six dimensions that are of importance to patients, paying particular attention to communication. Improving physiotherapists’ communication skills may better facilitate patient-centred physiotherapy in this client group. Further research is required to
Acknowledgements
The authors wish to thank the physiotherapists who facilitated recruitment, the people with CLBP who freely and willingly gave their time to be interviewed, and Dr. Neil Campbell for reading and commenting on an earlier draft of this manuscript.
Ethical approval: NHS Grampian Research Ethics Committee. Ref. No. 04/S0801/49.
Funding: Nursing, Midwifery and Allied Health Professions Research Training Scheme (Scotland), to which the first author was seconded as a doctoral candidate.
Conflict of
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