IMPLEMENTATION OF A BEHAVIOURAL MEDICINE APPROACH IN PHYSIOTHERAPY - A PROCESS EVALUATION

Fritz J.¹, Söderlund A.¹, Almqvist L.¹, Wallin L.², Sandborgh M.¹

¹Mälardalens University, School of Health, Care and Social welfare, Västerås, Sweden, ²Dalarna University, Falun, Sweden

Background: A behavioural medicine approach in physiotherapy for patients with persistent musculoskeletal pain is recommended based on evidence. The approach aims at an individually tailored treatment targeting motor behaviour, cognition, disability and active patient involvement. The behavioural medicine approach is complex and it is challenging in implementation to achieve clinically relevant behaviours in physiotherapy. Process evaluation is an essential part of designing and testing implementation interventions to improve the quality of the implementation. However, studies evaluating the implementation process of a behavioural medicine approach in physiotherapy are sparse.

Purpose: To explore the implementation process of a behavioural medicine approach in physiotherapy.

Methods: Qualitative and quantitative methods were used. 15 physiotherapists working in six primary health care units were consecutively included. A theory based implementation intervention was tailored to the participating individual physiotherapists. Active and multifaceted implementation strategies were used during a total of seven days spread over a six months implementation period. The main implementation strategies were external facilitation and peer-learning. Ten two-hours outreach sessions were offered to each unit. The physiotherapists were encouraged to use individual goal setting and video recordings of treatment sessions to facilitate feedback and reflection during the sessions with the external facilitator. Process data were collected using semi-structured interviews, self-reports of time allocation for different implementation strategies and documented individual goals. Qualitative content analysis and quantitative frequency scorings were used for data analyses.

Results: In median the physiotherapists participated in 9 (3-10) out of 10 sessions with the external facilitator. Discussing clinical experiences of the behavioural medicine approach together with the external facilitator was perceived as valuable. These discussions stimulated reflection and problem solving, and was also experienced as a reminder for practicing skills in behavioural medicine. Video recordings of treatment sessions were used by ten of the physiotherapists at 17 out of 57 possible sessions. Video recordings were experienced as too complicated to use in relation to the gains. Lack of time was also considered as a barrier for using video recordings. Individual goal-setting from one session to the next with the external facilitator was frequently used by all the participants. Relevant skills for the goals were practiced in between the sessions. However, goal setting was not considered important by the physiotherapists. In median the physiotherapists spent 3.25 (0-9.5) hours for peer discussions. Peer discussions were a strategy that the physiotherapists wanted to continue with, even after the implementation intervention period. Even though the physiotherapists had permission from the manager to spend time on the implementation intervention, it was challenging for the physiotherapists to prioritize the implementation intervention before patient care.

Conclusion(s): External facilitation and peer discussions were perceived as important strategies for stimulating practice of behavioural medicine skills in physiotherapy. Further, peer discussions could stimulate sustainability of the implementation. The physiotherapists needed support to use the designated time for the implementation.

Implications: Quantitative and qualitative analyses of the implementation process is useful for understanding the mechanisms of impact for the implementation intervention, how outcomes were achieved and for future replications.

Funding acknowledgements: The study was funded by AFA insurance, Sweden.

Topic: Musculoskeletal

Ethics approval: The study was approved by the Regional Ethical Review Board, Uppsala, Sweden.

All authors, affiliations and abstracts have been published as submitted.