Perceptions of physical therapists toward patient education.

Physical therapy is

... the examination, treatment, and instruction of human beings to detect, assess, prevent, correct, alleviate, and limit physical disability ... for the purpose of reducing the incidence and severity of physical disability, movement dysfunction, bodily malformations and pain. (1)(pii)

This definition, adopted by the American Physical Therapy Association (APTA) Board of Directors in 1986, identifies one role of the physical therapist as that of acting as a teacher. The definition also indicates that patient education is critical to a patient's recovery. Thus, patient education should be an important component of any physical therapy education program. The general purpose of this study was to assess the perceptions of physical therapists toward patient education in order to gain insight into the present state of patient education in physical therapy practice.

The importance of patient education in physical therapy practice is supported by the 1990 Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. 1 The development of educational skills for the entry-level physical therapist historically has been an accreditation requirement. The 1990 evaluative criteria, however, placed increased emphasis on the importance of program graduates being able to

... apply concepts of teaching and learning theories in designing, implementing, and evaluating learning experiences used in the education of patients, students, colleagues, and the community.(1)(p14)

The importance of the physical therapist as a teacher from the patients' perspective has been identified in several studies. Anderson et al(2) defined several roles of the physical therapist and studied how these roles related to the patients' overall evaluation of their physical therapy programs. The results of their study of 245 patients indicated all the respondents felt that teaching qualities were very favorable traits for a physical therapist. Grannis(3) used a questionnaire to identify what characteristics or roles of a physical therapist 32 elderly patients felt were most descriptive of the ideal physical therapist. She demonstrated that elderly patients ranked teaching qualities second only to the role of the therapist as being knowledgeable about physical therapy.

Few studies have been done regarding physical therapists' attitudes toward patient education. Sotosky(4) attempted to assess the attitudes of Pennsylvania physical therapists toward teaching by measuring the relationship between various concepts of patient education and several descriptor words. Results demonstrated that, in general, physical therapists had a strongly positive attitude toward teaching. Sotosky's study also indicated that the therapists had a strong interest in learning more about teaching and felt inadequately prepared to perform the role of a teacher in the clinic.(4)

A similar study, by May,(5) determined that 99% of a nationwide sample of physical therapists felt that teaching was an important skill in clinical practice. Further, 98% of physical therapists surveyed by May reported they participated in individual patient education. Only 34% of the respondents, however, had received instruction in teaching as part of their basic entry-level physical therapy education. These therapists agreed that they were not adequately prepared in teaching skills and felt that it would be beneficial to receive instruction in educational skills in both basic physical therapy education and continuing education courses.(5)

One of the problems encountered in studying patient education is the lack of an appropriate instrument for assessing therapist involvement in patient education. Sluijs(6) developed and tested a 65-item checklist that she believes can be used to assess current patient education activities in physical therapy practice. Sluijs also suggested that the checklist could be used to determine whether physical therapy programs include appropriate training in patient education.

Although checklists such as that developed by Sluijs(6) could be useful in identifying which educational activities physical therapists use, we believe the results would not be helpful in providing information about the process needed to provide effective patient education. We believe that determining how physical therapists teach is as important as what they teach. Information about process and content can be used to improve the education of entry-level physical therapists as well as to enhance the skills of practicing clinicians.

The purpose of this descriptive study was to assess the perceptions of practicing physical therapists regarding their involvement in patient education, that is, (1) what physical therapy procedures and activities are most often taught to patients, (2) what methods or tools of patient education are most often used, (3) what physical therapist behaviors related to patient education physical therapists perceive are most important, (4) what techniques are used to assess the effectiveness of teaching, (5) what factors are barriers to delivering effective patient education, (6) what is the relative value of patient education activities as compared with other patient care activities, and (7) what factors contribute most to the development of teaching skills. For the purpose of our study, patient education was defined as follows:

Patient education is a planned learning experience using a combination of methods such as teaching, counseling, and behavior modification techniques that influence patient's knowledge and health behavior.(7)(p323)

Method

The "Method" section of a descriptive study by Ballin and colleagues(8) served as a model for this study. The initial development of the survey instrument consisted of three parts: preliminary interview training, a series of personal interviews, and development of a questionnaire based on data gathered during the personal interviews.

Instrument Development

Interview training consisted of the first three authors, individually, interviewing the same three physical therapists regarding their involvement in patient education. The interview data collected by each author were compared across the three interviewers for comparability in content. The percentage of agreement for comparable interview data among the three interviewers was 75%. Each interview was videotaped for the purpose of analyzing interview styles. Based on this analysis, additional training on interviewing techniques was given to the first three authors by the fourth author.

Data were collected from 13 physical therapists practicing in the Philadelphia (Pa) area. The data were used to formulate the questionnaire. Thus, the questionnaire was based on information retrieved from practicing physical therapists rather than on information gathered solely from a literature review. By this method, called an emic" approach, we tried to obtain an insider's view of a particular element of a subculture,(9) in this case, how physical therapists engage in patient education.

The following criteria were used to choose the purposeful sample of 13 physical therapists interviewed: (1) spent greater than half their work week in direct patient care and (2) represented a proportional distribution of physical therapists based on clinical setting and gender in accordance with preliminary data based on the 1990 APTA Membership Profile Survey.

An interview protocol was designed with a standard-question, nonschedulized format (nonroutine ordering of questions).(10) The standardized questions were open-ended and, when appropriate, followed by nondirective probe questions.

The authors then aggregated the data collected from the 13 interviews. Conjoint responses given by the physical therapists were considered relevant and were included in the questionnaire.

Questionnaire Design

In the first part of the questionnaire, patient education was defined. The main body of the questionnaire was divided into seven subsections, which correlated with the patient education information sought under the purpose of the study (see titles of Tabs. 1-7). A Likert-type scale was used for responses, offering five possible choices from most important to least important or from nearly always to rarely or never, with the added category of not applicable. For each question, respondents were asked to star the items that were most important to them. Demographic data were collected from each respondent. A panel of 15 physical therapists who had practiced 5 or more years and were considered experienced in patient education stated that the questionnaire was content valid and gave suggestions for editorial refinement. Following questionnaire revisions as a result of input from the panel, a pilot study of 12 physical therapists from a variety of health care settings was conducted. Input from the pilot study was used to ensure understandable formatting of the final questionnaire to increase reliability of responses. We were, however, unable to directly examine the reliability of the responses gathered by questionnaire.

Sample

The questionnaire was distributed by mail to 300 APTA members who were selected from a random sample of the 1991 APTA Membership Directory. Two hundred fifteen (72%) of the 300 questionnaires distributed nationwide were returned. After the first mailing, 177 questionnaires (59%) were returned, and after the second mailing, 38 (13%) more questionnaires were returned. Fifteen of the returned questionnaires were excluded from analysis: 9 respondents were considered ineligible, as they were no longer involved in direct patient care; 4 respondents did not meet the deadline for questionnaire return; and 2 respondents did not complete the questionnaire. Thus, 200 questionnaires, or 69% of the eligible responses, were used in the analysis.

Female respondents outnumbered male respondents by four to one (80% and 20%, respectively). Thirty-four percent of the respondents reported they worked in private practice, which included outpatient orthopedic, sports medicine, acute care, rehabilitation, and pediatric centers as well as prepaid health care and physicians' offices. Twenty-nine percent of the respondents worked in acute care hospitals, which included inpatient, outpatient, and pediatric units. Ten percent of the respondents worked in a rehabilitation hospital, which included inpatient, outpatient, and pediatric rehabilitation units. The other category included respondents who worked in early intervention, military, industrial medicine, and registry in addition to a traveling physical therapist. With respect to number of years in practice, half of the respondents reported less than 10 years' experience and half reported 10 or more years. For additional demographic data, refer to Table 8.

The demographic profile of our sample was comparable to the 1990 APTA Membership Profile(11) in the areas of gender, primary employment setting, and number of years in practice. With respect to gender, the 1990 APTA Membership Profile reported 74% female and 26% male members. Regarding primary employment setting, the difference between the 1990 APTA-reported data and our data does not exceed 3.0%. In the area of total number of years in practice, the APTA reported 50% of its members have more than 10 years' experience. Based on these comparisons, the demographic profile of our sample closely resembles the APTA nationwide membership profile. Consequently, the results of our study may be a good indication of the state of patient education, as it exists in the APTA clinical membership at large.

Data Analysis

Response frequencies were compiled into tables by rank order of response. Hypothesis-generating chi-square analyses were performed to determine whether there were significant relationships between demographic data (primary employment setting, number of years in practice, number of years as a Clinical Instructor, and percentage of work week spent in direct patient care) and the highest-response frequency items (starred) in each question in the survey. Any relationships found to be significant could be used to generate hypotheses for future study.

Results

Eighty-seven percent of the physical therapists surveyed reported that they teach 80% to 100% of their patients. Over 90% of the physical therapists reported teaching their patients about treatment rationale, home programs, strengthening, and range of motion most of the time or nearly always (Tab. 1).

[TABULAR DATA OMITTED]

In regard to how often certain methods or tools of patient education are used, more than 95% of physical therapists surveyed used verbal discussion or demonstration most of the time or nearly always (Tab. 2).

[TABULAR DATA OMITTED]

All of the respondents recognized the importance of many different physical therapist behaviors related to patient teaching. Greater than 90% of the respondents indicated that 8 out of the 12 behaviors listed were most important or very important. Developing a trusting relationship with your patients was considered most important or very important by nearly 100% of the respondents (Tab. 3).

[TABULAR DATA OMITTED]

In regard to how often certain techniques are used to assess the effectiveness of clinical teaching, 96% of our respondents had the patient demonstrate what was taught. Therapists also reported frequent use of objective standards for assessing patient improvement (76%) and function in a task-oriented situation (72%) (Tab. 4).

[TABULAR DATA OMITTED]

Few respondents felt that any one factor was nearly always or most of the time a barrier to the delivery of patient education. Over 80% of the respondents, however, indicated that patients' attitudes about their illness or disability, assuming a passive role regarding therapy, emotional status, attitudes or expectations regarding physical therapy outcomes, and cognitive status became a barrier at least some of the time (Tab. 5).

[TABULAR DATA OMITTED]

Regarding the relative value of patient education, as compared with other patient care activities, over 90% of the respondents indicated that providing instruction needed to perform functional activities and providing hands-on treatment are very important or most important to the delivery of effective patient education (Tab. 6).

[TABULAR DATA OMITTED]

Nearly 95% of the respondents indicated that patient inter-action was most important for the development of their teaching skills. Greater than 75% considered interaction with colleagues, continuing education courses, and clinical instruction within the physical therapy program as the most important factors in the development of their skills (Tab. 7).

[TABULAR DATA OMITTED]

Of 28 chi-square analyses, 3 were proven to be statistically significant. A significant relationship existed between primary employment setting and the four most important items to teach patients: functional mobility, body mechanics, posture, and home programs ([X.sup.2] =40.06, P[less than or equal to].05). A significantly greater percentage (46%) of respondents in extended care facility/ nursing homes checked functional mobility as most important as compared with respondents in other employment settings. A significantly greater percentage (44%) of respondents in home health agencies checked home programs as the most important as compared with respondents in other employment settings. Private practice respondents rated body mechanics, posture, and home programs as relatively equal important areas of patient care to teach (26%, 30%, and 30%, respectively).

A significant relationship was also found between primary employment setting and the three most useful techniques used for assessing the effectiveness of teaching skills, that is, demonstration, objective standards, and task assessment in a functional situation ([X.sup.2] = 22.66, P[less than or equal to].05). A greater percentage of respondents practicing in schools (54%) and home health agencies (43%) reported assessing function in a task-oriented situation as a useful technique for assessing their teaching skills. A higher percentage of respondents from private practice settings (29%) as compared with acute care hospitals 18.6%), rehabilitation hospitals 17%), and home health agencies 7%) indicated that use of objective standards was a most useful technique for assessing their teaching skills.

Likewise, a relationship existed between primary employment setting and the factors that become barriers to delivering effective patient education, that is, patients' attitudes about illness or disability, assuming a passive role regarding therapy, attitudes or expectations regarding physical therapy outcome, and cognitive status [chi.sup.2] =30.01, P [greater than or equal to] .05). A greater percentage of respondents employed in schools (57%), extended care facilities/nursing homes (38%), and rehabilitation hospitals (33%) considered cognitive status to be the most problematic barrier in delivering patient education as compared with respondents in other settings.

Discussion

This study supports previous findings demonstrating physical therapists believe that patient education is an important aspect of patient care and that they act on that belief.

Physical therapists rarely reported the use of technological equipment or prepared materials for teaching. Instead, our respondents reported relying on methods and tools such as patient-specific instruction sheets with sketches, verbal discussion, and demonstrations that afforded them the opportunity to individualize patient education plans. Further research would be helpful in determining which methods are the most effective in delivering a high quality of patient education and whether these methods of patient education assist in improving the overall health status of patients.

A high percentage of respondents perceived a number of interpersonal and task-oriented behaviors related to patient teaching as most important or very important in delivering effective patient education. This finding may indicate that physical therapists use a variety of behaviors to adapt their teaching to individual patients. Further research, however, is warranted with respect to how physical therapists adapt their behavior to deliver optimal patient education.

Our results also indicate that physical therapists assess the effectiveness of their teaching skills by having the patient demonstrate what was taught. Thus, physical therapists appear to rely on their observation and evaluation skills in determining whether learning has taken place.

Barriers that were considered most problematic in delivering effective patient education were patient affective behaviors. This finding suggests that when delivering patient education, consideration of the impact of psychoemotional issues on patient learning is important. Bartlett[12] has described a teaching approach that uses the concept of behavioral diagnosis to address psychological barriers to patient education. Behavioral diagnosis is defined as the identification of variables (such as patient knowledge, attitudes, motivation, fears, and financial status) that positively or negatively influence desired patient behavior. Identification of these variables leads the clinician to select appropriate educational-behavioral strategies to meet the goal of improving the patient's health status.[12] A reasonable next step would be to determine what strategies physical therapists are currently using to address those barriers to patient education that they perceive as problematic. Further research would be helpful in determining which educational-behavioral strategies are most suited to dealing with specific barriers to effective patient education.

Nearly 95% of all physical therapists surveyed considered interaction with patients to be very important or most important to the development of their teaching skills. Only slightly more than half (53%) of the respondents, however, reported that academic education within their physical therapy program contributed most to the development of their teaching skills. Additionally, studies by Sotosky[4] and May[5] determined that physical therapists feel inadequately prepared for patient teaching. Therefore, it is possible that greater emphasis should be placed on developing patient teaching skills in physical therapy curriculums.

The significant relationship found between employment setting and areas of patient care taught, techniques used to assess effectiveness of teaching, and barriers to delivering patient education may be related to the phase of health care the patient is in. Redman[13] distinguishes between a diagnostic/treatment phase and a follow-through phase of health care. She suggests that in the diagnostic/treatment phase patients require information regarding their disease and the need for care and treatment. During the follow-through phase, patients require information regarding home care, continuing rehabilitation, and prevention of reoccurrence or complications.[13] Physical therapists in different settings may have different priorities with regard to patient education, based on the clinical problems the patients present. Further research exploring this area may lend insight into the process of patient education as it differs among health care delivery settings.

Summary

Physical therapists regard patient education as a very important aspect of patient care and agree that they are involved in patient teaching in some way Common responses were found among the physical therapists surveyed regarding what methods or tools they use to educate patients, what techniques they use to assess the effectiveness of their teaching, what patient education barriers they perceive as problematic, and how physical therapists perceive themselves as acquiring teaching skills. Significant differences in perceptions among physical therapists were noted to occur with respect to primary employment setting.

This study identified many areas in which additional research is indicated in order to gain more insight into the actual process of patient education. Results from such studies could be incorporated into physical therapy curricula and continuing education courses, with die intent of improving patient teaching skills and thereby improving overall patient care.

Table 8. Demographic Profile of
Sample (n=200)

                            Percentage of
Variable                    Respondents

Entry-Level physical
therapy degree
 Certificate                   8
Baccalaureate                 83
Entry-Level master's           9
Primary employment setting
 Private practice             34
Acute care hospital           29
Rehabilitation hospital       10
Home health agency            10
Extended care
facility/nursing home          7
School                         6

Other                          4
Total number of years
in practice
<5                            25

5-9                           25

10-14                         26

15                            24
Total number of years
as a Clinical Instructor

0                             25

<50                           38

0                             26

11                            11
Percentage of work week
spent in direct patient care
<50                           17

51-75                         21
76                            62

Acknowledgments

We thank all of the physical therapists who participated in this study. We would also like to acknowledge Rosalie Lopopolo, PT, MBA, for her assistance with our data analysis and join Bettendorf for her computer expertise.

References

[1] Commission on Accreditation in Physical Therapy Education. Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists. Alexandria, Va: American Physical Therapy Association; 1990. [2] Anderson HE, Aldredge HP, White BC, Wroe MC. The roles of the physical therapist: their importance to the patient. Phys Ther. 1965;45: 768-772. [3] Grannis CJ. The ideal physical therapist as perceived by the elderly patient. Phys Ther. 1981;61:479-486. [4] Sotosky JR. Physical therapists' attitudes towards teaching. Phys Ther. 1984;64:347-350. [5] May BJ. Teaching a skill in clinical practice. Phys Ther. 1983;63:1627-1633. [6] Sluijs EM. A checklist to assess patient education in physical therapy practice: development and reliability. Phys Ther. 1991;71:561-568. [7] Bartlett EE. At last, a definition. Patient Education and Counseling. 1985;7:323-324. [8] Ballin AJ, Breslin WH, Wierenga KAS, Shepard KF. Research in physical therapy philosophy, barriers to involvement, and use among California physical therapists. Phys Ther. 1980; 60:888-895. [9] Pelto P, Pelto G. Anthropological Research: The Structure of Inquiry Cambridge, Mass: Cambridge University Press; 1978. [10] Goetz JP, LeCompte MD. Ethnography and Qualitative Design in Educational Research. Orlando, Fla: Academic Press Inc; 1984:119. [11] 1990 Active Membership Profile Report Alexandria, Va; American Physical Therapy Association; 1991. [12] Bartlett E. Behavioral diagnosis: a practical approach to patient education. Patient Education and Counseling. 1982;4:29-35. [13] Redman B. The Process of Patient Education. St Louis, Mo: CV Mosby Co; 1988.