Orthopaedic physiotherapists’ perceptions of mechanisms for observed variation in the implementation of physiotherapy practices in the early postoperative phase after hip fracture: a UK qualitative study

Abstract

Objective to explore physiotherapists’ perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. Methods a qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at seven hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings. Results four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting ‘postoperative physiotherapy’ as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services. Conclusion physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care and allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice, which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles.

Multidisciplinary team healthcare professionals’ perceptions of current and optimal acute rehabilitation, a hip fracture example A UK qualitative interview study informed by the Theoretical Domains Framework

“…In accordance with reported sources of variation, we found that the main determinants of optimal rehabilitation were organisational features [17,18,23,24] and engagement of patients, carers and the multidisciplinary team [17][18][19][20][21][22][23][24]. For these to be addressed, the presence of supportive management and leadership often stood out as essential to promote a positive culture where multidisciplinary teams, adequately trained and supported, communicated and worked well together towards person-centred goals.…”

“…Particularly believed as detrimental for recovery outcomes was patients not taking ownership for their own rehabilitation journey. The importance of this responsibility has been priorly reported for this patient population [17,23]. In accordance, this and other studies state health professional's role on informing, educating, and encouraging patients and carers [17,[19][20][21][22][23][24].…”

“…Shared responsibility for rehabilitation (Intention) was also identified as a facilitator of optimal provision of rehabilitation with multidisciplinary team training (Social influences, Social/ professional role and identity, Skills) to equip all members of the team (including patients and carers) to deliver key components of rehabilitation irrespective of professional background. The desire for other health professionals to aid with therapy and share opportunities to rehabilitate hip fracture patients has been expressed in other studies [17,19]. Previous research has shown that patient benefits arise when nurses incorporate rehabilitation practices into their work [33].…”

“…To date, there have been several qualitative studies exploring healthcare professional perspectives of variation in access to, and delivery of, rehabilitation after hip fracture [17][18][19][20][21][22][23][24]. These studies have mainly focused on individual professional groups [17,24] and highlight resource constraints [17,18,22,24], poor patient engagement [17,19,[22][23][24], and limited multidisciplinary team engagement [17,18,20,21,23] as key contributors of unwarranted variation in rehabilitative care across hospitals.…”

“…To date, there have been several qualitative studies exploring healthcare professional perspectives of variation in access to, and delivery of, rehabilitation after hip fracture [17][18][19][20][21][22][23][24]. These studies have mainly focused on individual professional groups [17,24] and highlight resource constraints [17,18,22,24], poor patient engagement [17,19,[22][23][24], and limited multidisciplinary team engagement [17,18,20,21,23] as key contributors of unwarranted variation in rehabilitative care across hospitals. Despite the multidisciplinary nature of rehabilitation there are few studies which consider the perspectives of different multidisciplinary team members regarding what optimal rehabilitation after hip fracture looks like, and the perceived barriers to its implementation [20][21][22].…”