Patient-centeredness In Physiotherapy: What Does It Entail .

Downloaded by [Australian Catholic University] at 04:47 19 August 2017PHYSIOTHERAPY THEORY AND PRACTICEperformed by one researcher (AJW). Duplicates wereremoved. Retrieved records were first screened on titleand abstract.The reporting of components dealing with methodological quality was assessed by AJW and ANB. Achecklist based on three different checklists was createdto obtain a complete methodological overview. Thischecklist was based on the COREQ statement for qualitative research (Tong, Sainsbury, and Craig, 2007), thechecklist used by Schoeb and Burge (2012) and thechecklist of the British Medical Journal (BMJ). TheCOREQ contained non-informative items, was dichotomized and supplemented with relevant items of thechecklist by Schoeb and Burge (2012) and the BMJ. Thedevelopment of the checklist was done by the firstresearcher (AJW) and reviewed by the secondresearcher (ANB). The full checklist is displayed inAppendix 2. For each selected paper, all the itemsincluded in the checklist were rated as Yes (Y), No(N), or unclear (?) by summing all items scored positive(scored with a Y). According to Veerbeek, Van Wegen,Harmeling-Van Der Wel, and Kwakkel (2011), a studyhas low risk for bias when it scores 75% of the maximum score and at high risk for bias when it scores 75%. The methodological reviewing of the studies wasdone independently by AJW and ANB. Cohen’s Kappawas used to assess inter-rater agreement between thetwo researchers assessing the study quality of theincluded studies (Fleiss and Cohen, 1973).Data were extracted using a data extraction form,(available upon request with the corresponding author)prior to data analysis by one reviewer, AJW. The dataextraction form was pilot tested and refined.Information was extracted from each included articleon: 1) characteristics of participants; 2) type of studydesign; 3) findings; and 4) special features. Principlesummary measures were aspects that describe patientcenteredness. Data synthesis was done following themethod of thematic synthesis (Thomas and Harden,2008), in which approaches from both meta-ethnography and grounded theory are used for analysis. Beforedata synthesis, articles were read several times to ensurefamiliarization with the study. Further to the free lineby-line coding of these studies, performed by the firstauthor (AJW), the resulting “free codes” were reviewedby ANB and PvW. In case of discrepancy acrossreviewers, consensus was derived by discussion betweenthe reviewers.The “free codes” were then organized into relatedareas to construct “descriptive” themes and “analyticalthemes.” The development of the descriptive and analytical themes was performed by AJW and SCJMV andlater reviewed by PvW, (available upon request). Lastly,3a proposed conceptual framework was developed byAJW, ANB, and PvW through brainstorm sessionsbased on the analytical themes, and reviewed by allauthors. The goal of the proposed conceptual framework is to explain the interaction between the themesand to clearly state these connections. Empirical datasaturation was reached by consensus between thereviewers.ResultsThe flowchart of the study selection is displayed inFigure 1. All 14 selected articles were qualitative studiesand published in English.Although all the included studies collected qualitative data relevant to patient centeredness, the methodology varied. The study designs included: groundedtheory (Kidd, Bond, and Bell, 2011; Melander Wikmanand Fältholm, 2006; Rindflesch, 2009; Trede, 2000);nominal group technique (Potter, Gordon, andHamer, 2003); ethnography (Hiller, Guillemin, andDelany, 2015; Thomson, 2008); a descriptive qualitativeapproach (Pashley et al, 2010); phenomenography(Larsson, Liljedahl, and Gard, 2010); phenomenology(Cooper, Smith, and Hancock, 2008; Rutberg,Kostenius, and Ohrling, 2013); or no specific design(Harman, Bassett, Fenety, and Hoens, 2011; Leach,Cornwell, Fleming, and Haines, 2010; Thornquist,1991).Study quality was assessed for each study and variedfrom 40% up to 75% (Table 1). Five studies weredefined as high quality. The inter-rater agreementbetween the two researchers assessing the study qualityof the included studies was computed and resulted in aCohen’s Kappa of 0.511, p 0.005, which is a moderateagreement (Fleiss and Cohen, 1973; Landis and Koch,1977). Although the agreement was moderate, afterdiscussion the reviewers agreed on the final study ratings presented in Table 1.The combined number of participants (n 231)across the included studies were recruited throughphysiotherapy practices and rehabilitation centers.Some studies (N 7) included physiotherapists, others(N 5) included patients, and two studies includedboth (Leach, Cornwell, Fleming, and Haines, 2010;Trede, 2000) in the data collection. The participants’age ranged from 18 to 84; four studies did not reportthe participants’ age (Harman, Bassett, Fenety, andHoens, 2011; Hiller, Guillemin, and Delany, 2015;Leach, Cornwell, Fleming, and Haines, 2010; Trede,2000). Data collection methods varied from observations, open interviews, semi-structured interviews,emails, and semi-structured focus groups to highly

4A. J. WIJMA ET AL.Titles and abstracts screened(n 730)Papers excluded after screeningtitles/abstracts (n 692)Potentially-relevant papers retrievedfor evaluation of full text (n 38)Papers excluded after evaluation offull text (n 24)* Not an article (n 4) Quantitative research (n 8)Downloaded by [Australian Catholic University] at 04:47 19 August 2017 Did not asses patient-centeredness or aspects ofpatient-centeredness (n 7) Examined patient-centeredness inother medical professions (n 4) No full text available (n 1)Papers included in review (n 14)Figure 1. Flow of studies through the review.* Papers may have been excluded for failing to meet more than one inclusion- or exclusion criteria.structured focus groups. Study findings varied from aspecific aspect of patient centeredness to a descriptionof patient centeredness in physiotherapy. In Table 2, anoverview of study characteristics is provided.In the descriptive analysis, 13 descriptive themeswere found. During the analytical analysis phase,these were gathered into eight major descriptive themesand four subthemes (ST) (two ST were conjoined)described below and in the proposed conceptual framework (Figure 2). The descriptive themes were:(1) The concept of individuality in patientcenteredness(6) ST(4) Empowerment(7) Social characteristics of a patient-centeredphysiotherapist(8) A confident physiotherapist(9) Knowledge and skills of a physiotherapist inpatient centeredness(10) Individuality(11) Individuality was found in all of the articlesand was both from the patient’s and the therapist’s perspective referred to as important.This concerned specific patient-tailored education, communication, and treatment. STwere “getting to know the patient” and “individualized treatment.”ST (1) Getting to know the patient; and ST (2)Individualized treatment(1) Continuous tailored communication in layspeech(2) ST(3) Non-verbal communication(3) Education during and about all aspects of thetreatment(4) Working with patient-defined goals(5) A patient-centered treatment in which thepatient is supportedSubtheme: getting to know the patientIt was found that both patients and physiotherapistsbelieved that getting to know the patient as a personwas important for individualization in physiotherapy.This involved getting to know patients’ history, needs,preferences, personality, beliefs, values, expectations,motivation, and circumstances (Cooper, Smith, andHancock, 2008; Harman, Bassett, Fenety, and Hoens,2011; Kidd, Bond, and Bell, 2011; Larsson, Liljedahl,

Checklist YYYYNN?NYYNN?Y?Larsson,Pashley Liljedahl,et al, and Gard, dOhrling2000 Hoens,20112013* original from the COREQ statement (Tong, Sainsbury, and Craig, 2007), # original from Schoeb and Burge (2012), original from the British Medical Journal quality checklist (Checklist)Y described in the article/good quality, N definitely not described or poor quality, ? not clearly described in the article if it is done or notOverall quality in %.1 Was the researcher experienced ortrained? *2 Was the research question clearlydefined? 3 Was the methodological orientationsuitable for this research question? *4 Was theoretical or purposefulsampling used? *5 Was there stated how manyparticipants where approached? *6 Were the important characteristics ofthe sample described? *7 Does the sample produce the type ofknowledge necessary to understandthe structures and processes withinwhich the individuals or situations arelocated? #8 Was there stated that the interviewwas open, semi structured or if therewere focus groups? *9 Were repeated interviews carried out? *10 Were field notes made? *11 Was data saturation discussed/reached? *12 Were there two or more researchersthat coded the data?*13 Was software used to manage thedata?*14 Did themes derive from the data?*15 Were participant quotationspresented to illustrate themes/items?*16 Were major themes clearlypresented in the findings?*17 Is the description described insufficient detail to allow theresearcher or the reader to interpretthe meaning and context of what isbeing researched? #18 Does the researcher move fromdescription of the data, throughquotations or examples, to ananalysis and interpretation of theirmeaning and significance? #19 Are claims being made for thegeneralizability of the findings toother bodies of knowledge? (withinscientific research) #20 Are claims being made for thegeneralizability of the findings toother populations? #Overall quality in ,Wikman andandHancock,andThomson,Fältholm,2006 Bell,20112008Hamer,20032008Table 1. Methodological quality scores of the included studies.Downloaded by [Australian Catholic University] at 04:47 19 August 2017PHYSIOTHERAPY THEORY AND PRACTICE5

PopulationEnglandUSAThomson,2008Rindflesch,20099 Physiotherapists in acute care(3), inpatient (3) and outpatientrehabilitation (3) (age 28–56, 8female, 1 male, 4–32 years’experience) in an academicmedical center10 Physiotherapists in outpatientorthopaedics (age 30–62, mean44.4 years, 8 female, 2 male,1,5–41 years’ experience, mean18,65 years)5 Physiotherapists working withchronic pain patients, 3-weekintensive program (age 24–45, 4female, 1male, 2–20 years’experience)in a English NationalHealth Service Hospital26 Current and former patients,no common complaint (age20–79, mean 48.8 years, 10 male,16 female) in private 038 Musculoskeletal patients (age20–68, 4 female and 4 male)receiving a maximum of 10treatments25 Chronic low back pain patients(age 18–65, 5 male, 20 female)receiving physiotherapy in the last6 monthsPashley et al, ite observationin an Academicmedical center,where focusgroups took placeis not describedNot describedPrimary aim(s)MethodsIn depthinterviewsTo determine patients’ perspectives of Semi-structuredcomponents of patient-centeredinterviewsphysiotherapy and its essentialelementsTo describe the patient’sexperiences of influence andparticipation in therehabilitation process. Based onpatient-centered careNominal edtheory(1) to describe therelevant factors that physiotherapiststake into accountin discontinuing treatment of adultsin the outpatientorthopaedic setting and (2) to explorehow these factorsmediate the decision-making processTo explore patients’ perspectivesregarding the qualities of a “good”physiotherapist and to gain insightinto the characteristicsof good and bad experiences inprivate practicephysiotherapy. Based onpatient-centered private sectorphysiotherapyTo describe and interpret theinteractions betweentherapists and their patients on achronic pain unitin an English National Health Service(NHS)hospital from the perspectives of thetherapistsTo describe the practice of patienteducation in physical therapy amongninephysical therapists from three practiceareasMajor themesPerspectiveThe parallel process of rehabilitation: Patient’sThe traditional medical model withcompliance, sub ordinance and theinvisible physiotherapist (at thehospital) and the individual modelwith being confirmed, sense ofcoherence, searching for informationand daring to demand (within primaryhealthcare).Ability to communicate, confidence, Patient’sknowledge and expertise,understanding people and an abilityto relate, transparent focus onprogress and outcomeCommunication (most important),Patient’sindividual care, information sharing,the physiotherapist, decision-making,organization of care(Continued )Focus groupsPatient education is physical therapy, Therapist’sand observations patient education is empowerment,the content of patient education ispatient-centered, outcome of patienteducation is evaluated throughfunctionKey informantPhysiotherapists experience, funding Therapist’sinterviews andsource, facilitating self-management,focus groupsnegotiating patient goals andmanaging expectations, usingobjective findings, patient educationHighly structured Communication ability (interpersonal Patient’smeeting process skills, physiotherapist’s manner,(focus group)teaching/education), other attributesof the physiotherapist (professionalbehavior, organizational ability),characteristics of the service providedby the physiotherapist (diagnostic andtreatment expertise, the environment,convenience and accessibility)InterviewsTherapist-patient interactions,Therapist’sand observations communication, equality of power,rehabilitation as a risk-takingnegotiating processFrameworkTo define patient-centeredness, in the Semi-structuredmethod ofcontext of physiotherapy for CLBP,interviewsqualitative data from the patient’s perspectiveanalysisPhysiotherapistsCriticalwere shadowedethnographyand interviewed inan English NationalHealth ServiceHospitalAt home orNational HealthService hospital(not physiotherapydepartment)Not describedWorkplace (2),Groundedhome (1) or at the theoryresearchers’workplace (5)6 Patients rehabilitating at three In a room at theGroundeddifferent healthcare centers,healthcare (4) center Theory3 month or longer inand at home (2)rehabilitation (age 35–58, 2 male,4 female) with neurological,circulatory and/or orthopaedicdiseasesCooper,Scotland,Smith, and GrampianHancock,2008NewZealandKidd, ltholm,2006First author,yearTable 2. Detailed description of included studies.Downloaded by [Australian Catholic University] at 04:47 19 August 20176A. J. WIJMA ET AL.

44 Physiotherapists from private Not describedpractice (36 male, 8 female, mean17.5 years’ experience (range: 0.5–38 years)11 Patients with migraine (age20–69 years, 9 female, 2 men,migraine diagnosis 1–59 years)Australia,SydneyCanada,Nova Scotiaand BritishColumbiaSwedenTrede, tenius,andOhrling,2013Not describedGroundedTheoryNot describedNot describedTo explore client education provided Semi-structuredby physiotherapists in private practice focus groupswho treat injured workers withsubacute low back pain apist’sPerspectiveTherapist’s(Continued )Meeting a physical therapist withPatient’sprofessional tools and a personaltouch. Investing time and energy tofeel better, relying on the competenceof the physical therapist, wanting tobe treated and to become involved asan individual, being respected in atrustful relationshipProfessional power and compliance,hands-off attitude versus hands-ontechnique, the role of pain ineducation, and transformation fromphysiotherapist-centered to patientcentered approachesThe critical importance of education,education: A multidimensionalconcept, understanding thephysiotherapist-client relationshipSemi-structuredinterviewsTo examine current clinicalapproaches to goal-setting throughthe multiple disciplines ofoccupational therapy, speechpathology and physiotherapy withinone rehabilitation facility. Specifically,it aimed to identify thedegree and quality of patient inputinto the goal-setting process from theperspective of the therapist andcompare the therapists’ goals withthose perceived to be the patient’sgoals using the ICFframeworkWhat educational practices arecurrently applied and whateducational theories could informeffective educational practice?What do physiotherapists do toObservationsestablish a relationship in encounters (videos) andwith patients? Andinterviewsmore specifically: How do they relateto their patientsthrough their bodies?Major themesCollaboration as biopsychosocialclient-centered client participation.Guidance as biomedical perspective ofclient participation, blocks clientcenteredness. Expertise as well asbiomedical perspective of clientparticipation, but paternalistic and notclient-centered.Greeting; note taking; gaze; bodilyexpression of caring andattentiveness; body position,orientation and closeness; manualtherapy-practice: exchange of bodymessages; psychomotor practice:perception of body relationshipsGoal-setting approaches: Therapistcontrolled, therapist led, patientfocused.Goals identified by therapists versusperceived patient goals.Facilitators and barriersPrimary aim(s)MethodsTo describe how physiotherapistsSemi-structuredexperience client participation. Based interviewson patient-centered careAt the home orPhenomenology Exploring theSemi-structuredworkplace of thelived experience of physical therapy of interviewsparticipant (6), orpersons with migrainewere conducted atLuleå University ofTechnology (5)8 Physiotherapists and 7 patients Not describedwith low back painAustralia,8 Therapists (occupational, speech EmailsQueensland and physiotherapy) and 5 strokepatients (age 49–84, 1 female, 4male) in subacute rehabilitationFirst encounters atnormal worksurroundings(physiotherapistspractice) and athomeSettingMethodologyIn a room at Health PhenomenoSciences Centre at graphyLund University or,in 4 cases, at ndHaines,2010Manual, psychomotor and homevisiting physiotherapistsPopulation11 Physiotherapists i

synonym) in physiotherapy; 3) studies involving reha-bilitation mentioning physiotherapy (in that case only the parts/quotes involving physiotherapy were used for this review); and 4) articles written in English, Dutch, or German. Exclusion criteria were: 1) studies that examined patient center