Assessing physiotherapists' communication skills for promoting patient autonomy for self-management: reliability and validity of the communication evaluation in rehabilitation tool.

PURPOSE: To assess the inter-rater reliability and concurrent validity of the Communication Evaluation in Rehabilitation Tool, which aims to externally assess physiotherapists competency in using Self-Determination Theory-based communication strategies in practice. MATERIALS AND METHODS: Audio recordings of initial consultations between 24 physiotherapists and 24 patients with chronic low back pain in four hospitals in Ireland were obtained as part of a larger randomised controlled trial. Three raters, all of whom had Ph.Ds in psychology and expertise in motivation and physical activity, independently listened to the 24 audio recordings and completed the 18-item Communication Evaluation in Rehabilitation Tool. Inter-rater reliability between all three raters was assessed using intraclass correlation coefficients. Concurrent validity was assessed using Pearson's r correlations with a reference standard, the Health Care Climate Questionnaire. RESULTS: The total score for the Communication Evaluation in Rehabilitation Tool is an average of all 18 items. Total scores demonstrated good inter-rater reliability (Intraclass Correlation Coefficient (ICC) = 0.8) and concurrent validity with the Health Care Climate Questionnaire total score (range: r = 0.7-0.88). Item-level scores of the Communication Evaluation in Rehabilitation Tool identified five items that need improvement. CONCLUSION: Results provide preliminary evidence to support future use and testing of the Communication Evaluation in Rehabilitation Tool. Implications for Rehabilitation Promoting patient autonomy is a learned skill and while interventions exist to train clinicians in these skills there are no tools to assess how well clinicians use these skills when interacting with a patient. The lack of robust assessment has severe implications regarding both the fidelity of clinician training packages and resulting outcomes for promoting patient autonomy. This study has developed a novel measurement tool Communication Evaluation in Rehabilitation Tool and a comprehensive user manual to assess how well health care providers use autonomy-supportive communication strategies in real world-clinical settings. This tool has demonstrated good inter-rater reliability and concurrent validity in its initial testing phase. The Communication Evaluation in Rehabilitation Tool can be used in future studies to assess autonomy-supportive communication and undergo further measurement property testing as per our recommendations.

Communication Skills Training for Practitioners to Increase Patient Adherence to Home-Based Rehabilitation for Chronic Low Back Pain: Results of a Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the effect of an intervention designed to enhance physiotherapists' communication skills on patients' adherence to recommendations regarding home-based rehabilitation for chronic low back pain. DESIGN: Cluster randomized controlled trial. SETTING: Publicly funded physiotherapy clinics. PARTICIPANTS: A sample (N=308) of physiotherapists (n=53) and patients with chronic low back pain (n=255; 54% female patients; mean age, 45.3y). INTERVENTIONS: Patients received publicly funded individual physiotherapy care. In the control arm, care was delivered by a physiotherapist who had completed a 1-hour workshop on evidence-based chronic low back pain management. Patients in the experimental arm received care from physiotherapists who had also completed 8 hours of communication skills training. MAIN OUTCOME MEASURES: (1) Patient-reported adherence to their physiotherapists' recommendations regarding home-based rehabilitation measured at 1, 4, 12, and 24 weeks after the initial treatment session. (2) Pain and pain-related function measured at baseline and at 4, 12, and 24 weeks. RESULTS: A linear mixed model analysis revealed that the experimental arm patients' ratings of adherence were higher than those of controls (overall mean difference, .41; 95% confidence interval, .10-.72; d=.28; P=.01). Moderation analyses revealed that men, regardless of the intervention, showed improvements in pain-related function over time. Only women in the experimental arm showed functional improvements; female controls showed little change in function over time. The Communication Style and Exercise Compliance in Physiotherapy intervention did not influence patients' pain, regardless of their sex. CONCLUSIONS: Communication skills training for physiotherapists had short-term positive effects on patient adherence. This training may provide a motivational basis for behavior change and could be a useful component in complex interventions to promote adherence. Communication skills training may also improve some clinical outcomes for women, but not for men.

Undertaking capacity assessments for people with dementia in general hospitals.

Ensuring that older patients are discharged from hospital in a safe and appropriate manner is a fundamental aspect of nursing care. However, it is clear from the literature and clinical practice that determining people's capacity and whether they are able to decide where they live on discharge is a significant challenge. There is variation in practice despite the legal framework provided by the Mental Capacity Act (MCA) 2005, covering England and Wales, which raises questions about adherence to the legislation. Using a case study, this article explores aspects of the MCA and clinical practice that affect older patients' outcomes on discharge from general hospital settings. It demonstrates how effective multidisciplinary working, using the legal frameworks available, can ensure that an individual's independence and well-being are maintained.

A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation.

BACKGROUND: Clinical practice guidelines for the treatment of low back pain suggest the inclusion of a biopsychosocial approach in which patient self-management is prioritized. While many physiotherapists recognise the importance of evidence-based practice, there is an evidence practice gap that may in part be due to the fact that promoting self-management necessitates change in clinical behaviours. Evidence suggests that a patient's motivation and maintenance of self-management behaviours can be positively influenced by the clinician's use of an autonomy supportive communication style. Therefore, the aim of this study was to develop and pilot-test the feasibility of a theoretically derived implementation intervention to support physiotherapists in using an evidence-based autonomy supportive communication style in practice for promoting patient self-management in clinical practice. METHODS: A systematic process was used to develop the intervention and pilot-test its feasibility in primary care physiotherapy. The development steps included focus groups to identify barriers and enablers for implementation, the theoretical domains framework to classify determinants of change, a behaviour change technique taxonomy to select appropriate intervention components, and forming a testable theoretical model. Face validity and acceptability of the intervention was pilot-tested with two physiotherapists and monitoring their communication with patients over a three-month timeframe. RESULTS: Using the process described above, eight barriers and enablers for implementation were identified. To address these barriers and enablers, a number of intervention components were selected ranging from behaviour change techniques such as, goal-setting, self-monitoring and feedback to appropriate modes of intervention delivery (i.e. continued education meetings and audit and feedback focused coaching). Initial pilot-testing revealed the acceptability of the intervention to recipients and highlighted key areas for refinement prior to scaling up for a definitive trial. CONCLUSION: The development process utilised in this study ensured the intervention was theory-informed and evidence-based, with recipients signalling its relevance and benefit to their clinical practice. Future research should consider additional intervention strategies to address barriers of social support and those beyond the clinician level.

Effect of a self-determination theory-based communication skills training program on physiotherapists' psychological support for their patients with chronic low back pain: a randomized controlled trial.

OBJECTIVE: To examine the effects of communication skills training on physiotherapists' supportive behavior during clinical practice. DESIGN: Randomized trial. SETTING: Hospital outpatient physiotherapy clinics. PARTICIPANTS: Physiotherapists (N=24) and patients (N=24) with chronic low back pain. INTERVENTIONS: Two hospital clinics were randomly assigned to the intervention arm. Physiotherapists (n=12) received 8 hours of communication skills training focused on supporting patients' psychological needs. Physiotherapists (n=12) from 2 other hospital clinics formed a waitlist control arm. MAIN OUTCOME MEASURES: Verbal communication between each physiotherapist and a patient was recorded on an audiotape, and independent, blinded raters used the Health Care Climate Questionnaire to assess physiotherapists' needs-supportive behavior (primary outcome). RESULTS: Independent raters' Health Care Climate Questionnaire scores favored the intervention arm (Cohen's d=2.27; P<.01). CONCLUSIONS: Compared with controls, independent ratings demonstrated that physiotherapists who completed the Communication style and exercise compliance in physiotherapy training were found to provide greater support for patients' needs in a single assessed session. Long-term maintenance of this needs-supportive behavior should be examined.

The effect of dementia on patients, informal carers and nurses.

This article explores the effect of dementia on individuals with dementia, their families and nursing staff. It explores the diagnostic issues that are important for individuals, the effect of symptoms and avenues of support. The need to adapt to different roles and the importance of communication are discussed for families and informal carers. Lastly, the culture of nursing care and the need for education, training, professional development and clinical supervision is discussed. The literature emphasises the need for close collaborative working between those involved in dementia care, with individuals with dementia at the centre of decision making. It highlights how everyone involved can contribute to positive care experiences for those with the condition.

A cautionary tale on the use of antiplatelet treatment following TURP.

A pleasant 74-year-old man was discharged home following a complication-free transurethral resection of his prostate (TURP) and successful trial without catheter. Unfortunately, on postoperative day 6, he presented to A&E with chest pain requiring emergency intervention for a confirmed myocardial infarction. A drug-eluting stent was inserted into his right coronary artery and he was started on dual antiplatelet therapy of aspirin and clopidogrel. On day 7, the patient developed significant haematuria requiring transfusion and an obstructive uropathy, requiring an emergency laparotomy and 1 L of organised clot evacuation from his bladder. The dual antiplatelet treatment was restarted on day 4 postlaparotomy, following debate between both the cardiology and urology teams regarding its appropriate reintroduction. On day 7, he was rushed back to the theatre for a re-laparotomy after CT confirmed reaccumulation of clot following an acute deterioration at ward level. The patient made an excellent recovery and was discharged home with regular outpatient follow-up.

The mental capacity act and dementia research.

For research to have an impact on people with dementia, they need to be involved in studies. However, undertaking research with participants who may lack capacity to consent poses many challenges for researchers. This article explores the practical application of the Mental Capacity Act 2005 in the process and provides realistic advice on implementing its principles in research. The Integrated Research Application System, NHS research ethics committees and NHS research and development departments can provide additional guidance. Knowledge of the practicalities of implementing aspects of the act that relate to research will ensure that researchers who wish to involve people with dementia can do so with ethical expertise.

Communication style and exercise compliance in physiotherapy (CONNECT): a cluster randomized controlled trial to test a theory-based intervention to increase chronic low back pain patients' adherence to physiotherapists' recommendations: study rationale, design, and methods.

BACKGROUND: Physical activity and exercise therapy are among the accepted clinical rehabilitation guidelines and are recommended self-management strategies for chronic low back pain. However, many back pain sufferers do not adhere to their physiotherapist's recommendations. Poor patient adherence may decrease the effectiveness of advice and home-based rehabilitation exercises. According to self-determination theory, support from health care practitioners can promote patients' autonomous motivation and greater long-term behavioral persistence (e.g., adherence to physiotherapists' recommendations). The aim of this trial is to assess the effect of an intervention designed to increase physiotherapists' autonomy-supportive communication on low back pain patients' adherence to physical activity and exercise therapy recommendations. METHODS/DESIGN: This study will be a single-blinded cluster randomized controlled trial. Outpatient physiotherapy centers (N =12) in Dublin, Ireland (population = 1.25 million) will be randomly assigned using a computer-generated algorithm to either the experimental or control arm. Physiotherapists in the experimental arm (two hospitals and four primary care clinics) will attend eight hours of communication skills training. Training will include handouts, workbooks, video examples, role-play, and discussion designed to teach physiotherapists how to communicate in a manner that promotes autonomous patient motivation. Physiotherapists in the waitlist control arm (two hospitals and four primary care clinics) will not receive this training. Participants (N = 292) with chronic low back pain will complete assessments at baseline, as well as 1 week, 4 weeks, 12 weeks, and 24 weeks after their first physiotherapy appointment. Primary outcomes will include adherence to physiotherapy recommendations, as well as low back pain, function, and well-being. Participants will be blinded to treatment allocation, as they will not be told if their physiotherapist has received the communication skills training. Outcome assessors will also be blinded.We will use linear mixed modeling to test between arm differences both in the mean levels and the rates of change of the outcome variables. We will employ structural equation modeling to examine the process of change, including hypothesized mediation effects. DISCUSSION: This trial will be the first to test the effect of a self-determination theory-based communication skills training program for physiotherapists on their low back pain patients' adherence to rehabilitation recommendations.

Recurrence of post traumatic stress disorder.

Traumatic events can have an enduring effect on an individual's wellbeing, even causing a recurrence of trauma-related stress symptoms 50 years later. This lasting impact means that those working with older people need an awareness of those symptoms and education in their management.