Client centred practice

Tyson and DeSouza (2003) showed participants photographs of a “typical” stroke patient in sitting and standing positions (detailed characteristics and pictures were not published in the report). Participants (n=27; 6 focus groups) discussed rationale for assessing posture and balance for that presentation. Assessment suggested evaluating body segment alignment at rest and during movement, identifying specific muscle activation patterns and strength. This underpinned a complex reasoning process to establish what the person was able to do, understand how this was achieved and determine why that strategy was used. Physiotherapists’ conclusion was derived

through developing understanding of the interrelationship between the observed impairment and the balance disability.

Findings of Tyson and DeSouza (2003) and McGlynn and Cott (2007) supported previous studies (Sweetland & Craik, 2001; Rappolt & Tassone, 2002) and indicated that despite external pressure to use formal sources therapists base day to day practice decisions on informal sources of evidence. Information considered most valuable was from clinical

observation, relevant clinical experience, peer consultation and information from clients. Objective quantifiable sources of evidence (outcome measures, research literature) were used to a lesser extent in making practice

decisions. This information was used to identify clinical problems, determine patients’ potential and evaluate the effect of selected treatment options.

The findings of studies specific to neurological physiotherapy (Tyson and DeSouza, 2003; McGlynn and Cott, 2007) were used to inform the questions for phase 2 and 3 of the current study.

1.13.4 Client centred practice

Changing socio-political perspective defines practice context (Barr &

Threkeld, 2000; Edwards et al, 2004). Community based health care delivery has extended over the last 20 years to support an aging population (Edwards

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providers and service users and change emerged from acknowledgement of individuals’ right to participate in decision making affecting their health (World Health Organisation, 1978; Sim, 1998).

These changes are reflected in Government Policy (Department of Health, 2012), guidelines related to ‘Best Practice’ (Department of Health, 2001; ISWP: RCP, 2012; NICE, 2013) and directives regarding Professional responsibility and behaviour (CSP, 2011; Health and Care Professions Council, 2013). Use of the use of the World Health Organisation model: International Classification of Function which emphasizes the physical, personal and social aspects of patients’ conditions is widespread (Barr & Threkeld, 2000).

Physiotherapy education and practice acknowledges that individuals ascribe personal meaning to the pathological process that they experience. Clinical decisions made by physiotherapy practitioners are complex and context specific (McGlynn & Cott, 2007, Health and Care Professions Council, 2013). In order to identify clinical problems and develop effective strategies it is valuable for physiotherapists to understand the scope and epistemological basis of their professional practice and the way that it relates to that of other health care professions (Gladstone, 2012).

Client centred practice is supported by the Integrated Client Centred model of reasoning (Higgs et al., 2008), key features include:

• Use of cognition or reflective enquiry • Discipline specific knowledge

• Metacognition

• Mutual decision making involving the patient and /or carer • Contextual interaction

• Task impact

Thus physiotherapy practice includes integration between practitioner capabilities, evidence based practice, patient perspective and context.

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Clinical decisions are based on propositional & non-propositional discipline specific knowledge. Cognition and reflective inquiry are used to support analysis, synthesis & evaluation based around multiple perspectives. Finally, metacognition through reflective self-awareness is used to monitor the

effectiveness of reasoning about practice. However, research suggests that translation of these client centred objectives into practice decisions is varied.

Information derived from the interaction between the client and the therapist may influence expert practitioners’ decisions regarding content and delivery of physiotherapy interventions across a range of practice areas. Experts placed greater value on patient’s achievement of everyday tasks and collaborated with patients in making decisions about interventions (Jensen, Gwyer & Shephard, 2000; Schreiber & Stern, 2005; Jensen et al., 2007; Davies & Howell, 2012).

Findings from studies about discharge planning further demonstrated that physiotherapists considered individual patient attributes when making decisions. Jette, Grover and Keck (2003) interviewed seven physical therapists and three occupational therapists about decisions related to discharge from an acute care setting. Although results cannot be directly translated into neurology four constructs influenced therapists’ decisions: patient functioning and disability, patients’ wants and needs, patients’ ability to participate in care and patients’ life context. Authors concluded that discharge suggestions reflected therapists’ consideration of patients as individuals and regard for the environments in which they live although final decisions were tempered by Health Care Regulations and the opinions of other health care professionals.

Pashley et al., (2010) interviewed three physical therapists and conducted a focus group with a further seven about decisions about discharge from orthopaedic outpatient physiotherapy. Findings supported and extended previous work by identifying experienced therapists approach to client

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centred care recognised the patient's role in rehabilitation and promoting goals related to self-management.

However, these studies were undertaken from the therapists’ perspective, findings from research regarding shared decisions and empowerment

between client and therapist are inconclusive. Clients expressed desire to act in partnership with therapists (Slade et al., 2009), reach agreement over decisions on treatment plans or modalities (Melander & Fältholm, 2006) or be empowered to self‐manage their condition (back pain; May, 2007).

Clients’ expressed concerns regarding the paucity of information shared with them and perceived that treatment plans were influenced by clinicians

preferred options (Pellatt, 2004; Melander & Fältholm, 2006; Jones et al., 2008; Slade et al., 2009). Research suggests that clients’ value information about their rehabilitation, rationale for treatment, progress and recovery (Jones et al., 2008; Slade et al., 2009) and want therapists to deliver

accurate and comprehensible explanations, listen attentively and treat their suggestions and opinions seriously (Melander & Fältholm, 2006; Slade et al., 2009).

In contrast therapists perceive that patients adopt a passive approach secondary to lack of expertise in rehabilitation or recognition of prognosis (Ayana et al., 1998; Young et al., 2008). Studies exploring client participation in goal setting (Hale et al., 2003; Conneeley, 2004; Melander & Fältholm, 2006) and establishing content of treatment sessions (Wottrich et al., 2004) suggested that patient/therapist partnership during rehabilitation can be limited by clients’ perception of therapists as experts (Wottrich et al., 2004; Slade et al., 2009).

Wain, Kneebone & Billings (2008) explored patient experience of in-patient neurological rehabilitation for a small client group (n=8) using interpretative phenomenological analysis of semi-structured interviews. Data analysis suggested that the overarching theme which they termed ‘person

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centeredness’ comprised four key areas; ownership, personal value, holistic approach, and therapeutic atmosphere. These were based on patients’ perceptions of choice, control and feelings of personal respect and self- worth. Clients valued: understanding staff, achieving physical improvements, psychological gains and an informal, relaxed environment.

Proot et al., (2007) explored client perception of autonomy following stroke (n=22). The study was conducted in the Netherlands; findings are not directly transferable to UK healthcare structure but participating clients experienced rehabilitation in a residential environment where the objective was to return to living at home which matches UK healthcare goals.

Data were collected on admission, during rehabilitation and at discharge and explored constraints and professional approaches to client autonomy through semi structured interviews. Results generated using a grounded theory

approach identified that on admission clients considered they had little autonomy and independence but valued this ‘paternalistic’ approach by health care professionals in early stages of rehabilitation. Further, clients’ perceived that professional expertise and experience increased their physical recovery by supporting them to successfully attempt tasks they did not feel they could complete.

However, clients’ also reported that paternalistic care extended longer than was therapeutically required and identified desire for more opportunity to relate functional recovery to achieving independence. Participants requested more discussion regarding therapist rationale for inclusion/ exclusion of tasks and consultation over other decisions (for example timing of sessions).

Clients’ perceived that limited opportunities to control aspects of their life limited preparation for independent decision making after discharge. Thus key studies (Proot et al., 2007; Wain, Kneebone & Billings, 2008; Schoeb & Bürge, 2011), suggest that patients’ desired level of autonomy should be supported. Timing for ceding independence is individual to each patient but should increase during an episode of care in preparation for

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discharge. Clients’ suggest this encompasses non-treatment aspects of care in early stages of rehabilitation (for example waking-up time, and how to spend the day) and progress to shared decision making about treatment (for example, concerning which activities should be learned and to what extent) and discharge planning (necessary aids). Increased client autonomy could be achieved through greater provision of information (including progress evaluation) and discussion about treatment plans and discharge decisions.