Importance of a patient-centred approach in ensuring quality of post-fracture rehabilitation for working aged people: A qualitative study of therapists’ and patients’ perspectives

Abstract

BACKGROUND: Quality in rehabilitation is important for recovery and return to work for people at working age, who sustain fractures, but there is limited information about what constitutes quality in rehabilitation.

OBJECTIVE: To identify factors that therapists and patients define as quality in the rehabilitation process for working population after simple or multiple fractures.

METHODS: The study is a qualitative study based on grounded theory approach with semi-structured interviews conducted individually or in focus groups. Seven patients with fractures, 15 physiotherapists and eight occupational therapists from hospitals, municipalities and private practice were included in the study. Grounded theory was used to analyze data and develop a theory about quality in the rehabilitation process.

RESULTS: Partnership was identified as the core category with continuity of rehabilitation and patient-centred approach as its dimensions. Themes in the patient-centred approach were Biopsychosocial understanding and Professionalism. The patient’s perceived control enhanced when the therapist addressed the whole situation, especially return to work. Therapist’s individual considerations and patient’s involvement in decisions about the therapeutic methods had the same effect.

CONCLUSION: Quality in rehabilitation was enhanced in all its dimensions namely structure, process and outcome when therapists used the patient-centred approach and addressed the patient’s overall situation.

Keywords

Physical therapy occupational therapy qualitative research return to work occupation

1 Introduction

Fractures and their after effects can have a major impact on all dimensions and contextual factors of the International Classification of Functioning, Disability and Health (ICF) [1]. The dimension of body function is impaired due to the trauma and predictors for persistent pain and disability depend not only on the initial severity of lesion but also on the contextual aspects such as age and educational level [2, 3]. It is reasonable to assume that people in the working age group who sustain fractures have a relatively stable health and life trajectory prior to the accident [4]. Trauma leads to concerns about its consequences on employment and family life, which justifies the patient’s priority is to be normal at the earliest 5].

According to Clay et al., the length of sick leave has multiple associated factors and strong recovery beliefs and attitudes towards pain have been identified as predictors for early return to work [6]. The beliefs of patients in their ability to control their circumstances can predict recovery independent of the severity of physical disability [6] and self-perceived health can be considered a crucial factor in recovery [7]. Expectations about return to work are affected by a variety of biopsychosocial issues [8] and therapists in the rehabilitation process have the potential to influence realistic expectations and beliefs about recovery. Therefore, it is possible that quality in rehabilitation is enhanced when therapists assist such patients to adapt to the new situation as successful rehabilitation and complete recovery might not always be possible. According to Walton, health is a dynamic construct and ICF outlines that self-perceived health depends not only on body functions and personal resources but also on external resources such as family and the health care systems [4]. The rehabilitation process with therapists is an external resource but very little is known about what is going on in the process between the therapist and a patient with a fracture and which factors constitute quality. Guidelines play an important role in quality assurance especially in orthopedic management and such guidelines are crucial to ensure that the orthopedic problems are handled appropriately and safely [8]. Nevertheless, there might be other important issues, which therapists need to address in order to ensure quality of rehabilitation. Rehabilitation of persons with chronic diseases emphasizes self-management and empowerment facilitated by patient-centred care [9, 10] and it is possible that these intangible factors are also important for persons with acute injuries.

The aim of this qualitative study was to identify factors that determine quality of the rehabilitation process for patients in working age with simple or multiple fractures. We intended to develop an integrated theory about the rehabilitation process based on the patient’s as well as the therapist’s perspectives to get an in- depth understanding of crucial factors and their dynamic interaction. This article is an attempt to explain how the patient-centred approach contributes to quality in the rehabilitation process.

2 Method

This qualitative study is based on grounded theory approach [11] and semi-structured interviewing was used for data generation. Interview guides (Tables 1 & 2) were developed on the basis of available literature [6 , 13] and experience of the research group. We specifically asked all participants how they defined good quality in rehabilitation. The interview guides were revised after each interview e.g. interviews with the therapists gave rise to new themes in the subsequent interviews with the patients and vice versa.

ML and BH who conducted all interviews, are experienced interviewers and have no affiliations with hospitals and municipalities. Each interview lasted between 1-2½ hours and was audiotaped.

2.1 Participants and interviews

Five focus group interviews and two individual interviews were conducted with 15 physiotherapists and eight occupational therapists working in orthopedic wards in two hospitals, three municipalities and in a private institution (Table 3). Out of 15 physiotherapists who were interviewed, only three were males. The sampling was theoretical because we expected different views on rehabilitation quality depending on the sector, experience and specialization in orthopedic patient care. The two types of professionals were interviewed together or separately, depending on their preferences and the interviews were conducted at their work places.

Participating patients were in the age group of 18 and 64 years, had a history of fracture and were discharged from hospital 1–6 months prior to the interview (Table 4). We attempted to include a wide range of age, type of fracture, work profile and length of sick leave. Five male and two female patients with different types of fractures and job profiles were interviewed (Table 4). The patients were allowed to select the location of the interviews. Some of the participating patients had been through a long-term rehabilitation course while others had received only few therapist contacts. Two patients were undergoing outpatient rehabilitation at the hospital and five were on a rehabilitation program in the municipalities. Among the patients in the municipality rehabilitation, five had briefly attended private facilities. There were two patients and two physiotherapists from a single institute and coincidently they were unaware about each other’s participation in the project.

Our sampling of patients and therapists continued until we had the desired theoretical sampling and a substantial saturation of data.

Oral and written informed consent were obtained from all our participants. If the researchers felt that subjects were emotionally labile during the interview, the well-being of the patients was ascertained telephonically on the subsequent day.

2.2 Analysis

Interviews were transcribed verbatim. Each transcript was read several times and discussed by the researchers. Systematic procedures in grounded theory including open, axial and selective coding were used [11].

Two researchers performed the coding separately and subsequently the interpretations were discussed. Open coding emerged during the interviews which was followed by writing memos after each interview and reading the transcripts. Concepts and categories were developed during systematic line-by-line analysis and constant comparative analysis. In the process of axial coding, categories and subcategories were connected as per the paradigm model comprising context, conditions, actions/interactions and consequences. Statements from therapists and patients supplemented each other and contributed to the different dimensions of concepts and categories. Selective coding identified the core category, which was the central phenomenon with greatest analytic power to which the other categories could be related. During this process, an inductively derived theory about quality in rehabilitation was developed and validated by comparing it to raw data. Further details about the interviews and the analysis have been reported earlier [14].

3 Results

The analysis revealed the core category to be partnership with the properties of continuity of rehabilitation and patient-centred approach. Causal condition for partnership to emerge was the therapist’s use of the patient-centred approach including the elements of biopsychosocial understanding and professionalism (Table 5).

3.1 Biopsychosocial understanding

When the therapist addressed the consequences for the patient at all dimensions of ICF, a biopsychosocial understanding emerged as a category. This could be observed both in the context of short contacts and during the long course of rehabilitation. The two most important subcategories identified were perceived control and return to work.

The therapists highlighted the importance of psychological and social understanding of the problems faced by the patients. As a consequence of this understanding, patients perceived that they were getting assistance to manage the situation, which increased their sense of control.

“It is also about the psychological part. I can’t just work with few elements because I can’t be sure that my ideas and thoughts matches the needs of this patient. Maybe things develop, so I need to take everything into consideration” (Occupational therapist, private practice)

The therapists recognized the importance of early return to work to reduce the period of sick leave. Therapists also expressed that part time sick leave interfered with the rehabilitation program and affected the patient’s time and resources to exercise. On the other hand, long time sick leave made it difficult for the patients to believe that they could continue to work. A therapist explained the psychological problems in relation to return to work:

“When you get tired, it is important to distinguish between the physical and mental components because you haven’t been working for a long time – sometimes you have to separate things “(Physiotherapist, municipality)

The analysis showed that whether a patient could do the job or not depended on the job demands and the possibilities to make work-related decisions. For example, a white-collar worker could manage his job and took only few days leave after the injury. However, the consequence was that he had persistent edema and pain, which he attributed to the sedentary working hours.

Most patients appreciated that biopsychosocial understanding and holistic approach was emphasized. During the interviews, the patients were directly asked about their perceptions of the therapists who addressed their situation at home and at work and they were found to have different opinions. A male patient, who struggled to manage the situation, appreciated the interest:

“It made perfect sense and that is why I can use the word professional – they are really interested in you as a person” (Male, 32 years old with ankle fracture)

In contrast, another male patient did not consider the therapist’s interest in his job situation to be important. However, he seemed to be a very determined man with a focus on getting better and return to his company. Therapists should always investigate about the individual patient’s background and attitude to achieve a common understanding of the patient’s need for support.

“We find out what are their thoughts about the situation are, and what is concealed here? Is it a chronic problem or is it acute? What have they been through since it started and what do they think about it? It has a huge influence on how the patients cope with the situation during 98 percent of the time when they are not here. We should always explore the patient’s needs and thoughts about the situation and find a common solution. That is a crucial part of quality” (Physiotherapist, municipality)

The patients perceived better control when the therapist addressed acceptance of the situation and helped the patient to make realistic goals. For some patients, it seemed to be necessary to facilitate discussions about employment or education in future.

3.2 Professionalism

The category of professionalism provided four subcategories, which interacted closely. They were interpersonal relationship, patient education, therapeutic means and perceived control. Interpersonal relationship means that therapist and patient reached a common understanding about the nature of the problem and the therapeutic means. Both patients and therapists considered the quality to be good when the therapist involved the patient in the decision-making process.

“When I work with patients it is the small specific functions that together create a bigger function. So I believe that quality involves sitting down with the patient and guiding him in the right direction” (Occupational therapist, private practice).

If the therapist took patient’s ideas and expectations into account, the patient experienced that he/she was in control of the situation. Perceived control led to self-efficacy about ability to manage difficult situations related to disability and pain. It also strengthened the feeling of being in control of the situation.

“I was very much in- charge of how fast the exercises were being progressed. I could decide how much weight was appropriate and then we could start with that. I would not have felt safe if I had just been told to do something or just do some exercises at home. I would have felt upset and alone. I did not have that feeling at any time. I had considerable support and received good advice” (Male, 32 years old with ankle fracture)

Patient’s belief in therapist’s professionalism was crucial for the interpersonal relationship. The therapist’s experience with the injury and especially the prognosis was also essential for this belief. Experience meant that the therapist was familiar with that particular injury and could explain the association between the injury, its symptoms and loss of function. In addition, knowledge of the therapists about the prognosis was also important. Professionalism reflected when the therapist showed empathy towards the patient.

“Firstly, a dialogue is important - sympathy and professional knowledge are very important components too. It feels really good if the therapist exuberates competence – you come to me, nothing bad will happen to you, I know what I am doing. I know my profession - it speaks volumes about competence “(Male, 48 years old with a crushed hand)

Professionalism was also reflected in seeking advice from other therapists and it was evaluated as a commitment in the situation. Patients valued it as a personal quality that showed the therapist as a person. Therapists were aware that in the professional relationship with the patient, they were required to show empathy and emotional attention. Self-awareness about how to respond to the patient’s emotional reactions could also be considered an important factor. Therapists should be conscious about patient’s resources and work with self-efficacy and motivation during patient education.

“You have to enter it as professional but also as a human being in order to achieve cooperation, otherwise you don’t achieve anything in the personal area, where you share different issues. You can give the patient the feeling that many things are identical. You get the opportunity to share responsibility and discuss difficult things if the development is too slow or things are not going well” (Physiotherapist, municipality)

In addition, patient education was not only in the form of information but it also included developing problem solving skills, which promoted sense of control. It was important that the therapist knew what to do and was able to explain it in simple language to the patient. Also providing precise information about the fracture and the surgery was important. A woman with a Colles fracture told about the first contact with an occupational therapist at the hospital:

“He told me how the fracture looked like, what was done for it and how was it fixed. He tried to convince me that my hand looked quite similar to hands, which had been through surgery and immobilization. It was not uncommon that it could not be used for some time. He told me about it in a good and reasonable way – he was not an ‘I know all’ kind of person, if you can put it that way. A person to rely on” (Female, 60 years old with colles fracture)

When patients had confidence in the therapist, it was perfectly acceptable that the therapist cautiously pushed them beyond their pain thresholds and encouraged them to perform the exercises beyond their comfort zones.

“I was very impressed of the physiotherapist in private practice because of the way she handled my apprehension. The problem was that I could not walk as I was afraid of falling. She got me out of the wheelchair, she was a tough lady. She focused on it - we do this, and you will not fall, I’m right behind you. It was a funny feeling for a 59 year old man to walk with a woman holding your belt, but I overcame my fear of falling with her help” (Male, 59 years old with multiple fractures)

In addition to patient education, it was crucial that hands on methods were also utilized. Both therapists and patients expressed that it was essential to soften the scar tissue, decrease edema and mobilize joints to increase range of motion. The effect of hands on methods was immediate, which helped to build trust in the therapist and hope for recovery.

Therapeutic means used were not necessarily in complete accordance with evidence. To an extent, local guidelines concerning fracture and surgery were important for the therapists, but were not considered to contribute substantially to quality in the rehabilitation process. Individualized rehabilitation with special attention towards physical, psychological and social issues in the given situation was more important for therapists from the municipalities. Therapists in the municipalities expressed that guidelines were often too specific about when to introduce certain type of exercises.

“Often there is no room for your own professional evaluation of the patient because your professional opinion is bound to a piece of paper that directs you to do things in a particular way and does not take the individual into consideration. Guidelines are generally quite rigid” (Occupational therapist, municipality).

On the other hand, according to therapists in hospitals, it was important that guidelines were followed with the objective to protect the fracture. Occupational therapists particularly stressed that within the area of hand injuries, guidelines should be strictly followed to protect the tissue and they highlighted the importance professional competencies in that area.

3.3 Development of a model

Based on the analysis we suggest a model which can be called Quality-in-Rehabilitation after-Injury-Model (QRI-Model) as seen in Fig. 1. The model is grounded in data and shows how the core category of partnership and the properties of continuity of rehabilitation and patient-centred approach contribute to quality in rehabilitation and interact with each other.

Quality in rehabilitation is achieved when the therapist is able to create a partnership with both the patient and other involved health care providers. The conditions are that therapists take relevant actions to help the patient manage the situation in his/her way through the health care system in order to provide continuity in the rehabilitation process [14]. A prerequisite for this to occur is that the therapists use a patient-centred approach, which is defined as the biopsychosocial understanding and professionalism. The oval shape in Fig. 1 is displaced slightly to the right illustrating that patient-centred approach is relatively a more important component of partnership.

4 Discussion

Main finding of this study was that the patient-centered approach formed by the biopsychosocial model and professionalism contributed substantially to achieve quality in rehabilitation for adults with fractures. Despite the fact that the focus of the study was on a heterogenic group of patients with very different needs for rehabilitation and support, there was good coherence in the patients’ as well as the therapists’ views on what constituted quality in rehabilitation.

4.1 Components of the patient-centred approach

Patient-centredness has mostly been investigated from the patient’s point of view [9 , 16]. The present study to our knowledge, is among the first to investigate quality in rehabilitation for adults with fracture from the perspectives of both patients and therapists. The finding of biopsychosocial model and professionalism as important factors for quality is in accordance with some of the previous studies [4 , 17–20]. The present study emphasizes the significance of professionalism as a part of the patient-centred approach which has also been suggested by Kidd et al. [16]. Mead & Bower in a review investigated the concept of patient-centred approach and identified five key dimensions namely, biopsychosocial perspective, patient-as-person, sharing power and responsibility, therapeutic alliance and doctor-as-person. In the present study, the dimension of therapist-as-person emerged as a subcategory of interpersonal relationship, which means that the relationship with the therapist was important for quality in the rehabilitation process.

The analysis showed that both patients and therapists weighed professionalism as an element that constituted quality. This highlights the importance of providing the right treatment and exercises in a way that encourage patients towards self-management.

Also Rindflesh, in his interview with physiotherapists identified that patient education was an important part of practice [22]. Patient education was a means to increase patient’s beliefs in the ability to perform specific activities as part of rehabilitation. Martins explored self-efficacy beliefs in her study of working aged people with disabilities and identified self-efficacy to be an important personal factor to improve participation at work. Martins suggests that therapists should act on self-efficacy and attitudes towards disability and participation [23]. In the present study, patient education and specific guidance about exercises at home helped in sharing power and responsibility as it encouraged the patient’s participation in decision-making. Confidence about self-efforts to manage pain and disability supported the patient’s beliefs about return to work, which was the most important goal. This finding has also been reported as an important factor by Claudi Jensen in a two year follow-up study [24].

4.2 Dimensions in quality in rehabilitation

Donabedian suggests in his model three main dimensions of quality in health care, namely Structure-Process-Outcomes [25]. Our pre-understanding was that we should primarily investigate the dimension of process in the rehabilitation, but the analysis showed that the dimensions of structure and outcomes also played a crucial role in determining quality of rehabilitation. Part of the process was about the method with which the care was delivered and consisted of technical skills, knowledge and interpersonal relationship as suggested by Donabedian [26]. However, the outcome as a quality indicator did not emerge as the end outcome for the rehabilitation but was a part of the process. To an extent, patients were themselves capable of setting goals for the end outcome and expected to feel an effect after every meeting with the therapist. This indicates that means and ends in rehabilitation should not be separated but seen as a continuum of antecedent means followed by intermediate ends [26].

The dimension of structure emerged during professional networking when the therapist helped the patient to find his/her way through the health care system and engaged in the patient’s whole situation indicating that quality in the organization emerged in the dimension of process as described earlier [19]. All three dimensions in the Structure-Process-Outcome model [25] contributed to quality in rehabilitation and neither of them constituted quality separately.

The present study indicates that partnership and patient-centred approach mitigated the consequences of the injury and helped the patients to cope with the situation. Pinto et al. suggest in their systematic review that interaction styles categorized as facilitating, involving and supporting the patient are associated positively with the construct therapeutic alliance [27]. With the exception of professionalism, there is a correspondence between patient centred approach and therapeutic alliance. In the present study, both patients and therapists valued professional qualities such as skills, in-depth knowledge and personal traits.

Return to work is a multifactorial process [6] and for some patients it is necessary to change their life trajectory if they cannot go back to a normal life. Quality in the encounters with rehabilitation providers affect patients’ self-confidence, empowerment and perception of their ability to return to work positively or negatively [28]. This could be the reason why our results indicate that means and ends are a continuum because therapists support patients towards a new life trajectory and acceptance of some degree of disability. In the present study, therapists worked with a biopsychosocial understanding and supported patients’ competences in managing the new situation, which was considered to enhance quality in the rehabilitation. This is in line with Walton et al. who suggest a change in the end point from a hedonistic goal about pain or range of motion towards more eudaimonic goals [4]. This means that the person with disability after a trauma alters focus towards well-being and personal growth. He/she works towards re-engagement in life trajectory and regain of perceived control. ICF as a framework might be relevant to evaluate the impact of fracture on health and provide a broader view of healthcare interventions [1 , 29].

4.3 Methodological considerations

Strength of the present study is that both patients and therapists were interviewed and saturation of data was reached across the two groups because they spoke willingly and openly about their thoughts, experiences and visions. Analyzing data across the two groups contributed to a balanced picture of quality in rehabilitation. Some of the limitations of this study are that the therapists from hospitals and municipalities might have had a selection bias towards patients who had a positive attitude to the rehabilitation process. We mitigated this by addressing questions towards certain situations and asked very specifically, about what happened or did not happen [29].

We did not conduct participant specific data check after transcription but we took care of this issue by summarizing and checking the interpretation thoroughly during the interview process. This can also be considered as a minor limitation of the study.

5 Conclusions

This study identifies partnership to be an essential factor for quality in rehabilitation. The patient-centred approach contributes substantially to quality in rehabilitation for persons at working age who have sustained fractures. The study suggests that when physiotherapists and occupational therapists work with a biopsychosocial understanding integrated with professionalism, it leads to improved quality in process of rehabilitation. Supporting the patient’s return to work or assisting a new life trajectory are integral components of the patient-centred approach. When therapists use this approach, they also engage in continuity in rehabilitation on behalf of the patient and partnership emerges as illustrated in the QRI-Model (Fig. 1) [14]. Quality in rehabilitation can then be obtained in all three dimensions namely structure, process and outcome [25] which are already well established areas of quality in health care.

Future research should focus on developing a questionnaire based on elements of the QRI-Model and the dimensions of structure, process and outcome. For further investigation of quality in rehabilitation, a questionnaire encompassing these dimensions can be extremely beneficial.

Conflict of interest

The authors report no conflicts of interest.

Footnotes

Acknowledgments

We are grateful to participating patients and therapists for their contribution to the study. We are also extremely thankful towards Aase and Ejnar Danielsen’s Foundation, University College Zealand and The Danish Rheumatism Association for financial support.

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