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Download by: [Australian Catholic University] Date: 19 August 2017, At: 04:47
Physiotherapy Theory and PracticeAn International Journal of Physical Therapy
ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20
Patient-centeredness in physiotherapy: What doesit entail? A systematic review of qualitative studies
Amarins J Wijma, Anouck N Bletterman, Jacqui R Clark, Sigrid C.J.M Vervoort,Anneke Beetsma, Doeke Keizer, Jo Nijs & C. Paul Van Wilgen
To cite this article: Amarins J Wijma, Anouck N Bletterman, Jacqui R Clark, Sigrid C.J.M Vervoort,Anneke Beetsma, Doeke Keizer, Jo Nijs & C. Paul Van Wilgen (2017): Patient-centeredness inphysiotherapy: What does it entail? A systematic review of qualitative studies, PhysiotherapyTheory and Practice, DOI: 10.1080/09593985.2017.1357151
To link to this article: http://dx.doi.org/10.1080/09593985.2017.1357151
Published online: 18 Aug 2017.
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Patient-centeredness in physiotherapy: What does it entail? A systematic reviewof qualitative studiesAmarins J Wijma, Pt, Msca,b,c, Anouck N Bletterman, PT, MScd, Jacqui R Clark, MSca,e, Sigrid C.J.M Vervoort, MSc,PhDf, Anneke Beetsma, MScg, Doeke Keizer, Md, PhDb, Jo Nijs, PhDa,c, and C. Paul Van Wilgen, PhDa,b,c
aDepartment of Physiotherapy, Human Physiology and Anatomy, Vrije Universiteit Brussel, Brussels, Belgium; bTranscare, TransdisciplinaryOutpatient Treatment Centre, Groningen, The Netherlands; cPain in Motion International Research Group, Brussels, Belgium; dDepartment ofphysiotherapy, Fysio Stiens, Stiens, The Netherlands; eFaculty of Health Psychology and Social Care, Manchester Metropolitan University,Manchester, UK; fUMC Utrecht Cancer Center, University Medical Centre Utrecht, Utrecht, The Netherlands; gDepartment of Physiotherapy,Hanze University of Applied Sciences, School of Health Studies, Groningen, The Netherlands
ABSTRACTPurpose: The literature review is aimed at examining and summarizing themes related to patient-centeredness identified in qualitative research from the perspectives of patients and physiothera-pists. Following the review, a secondary aim was to synthesize the themes to construct aproposed conceptual framework for utilization within physiotherapy. Methods: A systematicsearch of qualitative studies was conducted including all articles up to 2015 September.Methodological quality was examined with a checklist. The studies were examined for themessuggestive of the practice of patient centeredness from perspective of the therapists and/or thepatients. Data were extracted using a data extraction form and analyzed following “thematicsynthesis.” Results: Fourteen articles were included. Methodological quality was high in fivestudies. Eight major descriptive themes and four subthemes (ST) were identified. The descriptivethemes were: individuality (ST “Getting to know the patient” and ST “Individualized treatment”),education, communication (ST “Non-verbal communication”), goal setting, support (ST“Empowerment”), social characteristics of a patient-centered physiotherapist, a confident phy-siotherapist, and knowledge and skills of a patient-centered physiotherapist. Conclusions: Patient-centeredness in physiotherapy entails the characteristics of offering an individualized treatment,continuous communication (verbal and non-verbal), education during all aspects of treatment,working with patient-defined goals in a treatment in which the patient is supported and empow-ered with a physiotherapist having social skills, being confident and showing specific knowledge.
ARTICLE HISTORYReceived 11 June 2015Revised 22 September 2016Accepted 12 October 2016
KEYWORDSModels (theoretical);patient-centered care;physiotherapy; qualitativeresearch; qualitative review;review
Introduction
Healthcare is continuously evolving globally, one rea-son being the increase in incidence and prevalence ofpatients with (multiple) chronic diseases. In response tothese changes, the complexity of healthcare is continu-ously expanding and the delivery of healthcare, evenwith all the advantages, may often be complicated,uncoordinated, and unsafe. According to the USInstitute of Medicine, patient-centered care has apotential to address some of these deficits in the health-care system. Therefore patient-centered care has a highpriority in the restructuring of healthcare in the twenty-first century. The federal government of the USA hasestablished a Patient-Centered Outcomes ResearchInstitute that underlines their recommendations forchanges in healthcare. These recommendations havebeen developed, however, without patient participation.
As Lorig (2012) suggests, “if a service is to be patientcentered, then both the health care system and thepatient have to be involved in determining what thismeans. Each has its own view of meaning, and patient-centered care will never be achieved if patients are notpart of the solution” (p. 524). This highlights theimportance of patient-centeredness in healthcare pol-icy-making today.
There are many different definitions of patient-cen-teredness in healthcare. Patient-centeredness was firstdescribed in medicine by McWhinney (1989) as, “thephysician tries to enter the patients” world, to see theillness through the eyes of the patients. Patient-centeredhealthcare in hospital settings entails eight characteris-tics of care: respect for the patient’s values, preferences,and expressed needs; coordinated and integrated care;clear, high-quality information and education for the
CONTACT Amarins J. Wijma, PT, MSc, PhD [email protected] VUB Jette, Department Kine, Building F, Laarbeeklaan 103, B – 1090 Jette, Brussels,Belgium.
PHYSIOTHERAPY THEORY AND PRACTICEhttps://doi.org/10.1080/09593985.2017.1357151
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patient and family; physical comfort, including painmanagement; emotional support and alleviation offear and anxiety; involvement of family members andfriends, as appropriate; continuity, including throughcare-site transitions; and access to care (Gerteis,Edgman-Levitan, Daley, and Delbanco, 2002).Probably the most commonly used framework ofpatient centeredness in medicine is a model describedby Mead and Bower (2000) with five interconnectingcomponents: 1) biopsychosocial perspective; 2) the“patient-as-person”; 3) sharing power and responsibil-ity; 4) the therapeutic alliance; and 5) the “doctor-as-person.” Patient centeredness has also been describedas a moral philosophy of healthcare professionals toendorse high-quality healthcare (Epstein et al, 2005).
In physiotherapy, however, there is a lack of under-standing surrounding the concept of patient centered-ness. It is considered important to examine the existingliterature on patient centeredness to assist in develop-ing a deeper understanding of the concepts and impli-cations in physiotherapy. Mead and Bower’s framework(2000) uses largely qualitative descriptives, and it couldbe argued that qualitative research is the most effectiveway to provide an in-depth understanding of patient-centeredness perspectives.
As physiotherapists we are healthcare professionalsthat endorse patients’ self-management in which weincorporate the biopsychosocial perspective, by com-bining functional training for the body and coaching(Bandura, 1977; Bandura, Adams, and Beyer, 1977). Inmedicine, it is known that patient centeredness canstrengthen the biopsychosocial perspective by enhan-cing the relationship (improving empathy, attentive-ness, and communication) between the healthcareprofessional and the patient. Furthermore, patient-cen-tered medicine shows positive effects on a range ofqualitative measures relating to clarify patients’ con-cerns and beliefs (Dwamena et al, 2012).
For the reasons outlined above, a systematic reviewof the available qualitative research literature related topatient-centeredness in physiotherapy was conducted.The literature review is aimed to: 1) examine and sum-marize themes related to patient centeredness identifiedin qualitative research; and 2) provide a frameworkfrom which to develop applications to physiotherapy.The particular phenomenon of interest was the under-standing of patient centeredness from the perspectivesof patients and physiotherapists.
We only included qualitative articles as they allowfor seeking meaning and understanding of a phenom-enon, in this case patient centeredness. Informationwas to be drawn from the experiences of both phy-siotherapists and patients. Following the review, a
secondary aim was to synthesize the themes to helpconstruct a conceptual framework describing patientcenteredness for utilization within the context of phy-siotherapy. Therefore, the research question of thisqualitative systematic review is: To what extent ispatient centeredness examined in physiotherapy in qua-litative research and can a theoretical framework beconstructed from this research for patient centerednessin physiotherapy?
Methods
A systematic search (Appendix 1) was conducted inPubMed (MEDLINE), EMBASE, Cochrane,PsychINFO, CINAHL, PEDro, and Scopus includingarticles from 1970 until 2015 September, 15. The timespan was limited as patient centeredness was firstintroduced in 1970 (Balint, 1970). In addition, thereference lists of all selected articles were screenedfor relevant papers not identified through the search.The search was carried out without additional limits.The PICo was used to identify the P-Population(adult patients who received physiotherapy and phy-siotherapists), the I-Interest (experiences), and Co-Context (physiotherapy in all settings). Based on thePICo, the following search terms were used to searcheach of the trial registers and databases listed above:“patient centeredness,” “patient centred,” “patientcentered,” “patient oriented,” “patient focused,” “phy-siotherapy,” “physical therapy,” “factors,” and“aspects.” Medical Subject Headings (MESH) termswere used for patient-centered care and physiother-apy. Search terms were combined using AND andOR. Search strategies were peer reviewed by PvWand ANB.
All articles were examined for eligibility by checkingthe inclusion and exclusion criteria. Inclusion criteriawere: 1) qualitative studies; 2) studies assessing patient-centeredness or aspects of patient centeredness (or asynonym) in physiotherapy; 3) studies involving reha-bilitation mentioning physiotherapy (in that case onlythe parts/quotes involving physiotherapy were used forthis review); and 4) articles written in English, Dutch,or German.
Exclusion criteria were: 1) studies that examinedpatient centeredness only in other medical professionsbesides physiotherapy; 2) articles that examined patientsatisfaction only; 3) articles that involved pediatric phy-siotherapy (due to the triangle-relationship with chil-dren, parents, and therapist); and 4) studies thatexamined themes suggestive of the practice of patientcenteredness from the perspective of therapists and/orthe patients. Eligibility assessment of the articles was
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performed by one researcher (AJW). Duplicates wereremoved. Retrieved records were first screened on titleand abstract.
The reporting of components dealing with metho-dological 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 qua-litative 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 dichot-omized 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 max-imum 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-ethnogra-phy and grounded theory are used for analysis. Beforedata synthesis, articles were read several times to ensurefamiliarization with the study. Further to the free line-by-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 ana-lytical themes was performed by AJW and SCJMV andlater reviewed by PvW, (available upon request). Lastly,
a 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 frame-work is to explain the interaction between the themesand to clearly state these connections. Empirical datasaturation was reached by consensus between thereviewers.
Results
The 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 qualita-tive data relevant to patient centeredness, the metho-dology 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 rat-ings 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 observa-tions, open interviews, semi-structured interviews,emails, and semi-structured focus groups to highly
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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 frame-work (Figure 2). The descriptive themes were:
(1) The concept of individuality in patientcenteredness
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 the
treatment(4) Working with patient-defined goals(5) A patient-centered treatment in which the
patient is supported
(6) ST(4) Empowerment(7) Social characteristics of a patient-centered
physiotherapist(8) A confident physiotherapist(9) Knowledge and skills of a physiotherapist in
patient centeredness(10) Individuality(11) Individuality was found in all of the articles
and was both from the patient’s and the thera-pist’s perspective referred to as important.This concerned specific patient-tailored edu-cation, communication, and treatment. STwere “getting to know the patient” and “indi-vidualized treatment.”
Subtheme: 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,
Titles and abstracts screened (n = 730)
Potentially-relevant papers retrieved for evaluation of full text (n = 38)
Papers included in review (n =14)
Papers excluded after screening titles/abstracts (n = 692)
Papers excluded after evaluation of full text (n =24)*
• Not an article (n = 4) • Quantitative research (n = 8) • Did not asses patient-
centeredness or aspects of patient-centeredness (n = 7)
• Examined patient-centeredness in other medical professions (n = 4)
• No full text available (n = 1)
Figure 1. Flow of studies through the review.* Papers may have been excluded for failing to meet more than one inclusion- or exclusion criteria.
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Table1.
Metho
dologicalq
ualityscores
oftheinclud
edstud
ies.
No
Checklist
item
Melander
Wikman
and
Fälth
olm,2006
Kidd
,Bo
nd,
and
Bell,2011
Coop
er,
Smith
,and
Hancock,
2008
Potter,
Gordon
,and
Ham
er,2003
Thom
son,
2008
Rind
flesch,
2009
Pashley
etal,
2010
Larsson,
Liljedahl,
andGa
rd,
2010
Thornq
uist,
1991
Leach,
Cornwell,
Flem
ing,
and
Haines,
2010
Trede,
2000
Harman,
Bassett,
Fenety,
and
Hoens,2011
Rutberg,
Kostenius,
and
Ohrling
2013
Hiller,
Guillem
in,
and
Delany,
2015
1Was
theresearcher
experienced
ortrained?
*?
??
?Y
?Y
??
??
??
?
2Was
theresearch
questio
nclearly
defin
ed?$
YY
YY
YY
YY
YY
YN
YY
3Was
themetho
dologicalo
rientation
suitableforthisresearch
questio
n?*
YY
YN
YY
NY
?N
Y?
YY
4Was
theoretical
orpu
rposeful
samplingused?*
YY
YY
YY
YY
?Y
NY
YY
5Was
therestated
howmany
particip
antswhereapproached?*
NN
YN
NY
NY
NN
YY
YN
6Weretheimportantcharacteristicsof
thesampledescrib
ed?*
YY
YY
YY
YY
NY
NY
YY
7Do
esthesampleproducethetype
ofknow
ledgenecessaryto
understand
thestructures
andprocesseswith
inwhich
theindividualsor
situations
are
located?
#
YY
Y?
YN
YN
YY
YY
YY
8Was
therestated
that
theinterview
was
open,sem
istructuredor
ifthere
werefocusgrou
ps?*
YY
YY
YY
YY
YY
YY
Y
9Wererepeated
interviewscarriedout?*
NN
NY
YY
?N
?Y
NN
NY
10Werefield
notesmade?
*?
YN
NY
?Y
N?
N?
??
Y11
Was
data
saturatio
ndiscussed/
reached?
*Y
YN
YN
NN
NN
NN
NN
Y
12Weretheretwoor
moreresearchers
that
codedthedata?*
Y?
YY
N?
YN
NY
?N
YN
13Was
softw
areused
tomanagethe
data?*
?Y
YN
YN
YN
NY
?Y
??
14Did
them
esderivefro
mthedata?*
YY
YY
YY
YY
YY
YY
YY
15Wereparticipantqu
otations
presentedto
illustratethem
es/
items?*
YY
YY
YY
YY
YY
YY
YY
16Weremajor
them
esclearly
presentedin
thefin
ding
s?*
YY
YN
YY
YY
YY
YY
YY
17Isthedescrip
tiondescrib
edin
sufficientdetailto
allow
the
researcher
orthereader
tointerpret
themeaning
andcontextof
whatis
beingresearched?#
YY
YN
YN
YN
YN
YY
YY
18Doestheresearcher
movefro
mdescrip
tionof
thedata,throu
ghqu
otations
orexam
ples,toan
analysisandinterpretatio
nof
their
meaning
andsig
nificance?#
YY
YN
YY
YY
YY
YY
YY
19Areclaimsbeingmadeforthe
generalizability
ofthefin
ding
sto
otherbo
dies
ofknow
ledg
e?(with
inscientificresearch)#
NY
NN
NN
NN
NN
NY
YN
20Areclaimsbeingmadeforthe
generalizability
ofthefin
ding
sto
otherpo
pulatio
ns?#
NN
NN
NN
YY
NN
NY
YY
Overallqu
ality
in%
6575
7045
7555
7555
4060
5065
7575
*=originalfro
mtheCO
REQstatem
ent(Ton
g,Sainsbury,andCraig,
2007),#=originalfro
mScho
ebandBu
rge(2012),$
=originalfro
mtheBritish
MedicalJournalq
ualitychecklist
(Checklist)
Y=describ
edin
thearticle/goodqu
ality,N
=defin
itelyno
tdescrib
edor
poor
quality,?
=no
tclearly
describ
edin
thearticle
ifitisdo
neor
not
Overallqu
ality
in%.
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Table2.
Detaileddescrip
tionof
includ
edstud
ies.
Firstauthor,
year
Coun
try
Popu
latio
nSetting
Metho
dology
Primaryaim(s)
Metho
dsMajor
them
esPerspective
Melander
Wikman
and
Fälth
olm,
2006
Sweden
6Patientsrehabilitatingat
three
diffe
rent
healthcare
centers,
3mon
thor
long
erin
rehabilitation(age
35–58,
2male,
4female)
with
neurolog
ical,
circulatoryand/or
orthop
aedic
diseases
Inaroom
atthe
healthcare(4)center
andathome(2)
Grou
nded
Theory
Todescrib
ethepatient’s
experiences
ofinfluence
and
participationin
the
rehabilitationprocess.Basedon
patient-centeredcare
Indepth
interviews
Theparallelp
rocess
ofrehabilitation:
Thetradition
almedicalmod
elwith
compliance,subordinanceandthe
invisib
leph
ysiotherapist
(atthe
hospital)andtheindividu
almod
elwith
beingconfirm
ed,sense
ofcoherence,searchingforinform
ation
anddarin
gto
demand(with
inprimary
healthcare).
Patient’s
Kidd
,Bon
d,and
Bell,2011
New
Zealand
8Musculoskeletalpatients(age
20–68,
4femaleand4male)
receivingamaximum
of10
treatm
ents
Workplace
(2),
home(1)or
atthe
researchers’
workplace
(5)
Grou
nded
theory
Todeterm
inepatients’perspectives
ofcompo
nentsof
patient-centered
physiotherapyandits
essential
elem
ents
Semi-structured
interviews
Ability
tocommun
icate,confidence,
know
ledg
eandexpertise
,un
derstand
ingpeop
leandan
ability
torelate,transparent
focuson
prog
ress
andou
tcom
e
Patient’s
Coop
er,
Smith
,and
Hancock,
2008
Scotland
,Gram
pian
25Ch
roniclowback
pain
patients
(age
18–65,
5male,20
female)
receivingph
ysiotherapyinthelast
6mon
ths
Atho
meor
NationalH
ealth
Serviceho
spital
(not
physiotherapy
department)
Fram
ework
metho
dof
qualitativedata
analysis
Todefin
epatient-centeredn
ess,in
the
contextof
physiotherapyforCLBP,
from
thepatient’sperspective
Semi-structured
interviews
Commun
ication(m
ostimpo
rtant),
individu
alcare,informationsharing,
theph
ysiotherapist,d
ecision
-making,
organizatio
nof
care
Patient’s
Potter,
Gordon
,and
Ham
er,
2003
Australia,
Western
26Cu
rrentandform
erpatients,
nocommon
complaint
(age
20–79,
mean48.8
years,10
male,
16female)
inprivatepractice
Not
describ
edNom
inal
grou
ptechniqu
eTo
explorepatients’perspectives
regardingthequ
alities
ofa“good”
physiotherapist
andto
gain
insig
htinto
thecharacteristics
ofgo
odandbadexperiences
inprivatepractice
physiotherapy.Basedon
patient-centeredprivatesector
physiotherapy
Highlystructured
meetin
gprocess
(focusgrou
p)
Commun
icationability
(interpersonal
skills,ph
ysiotherapist’smanner,
teaching
/edu
catio
n),o
ther
attributes
oftheph
ysiotherapist
(professional
behavior,o
rganizationala
bility),
characteristicsof
theserviceprovided
bytheph
ysiotherapist
(diagn
ostic
and
treatm
entexpertise
,the
environm
ent,
convenienceandaccessibility)
Patient’s
Thom
son,
2008
England
5Ph
ysiotherapistsworking
with
chronicpain
patients,3-week
intensiveprog
ram
(age
24–45,
4female,1m
ale,2–20
years’
experience)in
aEnglish
National
Health
ServiceHospital
Physiotherapists
wereshadow
edandinterviewed
inan
English
National
Health
Service
Hospital
Critical
ethn
ograph
yTo
describ
eandinterpretthe
interactions
between
therapistsandtheirpatientson
achronicpain
unit
inan
English
NationalH
ealth
Service
(NHS)
hospitalfrom
theperspectives
ofthe
therapists
Interviews
andob
servations
Therapist-patient
interactions,
commun
ication,
equalityof
power,
rehabilitationas
arisk-taking
nego
tiatin
gprocess
Therapist’s
Rind
flesch,
2009
USA
9Ph
ysiotherapistsin
acutecare
(3),inpatient
(3)andou
tpatient
rehabilitation(3)(age
28–56,
8female,1male,4–32
years’
experience)
inan
academ
icmedicalcenter
Onsite
observation
inan
Academ
icmedicalcenter,
where
focus
grou
pstook
place
isno
tdescrib
ed
Grou
nded
theory
Todescrib
ethepracticeof
patient
educationin
physical
therapyam
ong
nine
physicaltherapistsfro
mthreepractice
areas
Focusgrou
psandob
servations
Patient
educationisph
ysical
therapy,
patient
educationisem
powerment,
thecontentof
patient
educationis
patient-centered,
outcom
eof
patient
educationisevaluatedthroug
hfunctio
n
Therapist’s
Pashleyet
al,
2010
Canada,
Greater
Toronto
Area
10Ph
ysiotherapists
inou
tpatient
orthop
aedics
(age
30–62,
mean
44.4
years,8female,
2male,
1,5–41
years’experie
nce,
mean
18,65years)
Not
describ
edDescriptive
qualitative
approach
(1)to
describ
ethe
relevant
factorsthat
physiotherapists
take
into
accoun
tin
discon
tinuing
treatm
entof
adults
intheou
tpatient
orthop
aedicsettingand(2)toexplore
how
thesefactors
mediate
thedecisio
n-makingprocess
Keyinform
ant
interviewsand
focusgrou
ps
Physiotherapistsexperience,fund
ing
source,facilitatin
gself-managem
ent,
nego
tiatin
gpatient
goalsand
managingexpectations,u
sing
objectivefin
ding
s,patient
education
Therapist’s
(Con
tinued)
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Table2.
(Con
tinued).
Firstauthor,
year
Coun
try
Popu
latio
nSetting
Metho
dology
Primaryaim(s)
Metho
dsMajor
them
esPerspective
Larsson,
Liljedahl,
andGa
rd,
2010
Sweden,
southern
11Ph
ysiotherapistsin
diffe
rent
areas:orthop
aedics,
rheumatolog
y,neurolog
y,respiratory
diseases
andsurgery
(8female,3male,1–42
years’
experience,median15
years)
Inaroom
atHealth
Sciences
Centre
atLund
Universityor,
in4cases,at
the
respon
dent’s
workplace
Phenom
eno-
graphy
Todescrib
eho
wph
ysiotherapists
experienceclient
participation.
Based
onpatient-centeredcare
Semi-structured
interviews
Collabo
ratio
nas
biop
sychosocial
client-centeredclient
participation.
Guidance
asbiom
edicalperspectiveof
client
participation,
blocks
client-
centeredness.Expertiseas
wellas
biom
edicalperspectiveof
client
participation,bu
tpaternalistic
andno
tclient-centered.
Therapist’s
Thornq
uist,
1991
Norway
Manual,psycho
motor
andho
me
visitingph
ysiotherapists
Firstencoun
tersat
norm
alwork
surrou
ndings
(physio
therapists
practice)
andat
home
Not
describ
edWhatdo
physiotherapistsdo
toestablish
arelatio
nshipin
encoun
ters
with
patients?
And
morespecifically:H
owdo
they
relate
totheirpatients
throug
htheirbo
dies?
Observatio
ns(videos)and
interviews
Greetin
g;no
tetaking
;gaze;bo
dily
expressio
nof
carin
gand
attentiveness;bo
dypo
sition,
orientationandcloseness;manual
therapy-practice:exchange
ofbo
dymessages;psycho
motor
practice:
perceptio
nof
body
relatio
nships
Therapist’s
Leach,
Cornwell,
Flem
ing,
and
Haines,
2010
Australia,
Queensla
nd8Therapists(occup
ational,speech
andph
ysiotherapy)
and5stroke
patients(age
49–84,
1female,4
male)
insubacute
rehabilitation
Emails
Not
describ
edTo
exam
inecurrentclinical
approaches
togo
al-settin
gthroug
hthemultip
ledisciplines
ofoccupatio
naltherapy,speech
patholog
yandph
ysiotherapywith
inon
erehabilitationfacility.Specifically,
itaimed
toidentifythe
degree
andqu
ality
ofpatient
inpu
tinto
thego
al-settin
gprocessfro
mthe
perspectiveof
thetherapist
and
compare
thetherapists’go
alswith
thoseperceivedto
bethepatient’s
goalsusingtheICF
framew
ork
Semi-structured
emails
Goal-settin
gapproaches:Therapist
controlled,
therapist
led,
patient
focused.
Goalsidentifiedby
therapistsversus
perceivedpatient
goals.
Facilitatorsandbarriers
Patient’s
and
therapist’s
Trede,2000
Australia,
Sydn
ey8Ph
ysiotherapistsand7patients
with
low
back
pain
Not
describ
edGrou
nded
Theory
Whateducationalp
ractices
are
currently
appliedandwhat
educationaltheoriescouldinform
effectiveeducationalp
ractice?
Semi-structured
interviews
Professio
nalp
ower
andcompliance,
hand
s-offattitud
eversus
hand
s-on
techniqu
e,therole
ofpain
ineducation,
andtransformationfro
mph
ysiotherapist-centeredto
patient
centered
approaches
Patient’s
and
therapist’s
Harman,
Bassett,
Fenety,
and
Hoens,
2011
Canada,
NovaScotia
andBritish
Columbia
44Ph
ysiotherapistsfro
mprivate
practice(36male,8female,mean
17.5years’experience(ra
nge:0.5–
38years)
Not
describ
edNot
describ
edTo
exploreclient
educationprovided
byph
ysiotherapistsin
privatepractice
who
treatinjuredworkerswith
subacute
low
back
pain
(SA-LBP)
Semi-structured
focusgrou
psThecriticalimpo
rtance
ofeducation,
education:
Amultid
imensio
nal
concept,un
derstand
ingthe
physiotherapist-client
relatio
nship
Therapist’s
Rutberg,
Kostenius,
and
Ohrling,
2013
Sweden
11Patientswith
migraine(age
20–69years,9female,2men,
migrainediagno
sis<1–59
years)
Attheho
meor
workplace
ofthe
participant(6),or
werecond
uctedat
LuleåUn
iversityof
Techno
logy
(5)
Phenom
enolog
yExploringthe
lived
experienceof
physicaltherapyof
person
swith
migraine
Semi-structured
interviews
Meetin
gaph
ysical
therapist
with
professio
naltoolsandaperson
altouch.
Investingtim
eandenergy
tofeelbetter,relying
onthecompetence
oftheph
ysical
therapist,w
antin
gto
betreatedandto
becomeinvolved
asan
individu
al,b
eing
respectedin
atrustfu
lrelationship
Patient’s
(Con
tinued)
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and Gard, 2010; Leach, Cornwell, Fleming, and Haines,2010; Melander Wikman and Fältholm, 2006; Pashleyet al., 2010; Potter, Gordon, and Hamer, 2003; Rutberg,Kostenius, and Ohrling, 2013) and remembering them.Patients appreciated being seen as an integration ofbody and soul (Melander Wikman and Fältholm,2006) and knowing the patient as a person was anessential part of this integration.
Subtheme: individualized treatmentPatients wanted themselves, rather than the techniques,to be in the center of concern (Trede, 2000). An indi-vidualized treatment involved an individualized treat-ment plan so patients can learn independently (Trede,2000), including exercises, advice, and education thatwas composed in dialogue and collaboration with thepatient (Cooper, Smith, and Hancock, 2008; Harman,Bassett, Fenety, and Hoens, 2011; Pashley et al, 2010;Rindflesch, 2009; Rutberg, Kostenius, and Ohrling,2013). During the treatment, the therapist had to beaware of the changing needs of the patient (Rutberg,Kostenius, and Ohrling, 2013). The exercises and givenadvice affected patient adherence (Cooper, Smith, andHancock, 2008), suggesting that patient centerednessrequired the physiotherapist to ensure that the patientexperienced the exercises as important and individua-lized (Trede, 2000). Adjustments made by the phy-siotherapist in response to patients’ feedback wasexperienced as important (Cooper, Smith, andHancock, 2008; Trede, 2000). Not only the content ofthe treatment should be individualized, but the deliveryof treatment as well (Cooper, Smith, and Hancock,2008).
Communication
Both therapists and patients mentioned communica-tion as a part of patient centeredness in all the arti-cles. The most important aspect of communicationwas the need of an ongoing dialogue with patients.Moreover, the communication style should be tai-lored to the individual patient in clear and lay speech(Cooper, Smith, and Hancock, 2008; Hiller,Guillemin, and Delany, 2015; Kidd, Bond, and Bell,2011; Pashley et al, 2010; Rutberg, Kostenius, andOhrling, 2013; Trede, 2000). This required opennessof the therapist about themselves and the therapy,and ultimately created safety for the patient to openup (Rutberg, Kostenius, and Ohrling, 2013; Trede,2000). Personal communication and communicationskills were far more important than the provision ofscientific facts (Trede, 2000). By personal communi-cation, a bond was established and the therapy shiftedTa
ble2.
(Con
tinued).
Firstauthor,
year
Coun
try
Popu
latio
nSetting
Metho
dology
Primaryaim(s)
Metho
dsMajor
them
esPerspective
Hiller,
Guillem
in,
and
Delany,
2015
Australia
9ph
ysiotherapists(4
male,5
female,1,5–21
years’experience,
musculoskeletal,spo
rts,
neurolog
ical,con
tinence
and
pelvicfloor)
52patients(15male,37
female,
age20–70years,with
spinalpain,
workrelated,
knee,spo
rts,
perip
heral,balanceand
neurolog
ical,w
omen’sandchest
prob
lems)
Inprivate
physiotherapy
practices
inMelbo
urne
Ethn
ograph
icTo
firstexam
inewhether
andho
westablish
edmod
elsof
healthcare
commun
ication(practioner-centered
andpatient-centered)
are
incorporated
into
one-on
-one
consultatio
nsandsecond
toexam
ine
physiotherapists’interpretatio
nand
understand
ingof
theirclinical
commun
ication
Observatio
ns,
field
notesand
semi-structured
interviews
Observatio
nalthemes:Focus
onph
ysicalaspectsandpain,a
consistentstructure,ph
ysiotherapists
lead
thecommun
ication,useof
casual
conversatio
n,touchas
commun
ication
Physiotherapist
interview
them
e:A
senseof
purpose
Therapist’s
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from therapist to patient centered (Hiller, Guillemin,and Delany, 2015).
Communicative abilities of a patient-centered phy-siotherapist meant being receptive to what the patienthas to say, correctly interpreted, and giving explana-tions in a way patients understand (Fleiss and Cohen,1973; Trede, 2000). Purposefully changing communica-tion styles depending on the patient (Hiller, Guillemin,and Delany, 2015). Having the ability to explain in layterms, directly speaking to the patient, listening, andasking appropriate questions were of importance(Cooper, Smith, and Hancock, 2008; Kidd, Bond, andBell, 2011; Pashley et al, 2010; Potter, Gordon, andHamer, 2003).
Subtheme: non-verbal communicationNon-verbal communication incorporated eye contact,nodding, and facial expressions (Harman, Bassett,Fenety, and Hoens, 2011; Hiller, Guillemin, andDelany, 2015; Thornquist, 1991). This indicated interestinto the patient, availability for contact, and made surethe patient perceives the contact as “being seen”(Thornquist, 1991). Furthermore, therapists used theirown body language and facial expression, as well as thatof the patient, to establish a bond and reflect if it wasindeed established (Harman, Bassett, Fenety, andHoens, 2011; Hiller, Guillemin, and Delany, 2015).
Both the patients and the therapists experiencednon-verbal communication as consisting of phy-siotherapists’ body movements. It comprised of usingtheir hands, touch, cushions for comforting, and creat-ing a trustful body language (Hiller, Guillemin, andDelany, 2015; Rutberg, Kostenius, and Ohrling, 2013;Thornquist, 1991). Furthermore, non-verbal communi-cation comprised of active listening to the patient andmaking sure that the patient was aware of this activelistening (Cooper, Smith, and Hancock, 2008; Harman,
Bassett, Fenety, and Hoens, 2011; Potter, Gordon, andHamer, 2003; Thornquist, 1991; Trede, 2000).
Non-verbal communication created a sense of beingrespected (Hiller, Guillemin, and Delany, 2015;Rutberg, Kostenius, and Ohrling, 2013), caring for thepatient (Hiller, Guillemin, and Delany, 2015;Thornquist, 1991), demonstrating empathy, respect,consideration, made the patient feel at ease (Hiller,Guillemin, and Delany, 2015; Kidd, Bond, and Bell,2011), and created room for emotions.
Education
All studies mentioned education as related to patientcenteredness. Education was mentioned as explanationabout physical symptoms, the problem, intake, diagno-sis, treatment, and treatment course. The contenttaught during education should be useful and focusedon the patient’s problems (Kidd, Bond, and Bell, 2011).Visualizing, using metaphors and demonstratingtoward the patient was found to be constructive inpatient-centered education (Kidd, Bond, and Bell,2011; Potter, Gordon, and Hamer, 2003). Educationwas more than simplifying in plain language, the infor-mation had to be compatible with patients’ reality,perceptions, and be meaningful (Trede, 2000).
There was an interaction of this theme with socialcharacteristics, communication, individuality and goalsetting, as the content in the education should be inter-actively communicated in a manner that patientsunderstand and tailored on the patients’ needs andgoals (Cooper, Smith, and Hancock, 2008; Kidd,Bond, and Bell, 2011; Pashley et al, 2010; Potter,Gordon, and Hamer, 2003; Rindflesch, 2009). Writteneducation was not perceived as individualized andpatient centered by patients (Cooper, Smith, andHancock, 2008).
Figure 2. Proposed framework for patient-centeredness in physiotherapy.
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Goal Setting
Goal setting was used by physiotherapists to activateand motivate patients, to determine what meaningfultherapy would be for the patient and to set dischargelimits (Leach, Cornwell, Fleming, and Haines, 2010;Pashley et al, 2010; Rindflesch, 2009; Thomson, 2008).Goal setting seemed particular of physiotherapists’interest, as patients did not spontaneously mentiongoal setting as important for patient-centered phy-siotherapy. Patient-centered physiotherapists, however,tried to allow the patients to define their own goals incollaboration (Larsson, Liljedahl, and Gard, 2010;Pashley et al, 2010; Thomson, 2008; Trede, 2000).This was done by facilitating them and guiding them,using education and dialogue to determine the patients’goals (Larsson, Liljedahl, and Gard, 2010; Leach,Cornwell, Fleming, and Haines, 2010; Rindflesch,2009; Thomson, 2008; Trede, 2000). Goals were mostlycreated in collaboration between the physiotherapistand the patient (Leach, Cornwell, Fleming, andHaines, 2010; Trede, 2000). However, some phy-siotherapists made no or little mention of patient-cen-tered goals (Pashley et al, 2010).
Support
Support from the physiotherapist consisted of a mix-ture of individuality, equality of responsibility, under-standing, feeling important, reassuring, andempowerment (Cooper, Smith, and Hancock, 2008;Harman, Bassett, Fenety, and Hoens, 2011; Kidd,Bond, and Bell, 2011; Larsson, Liljedahl, and Gard,2010; Melander Wikman and Fältholm, 2006; Pashleyet al, 2010; Potter, Gordon, and Hamer, 2003;Rindflesch, 2009; Rutberg, Kostenius, and Ohrling,2013; Thomson, 2008; Trede, 2000). Patients valuedthe feeling of a physiotherapist having their back, bysupporting them, relating to them, and seeing them as acomplete person (Melander Wikman and Fältholm,2006).
Being supportive in patient-centered physiotherapydemanded an interaction with the descriptive themessocial characteristics, individualization, communica-tion, and education. As a physiotherapist could not besupportive until he knew and understood the patient(individualization). This support was established byverbal and non-verbal communication, such as touchand educating the patient. This supported and empow-ered the patient. This empowerment, however, couldnot be accomplished without the social characteristicsof a patient-centered physiotherapist.
Subtheme: empowermentPatient-centered empowerment was mentioned as apersonal feeling by the patient, where the physiothera-pist tries to give responsibility and power to the patient(Harman, Bassett, Fenety, and Hoens, 2011; MelanderWikman and Fältholm, 2006; Thomson, 2008).Strengthening of the empowerment was mostly doneby touch (Hiller, Guillemin, and Delany, 2015), educa-tion, or showing improvements in symptoms and func-tions (Kidd, Bond, and Bell, 2011; Rindflesch, 2009;Trede, 2000). Furthermore, counseling (exploration ofchoices, support, encouragement, and back-up) was anapplied strategy (Melander Wikman and Fältholm,2006; Trede, 2000). Being able to make an appointmentquickly made patients feel empowered and helped themwith coping (Rutberg, Kostenius, and Ohrling, 2013).Physiotherapists strived for optimal patient empower-ment (Thomson, 2008).
Social Characteristics of a Patient-CenteredPhysiotherapist
Patients described the social characteristics of a patient-centered physiotherapist as respectful, non-judgmental,non-egotistical with an open interested attitude andmind (Kidd, Bond, and Bell, 2011; Larsson, Liljedahl,and Gard, 2010; Pashley et al, 2010; Potter, Gordon,and Hamer, 2003; Rutberg, Kostenius, and Ohrling,2013; Thomson, 2008). Physiotherapists should be hon-est about his/her limitations and reflective of his/herown behavior and emotions (Harman, Bassett, Fenety,and Hoens, 2011; Potter, Gordon, and Hamer, 2003),put the patient’s needs first, and build a trusting rela-tionship and rapport with the patient (Kidd, Bond, andBell, 2011; Rutberg, Kostenius, and Ohrling, 2013;Thomson, 2008; Trede, 2000). This involved beingfriendly, supportive, considerate, patient, genuine,polite, positive, caring for the patient, the ability tocare for the patient, taking the patient seriously, believ-ing in the patient, recognition of the patients’ emotions,making a commitment to the patient, and making thebest effort (Cooper, Smith, and Hancock, 2008;Harman, Bassett, Fenety, and Hoens, 2011; Hiller,Guillemin, and Delany, 2015; Kidd, Bond, and Bell,2011; Rutberg, Kostenius, and Ohrling, 2013;Thomson, 2008; Trede, 2000). In essence, the therapistshould understand the patient and relate to them(Harman, Bassett, Fenety, and Hoens, 2011).
However, perceiving the therapist as “being nice”was not the only aspect of a patient-centered approach(Cooper, Smith, and Hancock, 2008). In addition, com-municative abilities of the physiotherapist were judged
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as important (Rutberg, Kostenius, and Ohrling, 2013).These abilities are mentioned in the theme“Communication.”
Although patients appreciated getting to know theperson behind the physiotherapist (Rutberg, Kostenius,and Ohrling, 2013), a professional distance and profes-sionalism should be maintained, as well as dedicationto the profession (Cooper, Smith, and Hancock, 2008;Kidd, Bond, and Bell, 2011; Potter, Gordon, andHamer, 2003; Rutberg, Kostenius, and Ohrling, 2013).From these examples it may be suggested that patientcenteredness is all about the role the physiotherapistadopts to place the patient at the center of thetreatment.
A Confident Physiotherapist
Both patients and physiotherapists underlined theimportance of a confident physiotherapist. Besides aconfident physiotherapist, it was also acknowledgedthat the physiotherapist should inspire confidence inthe patient (Kidd, Bond, and Bell, 2011). Confidentbody language and verbal communication, and confi-dence in explaining to the patient were described as keyingredients (Cooper, Smith, and Hancock, 2008; Kidd,Bond, and Bell, 2011; Rutberg, Kostenius, and Ohrling,2013). Feeling the confidence of the therapist in his/hertreatment inspired confidence in the patient (Kidd,Bond, and Bell, 2011) and decreased worries and fears(Rutberg, Kostenius, and Ohrling, 2013). Furthermore,patients felt that the physiotherapist should feel con-fident enough to discuss any issues with their patients(Harman, Bassett, Fenety, and Hoens, 2011; Potter,Gordon, and Hamer, 2003). The underlying conceptsand behaviors of a confident physiotherapist were notexplained in any of the studies.
Knowledge and Skills of a Physiotherapist inPatient-Centeredness
The physiotherapist should be competent enough todeal with the patient’s specific disorder (Cooper,Smith, and Hancock, 2008) and this is not onlyachieved by keeping skills and knowledge up to date,but also by using this knowledge and expertise withgood teaching skills (Cooper, Smith, and Hancock,2008; Kidd, Bond, and Bell, 2011; Potter, Gordon, andHamer, 2003; Thomson, 2008). Knowledge should bedisease specific, contains familiarity with body dysfunc-tion, and includes the understanding of the patient’sperspective. Besides, the therapist should have a verygood understanding of the patient in order to tailor
treatment (Larsson, Liljedahl, and Gard, 2010; Leach,Cornwell, Fleming, and Haines, 2010; Thomson, 2008).
Interestingly, physiotherapists found that thegreater their experience and maturity, the morethey felt being able to practice with patient cente-redness (Pashley et al, 2010; Potter, Gordon, andHamer, 2003; Rindflesch, 2009). This may be asso-ciated with increased confidence but how experi-ence, maturity, and patient centeredness wererelated was not described in detail.
Patients valued the input of physiotherapist’s knowl-edge by means of the physiotherapist being the expert(Kidd, Bond, and Bell, 2011), however, did not specifythis knowledge. Patients wanted to have clear explana-tions, but also desired the ability to make their own orshared decisions (Cooper, Smith, and Hancock, 2008).
The proposed conceptual framework (Figure 2)was based on brainstorm sessions and consensuswith multiple authors (AJW, ANB, and PvW) andreviewed by all authors. During the analysis, theauthors uncovered that patient centeredness in phy-siotherapy is a dynamic concept with closely relatedthemes and ST.
The analysis and brainstorm sessions uncoveredthat there is a difference in the themes we found.There are themes related to the physiotherapistcharacteristics and there are themes related to thepatient-physiotherapist interaction. Figure 2 isdesigned according to these two differences.
The themes related to the patient-physiotherapistinteraction (i.e., individuality, communication, edu-cation, goal setting, and support) are located on theleft side of the proposed conceptual frameworkbecause our writing directions are from left toright, thereby suggesting that these themes areprior to the themes related to the physiotherapistcharacteristics. The themes (i.e., individuality, com-munication, education, goal setting, and support)are all of equal importance, connected, intertwined,and all have an influence on each other.
Even though the patient is the most important inpatient centeredness, the physiotherapists in itself playan important role: he/she is the one who places thepatient in the center. Furthermore the physiotherapistand his/her behavior (i.e., social characteristics, knowl-edge and skills, and confidence) influences all otherthemes: the individuality of the therapy; communica-tion; education; goal setting; and support.
Discussion
This review identified 14 articles from qualitative stu-dies investigating patient centeredness in
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physiotherapy. From these studies, a synthesis of inter-related themes (individuality, communication, educa-tion, goal setting, support, social characteristics of apatient-centered physiotherapist, a confident phy-siotherapist, knowledge and skills of a physiotherapistin patient centeredness) with ST and a proposed con-ceptual framework (Figure 2) of patient centeredness inphysiotherapy was made. All relevant articles related topatient centeredness in physiotherapy were included.The findings from this review may be used as a basisfor educating students and continuous education ofclinicians. Whereby the proposed conceptual frame-work may be an indication and example of how thedifferent themes interact and relate to each other.Patient centeredness in physiotherapy entails the char-acteristics of offering an individualized treatment, con-tinuous communication (verbal and non-verbal),education during all aspects of treatment, workingwith patient-defined goals, a treatment in which thepatient is supported and empowered, and a phy-siotherapist with patient-centered social skills, confi-dence, and knowledge.
“Individuality” concerns specific patient-tailored educa-tion, communication, and treatment. “Communication” isthe need for a continuous individualized dialogue withpatients in clear and lay speech. When doing so patientsatisfaction and therapeutic alliance improves (Oliveiraet al, 2012). Physiotherapist should be aware of these com-munication needs and require training during and afterphysiotherapy education (Murray et al, 2015; Synnott et al,2015). “Education” primarily involves advice about theproblem, diagnosis, treatment, and treatment course.“Goal setting” is used by physiotherapists to activate andmotivate patients, however, was not spontaneously men-tioned by patients. “Support” from the physiotherapist isseen as amixture of individuality, equality of responsibility,understanding, reassuring, and empowerment. “The socialcharacteristics,” “confidence,” and “skills and knowledge”of a patient-centered physiotherapist are personal skills andencompass for instance: being able to relate to the patient,confident body language, up to date knowledge, and teach-ing skills. This theme can be used to create awarenessamong physiotherapist and offers the opportunity to phy-siotherapists to reflect upon whether their attitude andbehavior are patient centered.
The concepts of this review are to some extentsimilar to previous frameworks constructed for patientcenteredness in overall care: The Picker Institute’s prin-ciples (Gerteis, Edgman-Levitan, Daley, and Delbanco,2002); medicine (Epstein et al, 2005; Mead and Bower,2000); and nursing (Kitson, Marshall, Bassett, andZeitz, 2013). For instance, in all reviews, individualityof the patient (i.e., the patient as a person (Mead and
Bower, 2000) and respect for patients’ values, prefer-ences, and expressed needs (Gerteis, Edgman-Levitan,Daley, and Delbanco, 2002)) were identified as impor-tant, which in our review was the largest theme.Furthermore, both Mead and Bower (2000) as well asEpstein et al (2005) included “sharing power andresponsibility” in their framework. This is to someextent similar to “Support” in our review. “Patientparticipation and involvement” and “the relationshipbetween the patient and the healthcare professional”from the review of patient centeredness in nursing(Kitson, Marshall, Bassett, and Zeitz, 2013) are alsowell represented in the themes identified in the presentreview, highlighting the importance of these two topicsin both professions.
Unlike the frameworks in overall care, medicine andnursing, the setting/organization was not an importantpart of patient centeredness in physiotherapy. ThePicker Institute’s principles mention the “Involvementof family and friends,” “transition and continuity,” and“coordination and integration of care” (Gerteis,Edgman-Levitan, Daley, and Delbanco, 2002). In nur-sing, “the context where care is delivered” implied theenvironment, such as policy, equipment, lack of time,and deeper philosophical issues within the nurse andteam (Kitson, Marshall, Bassett, and Zeitz, 2013). Thisdiscrepancy might be due to the different settings, andhence may reflect true differences. Both, the PickerInstitute and nursing frameworks are based on thor-ough investigations of patient centeredness in hospitals(Gerteis, Edgman-Levitan, Daley, and Delbanco, 2002;Kitson, Marshall, Bassett, and Zeitz, 2013), whereasmost of the patients and physiotherapists from theoriginal studies in this review work in a private practiceand (sub-acute) rehabilitation settings.
From the above reflection of this review and priorresearch on patient centeredness in overall care, nur-sing, and medicine, it can be argued that there aresimilarities as well as differences between the models.The variance between these models might reflect ontrue dissimilarities between the professions and set-tings, hence represent various forms of patient cente-redness. Therefore it is proposed that there are distinctneeds of patient centeredness in physiotherapy com-pared to overall care, nursing, and medicine due toprofessional differences. As a result, this review andproposed conceptual framework are an enhancementon prior research in overall care, nursing, and medi-cine, as it is specific for physiotherapy.
The findings of this review are also comparable tothe findings of Edwards et al (2004) about clinicalreasoning strategies in physiotherapy. Their extensivegrounded theory study reveals several conceptual
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frameworks (clinical reasoning strategies, cue-basedcombining of reasoning strategies, and interplay ofreasoning strategies in different paradigms of knowl-edge generation) with subcategories. Even though theirstudy was based on defining clinical reasoning strate-gies, their constructs overlap with ours. This indicatesthat patient centeredness and clinical reasoning areclosely connected.
There are also comparisons between the review anda recent qualitative review of O’Keeffe et al (2016) onpatient-therapist interactions in musculoskeletal ther-apy. Whereby they found the following themes: phy-siotherapists interpersonal and communication skills(i.e., listening, encouragement, confidence, being empa-thetic and friendly, and non-verbal communication);practical skills (i.e., expertise and level of training,although the ability to provide good education wasconsidered as important only by patients); individua-lized patient-centered care (i.e., individualizing thetreatment to the patient and taking patient’s opinionsinto account); and organizational and environmentalfactors (i.e., time and flexibility with care and appoint-ments). Even though their aim was based on outcomes(i.e., to investigate the factors that influence the patient-physiotherapist interactions), and the aim of this reviewon determinants (i.e., creating a synthesis of patientcenteredness), the themes of both reviews are compar-able suggesting that maybe in which manner a phy-siotherapist works patient-centered affects theoutcomes of the interactions between the patient andphysiotherapist. While their search terms were differ-ent, both reviews included four articles that are thesame (Cooper, Smith, and Hancock, 2008; Harman,Bassett, Fenety, and Hoens, 2011; Kidd, Bond, andBell, 2011; Potter, Gordon, and Hamer, 2003), suggest-ing a great deal of overlap between the different con-structs. The difference to their review and the currentreview, besides the focus, is that they included studiesfocusing on satisfaction and excluded studies thatfocused on physiotherapy in a rehabilitation setting.While this review excluded studies focusing on satisfac-tion because it was suggested that satisfaction is anoutcome of patient centeredness rather than a base/determinant. Furthermore, this review included all set-tings and by that created an overall synthesis of patientcenteredness based on all settings in physiotherapy.
Study Limitations
Due to the limited number of available studies, weincluded several different qualitative study designs inthis review. There is a debate ongoing about combiningstudy designs in qualitative reviews. However, the use
of multiple methodologies can increase the understand-ing of the phenomenon/process, can compensate thelimitations of individual methods (Paterson, Thorne,Canam, and Jillings, 2001), and exclusion based onqualitative methodology diminishes insight in theresearch topic (Booth, 2001).
We included articles that either assessed patient cen-teredness or aspects of patient centeredness (or a syno-nym) in physiotherapy. As a result, the primary aim ofthe studies included were not all based on assessingpatient centeredness. However, all studies mentionedpatient centeredness in their full text. They either hadaims based on patient-centered care, used patient cen-teredness as an outcome of their results, or reflected ontheir findings in the light of previous definitions ofpatient-centered care.
Within qualitative research there is debate about thepreferred techniques one can use to assess the metho-dological quality of individual studies for examplesaturation (included as number 11 in the methodologi-cal checklist). Saturation is a technique wherebyresearchers stopped collecting data when no new infor-mation emerges from the data that will add to theunderstanding of the phenomenon under study(Creswell, 2007). Within GT it is mentioned that datasaturation is usually reached between 20–30 interviews(Creswell, 2007). However, other researchers suggestsaturation as a method to obtain methodological qual-ity may be inapplicable (O’Reilly and Parker, 2013).
The inter-rater agreement between the two research-ers assessing the study quality of the included studieswas “moderate” (Fleiss and Cohen, 1973; Landis andKoch, 1977). During the analysis we decided to notbring a third reviewer forward due to practical implica-tions, however, we did reach consensus on the finalscoring.
One could argue that within the profession of phy-siotherapy many differences exist between monodisci-plinary and multidisciplinary physiotherapy. Six of the13 included articles in this review conducted researchin acute or sub-acute rehabilitation, with the focus onphysiotherapy. Therefore, it can be assumed that thisreview gives a complete overview of patient centered-ness in the different areas of physiotherapy (except forpediatric physiotherapy).
More sound qualitative research on this topic shouldbe performed to further investigate in which mannerand to what extent patient centeredness is implementedin clinical practice. Hiller et al. were, to our knowledge,the first to investigate this with observations and inter-views and found that physiotherapists’ approach aremore likely to be therapist centered than patient cen-tered (Hiller, Guillemin, and Delany, 2015). Qualitative
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research should further enhance our understandingabout the perceptions of physiotherapists of patientcenteredness, see if there are differences between con-ditions (for instance between non-life threatening con-ditions, chronic conditions, and conditions in whichthe patient cannot clearly communicate) and how toimplement patient-centered strategies in clinical prac-tice. These qualitative studies should contain patientcenteredness or a well-defined synonym in the title orkey words to ease the search of qualitative articles(Jones, 2004).
Additionally, the present overview calls for quantita-tive research to study the implementation and implica-tions of working patient centered in physiotherapypractice according to the provided description and fra-mework. Not only does research show that patient-cen-tered medicine has positive effects on clarifying patients’concerns and beliefs (Dwamena et al, 2012), patient-centered medical care also reduces costs by loweringunnecessary diagnostic tests and referrals (Stewart et al,2000). This increased effectiveness might also occur inphysiotherapy and is worth studying further.
Our findings show a better understanding of theconcept patient centeredness in adult patients. Thismodel, however, cannot be generalized to all health inphysiotherapy conditions, for instance in patients withacute stroke or in patients with dementia of youngchildren. Further research may focus on potential mod-els of patient-centered strategies in these patient groups.
Conclusion
Patient centeredness in physiotherapy is a frameworkcontaining multiple closely related themes: individuality;communication; education; goal setting and support; thesocial characteristics, confidence and skills and knowl-edge of a patient-centered physiotherapist. The resultspresented in this review provide insights into patientcenteredness in physiotherapy. A proposed conceptualframework is constructed to help physiotherapistsimprove their understanding of patient centeredness. Itis hoped that the proposed conceptual framework devel-oped from these study findings will assist physiothera-pists in their understanding of patient centeredness andthe implications of patient centeredness in clinical prac-tice. Further research is needed in order to furtherenhance our understanding about the clinical applicabil-ity of the proposed conceptual framework and to assessthe implementation and implications.
Declaration of interest
The authors declare that there is no conflict of interest.
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Appendix 1. Search strategy
Search Strategy PubMed (MEDLINE):
Topic: Patient-centeredness
01. (((((((((((((((((((((“Patient centeredness”) OR patient cen-tered care[MeSH Terms]) OR “patient centered”) OR“patient centred”) OR “Patient orientated”) OR “patientoriented”) OR “Patient tailored”) OR “Patient Focused”) OR“Person centeredness”) OR “Person centered”) OR “Personcentred”) OR “person orientated”) OR “person oriented”) OR“person tailored”) OR “person focused”) OR “Client cente-redness”) OR “Client centered”) OR “Client centred”) OR“client orientated”) OR “client oriented”) OR “clientfocused”) OR “client tailored”
Topic: Physiotherapy
02. (((((((((“physical therapy”) OR physical therapist[MeSHTerms]) OR modalities, physical therapy[MeSH Terms]) ORphysical therapy specialty[MeSH Terms]) OR physiotherapy)OR rehabilitation) OR rehabilitation[MeSH Terms]) OR“remedial exercise”) OR remedial AND exercise) OR physicalAND therapy
Topic: Factors:
03. (((((Factors) OR aspects) OR components) OR features)OR elements) OR parts
04. ((#01) AND #02) AND #03
Search Strategy EMBASE:
01. ‘physiotherapy’/exp OR (physical AND ‘therapy’/exp) OR‘physical therapy’/exp
02. ‘patient centred’ OR ‘patient orientated’ OR ‘patientoriented’ OR ‘patient tailored’ OR ‘patient focused’ OR‘person centredness’ OR ‘person centred’ OR ‘personorientated’ OR ‘person oriented’ OR ‘person tailored’ OR‘person focused’ OR ‘client centredness’ OR ‘client centred’OR ‘client orientated’ OR ‘client oriented’ OR ‘clientfocused’ OR ‘client tailored’ OR ‘patient centredness’AND [embase]/lim
03. factors OR aspects OR components OR features OR‘elements’/exp OR parts AND [embase]/lim
04. #01 AND #02 AND #03
05. #04 AND ‘qualitative research’/de(limit)
Appendix 2. Checklist methodological qualityassessment
Key search terms
Patient/person/client centeredness Physiotherapy FactorsPatient/person/client centered care Physical Therapy AspectsPatient/person/client centred Rehabilitation ComponentsPatient/person/client centered Remedial exercise FeaturesPatient/person/client orientated ElementsPatient/person/client tailored PartsPatient/person/client focusedDatabasesPubMed (MEDLINE)EMBASECochranePsychINFOCINAHLPEDroScopus
No. Checklist item Definition
1 Was the researcher experiencedor trained?
2 Was the research question clearlydefined?
3 Was the methodologicalorientation suitable for thisresearch question?
Grounded theory, discourseanalysis, ethnography,phenomenology, case study
4 Was theoretical or purposefulsampling used?
5 Was there stated how manyparticipants where approached?
6 Were the importantcharacteristics of the sampledescribed?
Demographic data, date, wheredata was collected
7 Does the sample produce thetype of knowledge necessary tounderstand the structures andprocesses within which theindividuals or situations arelocated?
Choice of informants whoseknowledge or experience isrelevant to the substantivefocus and theoretical frameworkof the study
8 Was there stated that theinterview was open, semistructured or if there were focusgroups?
9 Were repeated interviews carriedout?
Repeated interviews derivemore information
10 Were field notes made?11 Was data saturation discussed/
reached?12 Were there two or more
researchers that coded the data?Triangulation of coders
13 Was software used to managethe data?
14 Did themes derive from the data? Themes in advance or derivedfrom the data, if themes whereidentified in advance the qualityof data analysis is less
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 tointerpret the meaning andcontext of what is beingresearched?
Appropriate presentation ofprimary data and description ofcontext
18 Does the researcher move fromdescription of the data, throughquotations or examples, to ananalysis and interpretation oftheir meaning and significance?
Evidence of analysis andinterpretation of data atconceptual and theoretical level
19 Are claims being made for thegeneralizability of the findings toother bodies of knowledge?(within scientific research)
Findings are related to broadertheoretical concerns and/orother empirical context
20 Are claims being made for thegeneralizability of the findings toother populations?
Findings are related to broadertheoretical concerns and/orother empirical context
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