In a Person-centred Model of Physiotherapy Care, Should a Patient Be Able to Choose Their Own Management Plan?

2129 words (9 pages) Essay in Psychology

08/02/20 Psychology Reference this

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Governments, organisations, health services and practitioners globally are implementing a model of person-centred care (PCC) to improve their health systems and performance (Ward et al., 2018).  The physiotherapy profession in Australia supports PCC as the provision of good care to interactions with patients (Physiotherapy Board of Australia, 2014).

No country appears to have a clear definition of PCC in physiotherapy.  A database review of qualitative research studies to identify both patient and therapist perceptions of PCC concluded: the physiotherapist offers individualised treatment, ongoing communication using lay language, education during assessment and treatment, and working with patient defined goals, in which the patient is supported and empowered through equal responsibility and understanding (Wijma et al., 2016).  It is an approach to practice where there is a focus on a person’s values, beliefs, preferences and priorities during planning, developing and implementing treatment.

Wanting control over their own lives and decisions that affect their bodies and health, many people wish to be actively involved in their own treatment decisions and therefore management plan. Conversely there are also many people who devolve the responsibility of making these decisions to the health practitioner, who they see as “the expert” (Hiller & Delany, 2018, p. 325).  Many Australian physiotherapists continue to work in a practitioner-centred approach to care by focusing on the biomedical aspects of a patient’s presenting problem and by making the treatment decisions (Hiller & Delanys, 2018, p. 322).  Physiotherapists need to overcome the challenge of focusing on the biomedical aspects of the person in their care, and by incorporating PCC principles, to truly put the person at the centre of care (Dukhu, Purcell & Bully, 2018; Hiller & Delanys, 2018; Mudge, Stretton, & Kayes, 2013).

This essay argues in favour of supporting the proposition that in a PCC model of physiotherapy care, where the components of communication, shared decision making and defined goals, and concepts of collaborative relationships, empowerment and self-efficacy are embedded in the model, the patient should be able to choose their own management plan. These concepts and components of PCC leading to positive patient outcomes will be discussed, including challenges PCC presents to the physiotherapy profession (Santana et al., 2017; Ward et al., 2019). The conclusion shows it is important for health professionals to engage in PCC to provide people with the best possible health outcomes.

A core component of PCC is the fostering of collaborative relationships through mutual respect and understanding between patients, those people who are important to them, and health practitioners.  The relationship encourages shared decision making and goal setting in the development of an individual’s care or management plan (Ward et al., 2018).  Dorsch (2019) illustrates the importance of this physiotherapist and patient relationship on where the patient finds reassurance in the knowledge that her therapist would help her find a solution to her goal of transferring in and out of a car (para. 2). A therapist’s good communication and empathy are factors in motivating an individual when their personal goals are recognised and encouraged, even if they might seem unachievable (Dorsch, 2019, para. 2).

Communication is a core professional competency in physiotherapy codes of conduct (Physiotherapy Board of Australia, 2014). Within a PCC approach communication is used to share information and responsibility, demonstrate respect and reduce perceived power differences (Hiller & Delany 2018, p. 321). Features include the use of open-ended and non-directive questions, “including and responding to emotional aspects of the person’s experience” (Hiller & Delany 2018, p. 322) where the person’s feelings are validated, and where shared decisions can be made within a collaborative approach. Those physiotherapists who predominantly function from a biomedical model may not have the advanced communication skills needed to address complex emotions and facilitate person-centred goal setting (Dukhu et al., 2018; Ward et al., 2019).

   Communication between physiotherapist and patient is a component of the PCC relationship that can directly influence patient outcomes. “Physiotherapists’ process of questioning can… facilitate or impede patients’ capacities to express what matters most to them about their health and wellbeing” (Hiller & Delany, 2018, p. 310).  Stenner, Swinkles, Mitchell and Palmer (2016) also suggest that when physiotherapists wish to focus on issues that are of most importance to people, they may need to reflect on the wording of their questions to elicit patient perspectives. Scotlands Health (2019) suggests questions such as “What matters to you?”, “What are some of the things that are important to you at the moment?” or  “What are some of the things you would like to achieve as a result of physiotherapy?” as examples to help understand the person in the context of their own life.

   A presentation on the Chartered Society of Physiotherapy webpage (2018) describes how, by asking the question “What matters to you?”, therapists at a London hospital have been able to connect more personally with patients, leading to a deeper understanding of their needs and therefore more meaningful therapy (How WMTY worked for us, para. 6). This is exemplified in the description of a woman who reported reduced shoulder movement after breast reconstructive surgery. The therapist struggled to engage her in exercises and her symptoms were not improving. When asked “Rachel, what matters to you?” she replied that her main concern was a fat necrosis that had developed from the surgery.  She was convinced it would develop into another tumour and all she wanted was it massaged away. This breakthrough enabled the therapist to understand why the patient was less concerned about arm function than she was, resulting in improved communication and engagement in physiotherapy with positive outcomes for the patient (Chartered Society of Physiotherapy, 2018, “Rachel’s breakthrough”).

Shared decision-making includes engaging the individual to share their preferences in treatment decisions and also respecting when they do not wish to play an active role in decision making (which may be due to lack of information of different management options). To support shared decision-making, it is essential to provide information about a patient’s condition and the options for managing it, at the level of understanding of the individual. This education can then guide patients’ preferences for treatment and what they engage in over time (Stenner et al., 2016).  Patients who understand the information given to them and therefore feel a sense of control over the decision-making process are more likely to feel hopeful and therefore be motivated to adhere to the treatment/management plan (Grocott & McSherry 2018). The associated benefits to patients of shared decision making include being less anxious and more confident and having a better knowledge of their health status; additional benefits are improved patient satisfaction leading to treatment adherence and therefore better health outcomes (Dierckx, Deveugele, Roosen & Devisch, 2013).

Shared decision-making leads to setting and prioritising goals.  Asking the question “what matters to you?” can facilitate this goal setting component of PCC by assisting the person to focus on their preferences and priorities.  Participants with chronic low back pain in an Australian patient-led goal setting pilot study (Gardener et al., 2016), identified problem areas important to them, then defined goals and developed evidence-based strategies to achieve the goals in collaboration with a therapist. This resulted in significant improvements for the patients in measures of disability, pain, fear avoidance, quality of life, and self-efficacy.

Self-efficacy, the confidence in one’s ability to cope with challenges, was significantly increased in a primary care setting after PCC was implemented and was found to be more important than the duration and intensity of pain in determining disability among patients with chronic musculoskeletal pain (Olsson, Hansson & Ekman, 2016). A process of supporting empowerment through the provision of information and education to support decision making can build person self-efficacy (Ward et al., 2019).  In contrast, where patients felt the therapist was dominant in structuring the interactions, some were left feeling disempowered to question and contribute to the decision-making (Stenner et al., 2016).  PCC has been found to positively influence self-efficacy and self-management in patients with acute coronary syndrome, resulting in sustained improvements in health outcomes, particularly for those patients of low socioeconomic status who may not persevere with treatment (Fors, Swedberg, Ulin, Wolf & Ekman, 2017).

There are now many research studies supporting the implementation of PCC to positively affect health outcomes and to reduce health care costs. The UK Health Foundation (2012) states that PCC has been shown to result in patients who are more likely to adhere to their management plan and also tend to choose less invasive and costly treatments. For health practitioners to be committed to delivering PCC they need organization support to ensure adequate resources, including “continued professional education and mentorship” (Santana, et al., 2017).  The workplace needs a PCC service culture with structures that support staffing, flexibility, time and continuity (Ward et al., 2019).

When a person can choose their own management plan, with goals chosen through a process of shared decision making and collaboration with the physiotherapist, leading to patient empowerment and self-efficacy, the evidence shows there is a more likely adherence to the plan. There is less patient satisfaction resulting in less motivation to adhere to the plan without PCC and patient outcomes are then less beneficial. It is therefore essential for physiotherapist to overcome the challenge of only focusing on the biomedical aspects on the person in their care, and to adopt PCC to truly put the person at the center of care.

References

  • Chartered Society of Physiotherapy. (2018). Sharing decisions: what matters to you? Retrieved from https://www.csp.org.uk/frontline/article/sharing-decisions-what-matters-you
  • De Silva, D. (2012). Helping people share decision making. Retrieved from: www.health.org.uk/publications/helping-people-share-decision-making
  • Dierckx, K., Deveugele, M., Roosen, P., & Devisch, I. (2013). Implementation of shared decision making in physical therapy: Observed level of involvement and patient preference. Physical Therapy 93(10), 1321-1330. doi: http://dx.doi.org/10.2522/ptj.20120286
  • Dorsch, S. (2019). Motivating Neuro Patients. Retrieved from: http://australian.physio/inmotion/motivating-neuro-patients
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  • Gardener, T., Refshauge, K., McAuley, J., Goodall, S., Hubscher, M., & Smith, L. (2016). Patient-led Goal Setting: A Pilot Study Investigating a Promising Approach for the Management of Chronic Low Back Pain. Spine, 41(18), 1405–1413. doi: 10.1097/BRS.0000000000001545
  • Grocott, A., & McSherry, W. (2018). The patients experience: Informing practice through identification of meaningful communication from the patient’s perspective. Healthcare 6(26), 1-14. doi: 10.3390/healthcare6010026
  • Hiller, A., & Delany, C. (2018). Communication in physiotherapy: challenging established theoretical approaches. In B.E. Gibson, D.A. Nicholls, J. Setchell & K. Synne Groven (Eds), Manipulating practices: A critical physiotherapy reader (1st ed., pp. 308-333).  Oslo, Norway: Nordic Open Access Scholarly Publishing.
  • Mudge, S., Stretton, C. & Kayes, N. (2013). Are physiotherapists comfortable with person-centred practice? An autoethnographic insight. Disability and Rehabilitation, 36(6), 457-463. doi: 10.3109/09638288.2013.797515
  • Olsson, L., Hansson, E., & Ekman, I. (2016). Evaluation of person-centred care after hip replacement – a controlled before and after study on the effects of fear of movement and self-efficacy compared to standard care. BMC Nursing, 15(53), 1-10. doi: 10.1186/s12912-016-0173-3
  • Physiotherapy Board of Australia. (2014). Code of Conduct for registered health practitioners. Retrieved from https://www.physiotherapyboard.gov.au/codes-guidelines/code-of-conduct.aspx
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