The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care.

AIM: The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care. BACKGROUND: The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role. METHOD: A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data. FINDINGS: Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty. CONCLUSION: This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

What matters most to people in musculoskeletal physiotherapy consultations? A qualitative study.

BACKGROUND: Person-centred approaches to care require clinicians to engage in trying to understand the full range of problems and concerns, treatment and investigation requests, and emotional and social issues that people bring to the consultation. If, however, the main issues of importance are not openly declared and discussed they cannot be addressed. This is likely to result in people receiving the care that clinicians think they need, rather than care based on individual needs and preferences. OBJECTIVE: To understand people's abilities to express the issues of importance to them within a consultation and clinicians' abilities to acknowledge and address those issues. DESIGN: A qualitative study using an interpretive phenomenological approach. METHODS: Fifteen people and their physiotherapists were interviewed and their consultations recorded. The resulting data sets were analysed to identify and report themes within the data. FINDINGS: The findings revealed that people present with what are often simple issues, but which are sometimes expressed in an unstructured way in clinical encounters and are often difficult for clinicians to establish. Three linked themes emerged: (1) clear versus unstructured agendas; (2) people need information and understanding; and (3) developing a sense of collaboration. CONCLUSIONS: The issues of importance that people bring to a consultation are varied and often vague. This research highlights the importance of communication to elicit, identify and address the issues of importance to people in clinical encounters to ensure a positive experience and outcome for both the individual person and clinician. TWEETABLE ABSTRACT: Achieving desirable health outcomes is more likely when people are supported to think about their priorities and 'what matters to them'.

The role of Philosophical Hermeneutics in contributing to an understanding of physiotherapy practice: a reflexive illustration.

This paper provides an overview of Philosophical Hermeneutics based on the work of German philosopher Hans Georg Gadamer. The concepts of the 'hermeneutic circle' as a vehicle for interpretation, management of the researcher's pre-understandings (prejudices), and the 'fusion of horizons' are introduced and illustrated by examples from the first author's research, before considering how rigour can be achieved in this type of research. The actual research study which aimed to explore how shared decision making and patient partnership are addressed by physiotherapists in the process of exercise prescription for patients with low back pain (LBP) is not the focus of this paper. However short descriptions of the study are used to explore issues surrounding a hermeneutic inquiry. For physiotherapists interested in research or considering undertaking an interpretive phenomenological inquiry, this theoretical discussion paper explores how Gadamer's philosophy offers a credible framework for undertaking such research.

Exercise prescription for patients with non-specific chronic low back pain: a qualitative exploration of decision making in physiotherapy practice.

BACKGROUND: Providing an effective exercise prescription process for patients with non-specific chronic low back pain (NSCLBP) is a challenging task. Emerging research has indicated that partnership in care and shared decision making are important for people with NSCLBP and calls for further investigation into the approaches used to prescribe exercise. OBJECTIVE: To explore how shared decision making and patient partnership are addressed by physiotherapists in the process of exercise prescription for patients with NSCLBP. DESIGN: A qualitative study using a philosophical hermeneutic approach. METHODS: Eight physiotherapists were each observed on three occasions undertaking their usual clinical activities (total n=24 observations). They conducted brief interviews after each observation and a later in depth semi-structured interview. Iterative hermeneutic strategies were used to interpret the texts and identify the characteristics and processes of exercise prescription for patients with NSCLBP. FINDINGS: The findings revealed how physiotherapy practice often resulted in unequal possibilities for patient participation which were in turn linked to the physiotherapists' assumptions about the patients, clinical orientation, cognitive and decision making processes. Three linked themes emerged: (1) I want them to exercise, (2) which exercise? - the tension between evidence and everyday practice and (3) compliance-orientated more than concordance based. CONCLUSIONS: This research, by focusing on a patient-centred approach, makes an important contribution to the body of evidence relating to the management of NSCLBP. It challenges physiotherapists to critically appraise their approaches to the prescription of exercise therapy in order to improve outcomes for these patients.

Exercise prescription for non-specific chronic low back pain (NSCLBP): a qualitative study of patients' experiences of involvement in decision making.

BACKGROUND: The culture of current clinical practice calls for collaboration between therapists and patients, sharing power and responsibility. This paper reports on the findings of a qualitative study of exercise prescription for patients with NSCLBP, taking into account issues such as decision making and how this accords with patient preferences and experiences. OBJECTIVE: To understand the treatment decision making experiences, information and decision support needs of patients with NSCLBP who have been offered exercise as part of their management plan. DESIGN: A qualitative study using a philosophical hermeneutic approach. METHODS: Semi-structured interviews with eight patients (including use of brief patient vignettes) was undertaken to explore their personal experiences of receiving exercise as part of the management of their NSCLBP, and their involvement in decisions regarding their care. FINDINGS: The findings provide a detailed insight into patients' perceptions and experiences of receiving exercise-based management strategies. Four themes were formed from the texts: (1) patients' expectations and patients' needs are not synonymous, (2) information is necessary but often not sufficient, (3) not all decisions need to be shared, and (4) wanting to be treated as an individual. CONCLUSIONS: Shared decision making did not appear to happen in physiotherapy clinical practice, but equally may not be what every patient wants. The overall feeling of the patients was that the therapist was dominant in structuring the interactions, leaving the patients feeling disempowered to question and contribute to the decision making.