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Physiotherapy Theory and PracticeAn International Journal of Physical Therapy

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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

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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 awijma@vub.ac.be VUB Jette, Department Kine, Building F, Laarbeeklaan 103, B – 1090 Jette, Brussels,Belgium.

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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

2 A. J. WIJMA ET AL.

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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.

4 A. J. WIJMA ET AL.

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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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