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Conceptions of physiotherapy knowledge among Swedish physiotherapists: a phenomenographic study
Physiotherapy 92 (2006) 110–115
Conceptions of physiotherapy knowledge among Swedish physiotherapists: a phenomenographic study Ingalill Larsson ∗ , Gunvor Gard Department of Health Sciences, Division of Physiotherapy, Lund University Hospital, SE 221 85 Lund, Sweden
Abstract Objectives and design Knowledge in physiotherapy is based on both scientific evidence and clinical practice. Different perspectives of knowledge generate different implications for theory development. The aim of this qualitative, phenomenographic study was to describe physiotherapists’ conceptions of physiotherapy knowledge. Intervention and participants Open, semi-structured interviews were conducted with 10 physiotherapists working in different sectors of physiotherapy. The transcribed material was analysed according to phenomenographic analysis. Results The physiotherapists’ conceptions of various aspects of physiotherapy knowledge are described by four qualitatively different categories: (a) interaction, i.e. the ability to create opportunities for patients and develop patients’ competencies, equally influenced by both theoretical and practical knowledge, with a patient-oriented perspective conceiving the physiotherapist as a coach; (b) personal competencies, i.e. the ability to provide good therapy influenced more by practical knowledge oriented towards the physiotherapist; (c) professional demands, i.e. the ability to be professional according to rules and scientifically proven interventions, influenced more by theoretical knowledge oriented towards the physiotherapist; and (d) scientific areas, i.e. the ability to use different knowledge, as an expert, in the interaction with the patient, strongly influenced by theoretical knowledge and oriented towards the patient. Conclusions The results can contribute to physiotherapy students’ understanding of the multi-dimensional nature of physiotherapy. The paradigm of physiotherapy must be studied further in order to understand and explain its complexity. © 2005 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Physiotherapy; Knowledge; Theory; Practice; Phenomenographic
Introduction Physiotherapy has developed from both experience in clinical practice, which regards the body as a living, dynamic entity, and from theoretical knowledge, which regards the body as an object of scientific study [1]. Physiotherapy is described as encompassing knowledge from the scientific disciplines of anatomy, physiology, movement science, psychology and pedagogy [2]. In Sweden, physiotherapy has been an academic profession since 1977, with the emphasis on using academic knowledge in clinical practice. The physiotherapist is responsible for clinical decision-making, choice of treatment and methods of evaluation, all of which require a theoretical base, authority and professional independence accompanied by ethical rules [3]. The development of ∗
Corresponding author. Tel.: +46 46 222 3784; fax: +46 46 222 4202. E-mail address: [email protected] (I. Larsson).
knowledge concerning physiotherapy depends on the physiotherapist’s self-reflection and theoretical knowledge in his or her professional role, as well as on awareness of differences in communication and problem-solving skills that can influence patient participation [4]. According to Rolf [5], physiotherapists may be influenced by two main theories of professional, practical knowledge. The Platonic theory states that the rules of practice arise from scientific laws, and that all professional knowledge is the application of a scientific theory. The Aristotlean theory claims that some of the rules of practice may never find a basis in scientific laws because the clinical practitioner deals with phenomena that are not governed by the laws of nature [5]. According to Molander [6], knowledge includes both practical and theoretical aspects that cannot be divided. Knowledge is active and living, and requires an understanding and awareness of the concept in which it is used as knowledge in action. Different traditions are based on different perspec-
0031-9406/$ – see front matter © 2005 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2005.12.001
I. Larsson, G. Gard / Physiotherapy 92 (2006) 110–115
tives of knowledge and science. A tradition of theoretical knowledge regards clinical practice as an information base for theory building. A tradition of practical knowledge views clinical practice as the root of knowledge through personal experience and role modelling [6]. The knowledge tradition, together with individual perception of a phenomenon, is influenced by the culture in which learning takes place, and results in living and personal tacit knowledge [7]. Within the physiotherapy profession, it is necessary to describe and explain physiotherapy in a systematic way, and to clarify definitions and terminology [8]. Studies have focused on physiotherapists’ understandings of physiotherapy expert practice [9] and on clinical reasoning strategies [10], as well as on how the perspective of the patient and the physiotherapist differ in the rehabilitation process [11]. Differences between physiotherapists regarding their conceptions of knowledge, science, health, humanity, the world and values lead to different approaches and different treatment strategies [9,10–14]. The aim of this study was to describe physiotherapists’ conceptions of physiotherapy knowledge.
Method A qualitative, phenomenographic interview was conducted. Marton et al. developed phenomenography within educational research in Gothenburg, Sweden in the 1970s [15]. The purpose of a phenomenographic study is to describe how different people conceptualise and understand various aspects of a phenomenon in the world as they understand it. According to Marton [16], the difference between phenomenology and phenomenography is that a phenomenon can be interpreted and described from two perspectives. A first-order perspective, which is used in phenomenology, describes the essence of the phenomenon as an aggregated mental construction. The aim is to interpret the respondent’s statements and describe what the phenomenon is. The phenomenographic approach, on the other hand, uses a second-order perspective that describes (not interprets) people’s non-reflected conceptions of various perspectives of the phenomenon. People conceive the everyday world in different ways and this, in turn, leads to differences in how they conceptualise phenomena. The aim is to identify some of the qualitatively different conceptions of a phenomenon that exist within a population and describe these differences [16,17]. Ten physiotherapists were selected strategically to participate in the study. They were selected with consideration to variation in gender, number of years in the profession, sectors of physiotherapy and cultural background. Three men and seven women with a median working experience of 18 years (range 0.3–30 years) were chosen. They worked in different sectors of physiotherapy: neurology; respiratory; orthopaedics; habilitation; psychiatry; elder rehabilitation; primary health care and education and research. One was born, raised and educated in another European country. One
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was born abroad, but raised and educated in Sweden. One was Swedish but educated elsewhere in Europe. The two respondents with a foreign background spoke Swedish fluently. The other seven respondents were born and educated in Sweden. Interview An interview guide was constructed consisting of the following open, semi-structured questions. • • • •
How do you conceptualise knowledge? What is physiotherapeutic knowledge in general? How have you obtained your knowledge? What is the content of professional physiotherapeutic knowledge? • How should this knowledge best be communicated to others? • What knowledge is valuable within physiotherapy? • What knowledge is necessary to become a professional physiotherapist? A pilot interview was conducted but did not result in any changes in the interview guide. The first author interviewed the respondents. The questions were addressed to the respondents in the same order. The interviewer followed up what was said through additional questions, such as ‘That is interesting, can you tell me more?’ or ‘What do you think about that?’, in order to obtain additional information. The interviews were conducted at the respondents’ workplace in all cases except one. Each interview lasted about 45 minutes, was tape recorded and subsequently transcribed. Analysis The transcribed material was analysed in seven steps according to accepted phenomenographic procedure [18]. The first author analysed the first three steps. In the following steps, the second author and another physiotherapist, experienced in qualitative methods but not involved in this study, assisted. Steps 4 and 5 were repeated several times before the analysis was deemed to be satisfactory. 1. Familiarisation. First the transcription of the interviews was read carefully several times in order for the assessor to become acquainted with the text. 2. Condensation. The answers from the interview were then reduced to significant statements. 3. Comparison. These statements were compared to identify sources of variation or agreement. 4. Grouping. Statements with similar condensed content were then assigned to groups for preliminary classification. 5. Articulation. The essence of the similarities within each group was described by a limited and central content for each qualitatively different and non-overlapping category. 6. Labelling. Each category was assigned a tailored linguistic expression.
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7. Contrasting. Finally, the categories were compared, in a more abstract way with regard to similarities and differences, based on the first author’s perspective.
Results Four qualitatively different categories were identified in this study. The same physiotherapist expressed a range of different conceptions within a specific interview. Category A: interaction The conception of physiotherapy knowledge is described in terms of how different types of knowledge are used to collaborate and interact with patients. This interaction is influenced by theoretical and practical knowledge. From the patient-oriented perspective, the physiotherapist is conceived as a coach, and patient participation is conceived to increase through sharing knowledge on how to manage problems as a prerequisite for good clinical assessment and treatment. ‘Lots of people don’t have the ability to establish contact with others; they only have a lot of theoretical knowledge. They may also have a lot of experience but not the ability to cooperate or interact empathetically. A physiotherapist can’t be like that. As you work alone with a patient for a long time, the ability to cooperate and interact must be there . . ..’ (Respondent 7) ‘Yes, I must be able to adapt, to get my message across to different people. There is no single answer. All the people I meet are different, so I must adapt to different patients and relate to them in a way that suits them. So first I must be aware of how they perceive the situation based on their own knowledge and understanding of what I say . . .. And from there I have to find an appropriate level for communicating with the patient.’ (Respondent 10) Category B: personal competencies Physiotherapy knowledge is conceived to be tacitly and individually related to practice and experience. Scientific areas and clinical practice are conceived to be strongly related to each other as a complex entity or process, which is influenced more by practical knowledge. The statements have a physiotherapist-oriented perspective, and knowledge development is conceived as being dependent on time, interest and the person’s ability to understand. ‘This knowledge regarding what you’re . . . doing . . . and why you’re doing something . . . and the background as to why you do what you do. Partly to provide as good-quality treatment or care as possible. And also for your own wellbeing and self-esteem . . . To, in a way, not do things routinely without having something in the back of your mind that . . . tells you what you’re doing, you know. You recognise that
you know anatomy, physiology, you know about different types of disease. You understand what’s going on and what you want to accomplish.’ (Respondent 5) ‘Bit by bit things have fallen into place . . . so I’m sometimes surprised over the fact that I see things in the movement analysis—that I sometimes catch myself seeing why the patient has trouble moving his leg; if it’s the result of weak hip flexion or if they can’t bend their knee so that they can swing their leg back and forth, or whatever it is. And it’s fun to discover that you see something yourself . . .. But it’s sort of fallen into place bit by bit.’ (Respondent 9) ‘People are interested in different things . . .. So I don’t think its possible to train anyone as a fully fledged physiotherapist . . .. It’s just something you have to try . . . once you’ve, sort of, tried various bits and pieces. Then you just have to do it by trial and error.’ (Respondent 6) ‘During training, you do each bit, but you don’t really go into it . . .. So, I don’t think you really learn how to do it . . . until afterwards.’ (Respondent 3) Category C: professional demands Physiotherapy knowledge is conceived as being related to the professional demands that education, healthcare units, society and the influence of different workplaces and cultural traditions place on the profession. The conception is more influenced by theoretical knowledge as a conviction that knowledge mirrors reality and can be defined. The perspective is oriented towards the physiotherapist. ‘To be a professional in a surgical department I have to establish good relationships in a short period of time, and I have to be good at everything that may be required of me. To be good in home care, I have to be good at communicating with the elderly, have patience, and know a lot about how they function. I have to be good at what I do. I have to be good at relating to others in the relevant context.’ (Respondent 1) ‘So we have to stick to the rules of the profession . . . and we have laws and regulations we have to obey. We keep to what . . . what we’ve been trained to do, and what it says in the rules.’ (Respondent 4) ‘And then . . . there’s the business of always learning something new . . .. I think that’s important. Always taking a step forward, and . . . you know . . . improving.’ (Respondent 8) Category D: scientific areas The conception of physiotherapy knowledge is described as a well-defined area of knowledge that can be separated into different scientific areas strongly influenced by theoretical tradition. This knowledge can be accumulated and put into practice. The perspective is oriented towards the patient, and the physiotherapist is conceived as an expert.
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‘It’s fundamental knowledge in physiology, anatomy, biomechanics, social science, and psychology of learning and general teaching practice. Physiotherapists usually use their expertise when they meet an individual who has a dysfunction . . .. Where the physiotherapist hopefully can take their preclinical knowledge regarding physiology and anatomy . . . and can then combine this knowledge with biomechanics and, hopefully, with their enthusiasm . . . to convince the individual to participate in rehabilitation.’ (Respondent 2) ‘Yes, it’s about the prerequisites for human movement . . . using one’s ability to move. I can perform a movement analysis on a patient . . . no other professional group can do that. Many groups think they can. But to put together prerequisites for movement with abilities for movement and movement behaviour in a special situation . . . I’m the one who can say whether the patient is able to go to the toilet herself. I can assess whether she doesn’t want to or if she doesn’t have the ability to.’ (Respondent 1) Discussion This study attempted to describe how 10 Swedish physiotherapists conceive physiotherapy knowledge using a qualitative phenomenographic approach. The results are in accordance with previous qualitative studies, which demonstrated that people vary in their conception of a certain phenomenon [15–18]. In Category A, knowledge is described as an interaction and an active collaborative process in which dialogue with the patient is fundamental. Edwards et al. [10] described this type of clinical reasoning as narrative reasoning, i.e. understanding of patient stories, and collaboration reasoning, e.g. a consensual approach to goals and interventions. A fundamental factor in interaction is the physiotherapist’s ability to correctly identify the problem from both the patient’s and the physiotherapist’s perspective. Rehabilitation through the service that professionals provide is not always what patients perceive as their need. It may therefore be beneficial to establish both users’ and providers’ views of rehabilitation and goal setting [11,19]. The patient is an important source of knowledge [9], and even if it is sometimes difficult to achieve full patient participation, it is nonetheless necessary [20] as the goal of rehabilitation is to encourage active participation and autonomy [21]. An empowerment strategy such as involving patients in goal setting and allowing them to make their own decisions is fundamental [22]. To assess impairment in body function, activity limitations and participation restrictions and to discuss goals and life situations requires interaction skills, tolerance and acceptance of individual goal setting [23]. This multi-dimensional conception of knowledge relates to what Molander [6] described as knowledge in action, as an ability to observe what is going on and understand the situation and traditions. It is also in accordance with how Jensen et al. [9] described expert practice in physiotherapy.
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In Category B, knowledge is described as a process that occurs within each individual. As competence and interest can be seen as determining the individual’s ability to master a situation, the development of knowledge depends on how the individual physiotherapist perceives the world and his or her views of life [6]. Experience in practicing physiotherapy develops professional skills, but there is a risk that the knowledge will remain tacit if the process only occurs within each person [6,7]. Even if the development of knowledge is guided by the ability to be innovative and creative in clinical practice, it is important that it is verbalised. According to Rolf [7], tacit knowledge can be categorised and verbalised from three different perspectives: the content, the function and the origin of knowledge. This requires an ability to analyse, value and reflect over the way things are done, what treatment strategy is used and how this is related to current scientific knowledge. In Category C, knowledge is described as originating from demands that are placed on the profession. In order to function as a physiotherapist in different situations and contextual environments, it is necessary to gain the knowledge required [6,7,24]. Professional intervention requires the use of rules and ethical principles in accordance with science and clinical practice. Research reports and articles have to be read, used and reflected upon, and must therefore be written in such a way that they can be easily understood. Theories that cannot be tested or evaluated, or which are not relevant or useful in busy clinical settings, will seldom be implemented. Although randomised studies based on scientifically sound, credible, evidence-based practices are imperfect, they are nevertheless necessary [25]. Physiotherapy intervention must be based on individual responsibility as well as on a high degree of competence and high-quality clinical decision-making. In Category D, the conception of knowledge is related to specific areas of science. The patient is implicitly described as a passive consumer of physiotherapy. According to the respondents and the literature, knowledge in physiotherapy is described as including the ability to analyse human movement behaviour, and to focus on making individuals aware of the importance of body movements, and of how experience and habits influence body movements [1,2]. This fundamental area of knowledge is believed to distinguish the physiotherapy profession from other clinical healthcare professions. Each profession has a tendency to look at problems and interventions from their own discipline’s point of view and regard themselves as experts [26]. Since the aim of intervention is to empower the patient’s self-awareness and self-esteem [22,27,28], the physiotherapist has to know how to use his or her expertise. Instead of merely focusing on treatment and problem-solving that require professional expertise, focus can be directed towards the patient’s own competence, resources and goals in optimising their physical function in daily life. Perhaps it is time to regard different conceptions as a challenge in the dynamic process that knowledge develop-
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ment constitutes. The World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) [29] has been used to explain and understand the relationship between theories and patients’ problems [30,31]. The WHO classification describes health as a dynamic process that integrates body function/structure, activity and participation in a relationship with contextual and personal differences, and provides views on disabilities from different perspectives. Physiotherapy requires understanding of the social and contextual environment in which the patients live their lives, and how activity and participation are affected by their disability. The ICF can provide a conceptual model that can help physiotherapists to be aware of which perspective of health they use, and to describe how and within which component of the ICF they intervene.
Conclusions This study has resulted in four different conceptions of physiotherapy knowledge based on different knowledge traditions, different perspectives and a variety of experiences that affect the interaction with the patient and the development and use of knowledge. The implications of this study are relevant from an educational perspective. Quality of learning can be improved if students become aware of how different conceptions of physiotherapy knowledge and different paradigms interact within physiotherapy. Marton [16] argued that the way in which people conceive a phenomenon influences their way of thinking and acting. In education, students’ conceptions are altered as their experience and knowledge grow. Students learn to analyse and discuss different physiotherapy interventions. Is it the movement components in the patient’s performance, related to the ICF body function/structure component [29], or the way in which the patient uses his or her abilities in everyday life, related to the ICF activity/participation component [29], that is important? Does the student take on the role of a coach (i.e. Category A) or an expert (i.e. Category D)? Which assessment and evaluation instruments are used? Do they choose to assess patients in the same way as their tutor in the clinic because he or she is their role model, an expert in the area who has a great deal of experience (i.e. Category B)? Do they only choose valid and reliable instruments because it is always ‘the right thing to do’ (i.e. Category C)? Is one perspective always right and the others always wrong, or does it depend on the patient, the disability and the physiotherapist? Learning physiotherapy is a challenge. To be a physiotherapist is to use different scientific areas according to the demands placed on the profession and to use personal competencies in interactions with the patient. Being able to describe how physiotherapists conceive physiotherapy knowledge can perhaps also be a way of bridging the gap between theory and practice. Further studies are necessary.
Acknowledgement The authors wish to thank Anette Wennstr¨om for her contribution to the analysis process. Ethical approval: Not required. Funding: None. Conflict of interest: None. References [1] Thornquist E. Diagnostics in physiotherapy—processes, patterns and perspectives. Part 1. Adv Physiother 2001;3:140–50. [2] Bergman B. Definition av a¨ mnet och yrket sjukgymnastik. Sjukgymnasten 1998;1:32. [3] Socialstyrelsen (homepage on the Internet). Kompetensbeskrivningar f¨or sjukgymnaster (updated 10/11/2004; cited 19/11/2004). Available from: http://www.sos.se/fulltext/9903-001/9903-001.htm. [4] Abrandt M. Learning physiotherapy: the impact of formal education and professional experience. Dissertation. Link¨oping: Link¨oping University; 1997. [5] Rolf B. Theories of practical knowledge. Nordisk fysioterapi 1998;2:27–35. [6] Molander B. Kunskap i handling. G¨oteborg: Daidalos AB; 1993. ¨ [7] Rolf B. Profession, tradition och tyst kunskap. Ovre Dalkarlshyttan: Nya Doxa; 1991. [8] Higgs J, Titchen A. Research and knowledge. Physiotherapy 1998;84:72–80. [9] Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert practice in physical therapy. Phys Ther 2000;80:28–43. [10] Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in physical therapy. Phys Ther 2004;4:312–30. [11] Wohlin Wottrich A, Stenstr¨om CH, Engardt M, Tham K, von Koch L. Characteristics of physiotherapy sessions from the patient’s and therapist’s perspective. Disabil Rehabil 2004;26:1198–205. [12] van Meeteren NLU, Helders PJM. Phys therapy: what about basic sciences. Adv Physiother 2000;2:14–21. [13] Kalman H. Are some sciences more basic than others. Adv Physiother 2000;1:22–4. [14] Richardson B. The way forward—how and why. Adv Physiother 2000;1:13–6. [15] Marton F, Dahlgren LO, Svensson L, S¨alj¨o R. Inl¨arning och omv¨arldsuppfattning. Stockholm: Almqvist & Wiksell F¨orlag AB; 1977. [16] Marton F. Phenomenography—describing the conception of the world around us. Instruct Sci 1981;10:177–200. [17] Sj¨ostr¨om B, Dahlgren LO. Applying phenomenography in nursing research. J Adv Nurs 2002;40:339–45. [18] Dahlgren LO, Fallsberg M. Phenomenography as a qualitative approach in social pharmacy research. J Soc Adm Pharm 1991;8:150–6. [19] Kersten P, George S, McLellan L, Smith JAE, Mulle MA. Disabled people and professionals differ in their perception of rehabilitation needs. J Publ Health Med 2000;22:393–9. [20] Baker SM, Marshak HH, Rice GT, Zimmerman GJ. Patient participation in physical therapy goal setting. Phys Ther 2001;81:1118–26. [21] Cardol M, De Jong BA, Ward CD. On autonomy and participation in rehabilitation. Disabil Rehabil 2002;24:970–4. [22] Tilley S, Pollock L, Tait L. Discourses on empowerment. J Psychiatr Ment Health Nurs 1999;6:53–60. [23] Lundvik Gyllensten A, Gard G, Salford E, Ekdahl C. Interaction between patient and physiotherapist. A qualitative study reflecting the physiotherapist’s perspective. Physiother Res Int 2001;4:89–109. [24] Richardson B. A study of physiotherapy student’s understanding of their profession. Nordisk fysioterapi 1997;1:34–9.
I. Larsson, G. Gard / Physiotherapy 92 (2006) 110–115 [25] Herbert RD, Sherrington C, Maher C, Moseley AM. Evidencebased practice—imperfect but necessary. Physiother Theory Pract 2002;17:201–11. [26] Larsson M. Organiserande av st¨od och service till barn med funktionshinder. Dissertation. Lund: Lund University; 2001. [27] Martin-Crawford L. Empowerment in healthcare. Participat Empower 1999;7:15–24. [28] Lewin B. Empowerment-begreppet och ICF. Socialmedicinsk tidskrift 2002;6:533–7.
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[29] World Health Organisation. International classification of functioning, disability and health. World Health Organisation; 2001. [30] Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther 2002;82:1098–107. [31] Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disabil Rehabil 2002;24:932–8.
Conceptions of physiotherapy knowledge among Swedish physiotherapists: a phenomenographic study Ingalill Larsson ∗ , Gunvor Gard Department of Health Sciences, Division of Physiotherapy, Lund University Hospital, SE 221 85 Lund, Sweden
Abstract Objectives and design Knowledge in physiotherapy is based on both scientific evidence and clinical practice. Different perspectives of knowledge generate different implications for theory development. The aim of this qualitative, phenomenographic study was to describe physiotherapists’ conceptions of physiotherapy knowledge. Intervention and participants Open, semi-structured interviews were conducted with 10 physiotherapists working in different sectors of physiotherapy. The transcribed material was analysed according to phenomenographic analysis. Results The physiotherapists’ conceptions of various aspects of physiotherapy knowledge are described by four qualitatively different categories: (a) interaction, i.e. the ability to create opportunities for patients and develop patients’ competencies, equally influenced by both theoretical and practical knowledge, with a patient-oriented perspective conceiving the physiotherapist as a coach; (b) personal competencies, i.e. the ability to provide good therapy influenced more by practical knowledge oriented towards the physiotherapist; (c) professional demands, i.e. the ability to be professional according to rules and scientifically proven interventions, influenced more by theoretical knowledge oriented towards the physiotherapist; and (d) scientific areas, i.e. the ability to use different knowledge, as an expert, in the interaction with the patient, strongly influenced by theoretical knowledge and oriented towards the patient. Conclusions The results can contribute to physiotherapy students’ understanding of the multi-dimensional nature of physiotherapy. The paradigm of physiotherapy must be studied further in order to understand and explain its complexity. © 2005 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Physiotherapy; Knowledge; Theory; Practice; Phenomenographic
Introduction Physiotherapy has developed from both experience in clinical practice, which regards the body as a living, dynamic entity, and from theoretical knowledge, which regards the body as an object of scientific study [1]. Physiotherapy is described as encompassing knowledge from the scientific disciplines of anatomy, physiology, movement science, psychology and pedagogy [2]. In Sweden, physiotherapy has been an academic profession since 1977, with the emphasis on using academic knowledge in clinical practice. The physiotherapist is responsible for clinical decision-making, choice of treatment and methods of evaluation, all of which require a theoretical base, authority and professional independence accompanied by ethical rules [3]. The development of ∗
Corresponding author. Tel.: +46 46 222 3784; fax: +46 46 222 4202. E-mail address: [email protected] (I. Larsson).
knowledge concerning physiotherapy depends on the physiotherapist’s self-reflection and theoretical knowledge in his or her professional role, as well as on awareness of differences in communication and problem-solving skills that can influence patient participation [4]. According to Rolf [5], physiotherapists may be influenced by two main theories of professional, practical knowledge. The Platonic theory states that the rules of practice arise from scientific laws, and that all professional knowledge is the application of a scientific theory. The Aristotlean theory claims that some of the rules of practice may never find a basis in scientific laws because the clinical practitioner deals with phenomena that are not governed by the laws of nature [5]. According to Molander [6], knowledge includes both practical and theoretical aspects that cannot be divided. Knowledge is active and living, and requires an understanding and awareness of the concept in which it is used as knowledge in action. Different traditions are based on different perspec-
0031-9406/$ – see front matter © 2005 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2005.12.001
I. Larsson, G. Gard / Physiotherapy 92 (2006) 110–115
tives of knowledge and science. A tradition of theoretical knowledge regards clinical practice as an information base for theory building. A tradition of practical knowledge views clinical practice as the root of knowledge through personal experience and role modelling [6]. The knowledge tradition, together with individual perception of a phenomenon, is influenced by the culture in which learning takes place, and results in living and personal tacit knowledge [7]. Within the physiotherapy profession, it is necessary to describe and explain physiotherapy in a systematic way, and to clarify definitions and terminology [8]. Studies have focused on physiotherapists’ understandings of physiotherapy expert practice [9] and on clinical reasoning strategies [10], as well as on how the perspective of the patient and the physiotherapist differ in the rehabilitation process [11]. Differences between physiotherapists regarding their conceptions of knowledge, science, health, humanity, the world and values lead to different approaches and different treatment strategies [9,10–14]. The aim of this study was to describe physiotherapists’ conceptions of physiotherapy knowledge.
Method A qualitative, phenomenographic interview was conducted. Marton et al. developed phenomenography within educational research in Gothenburg, Sweden in the 1970s [15]. The purpose of a phenomenographic study is to describe how different people conceptualise and understand various aspects of a phenomenon in the world as they understand it. According to Marton [16], the difference between phenomenology and phenomenography is that a phenomenon can be interpreted and described from two perspectives. A first-order perspective, which is used in phenomenology, describes the essence of the phenomenon as an aggregated mental construction. The aim is to interpret the respondent’s statements and describe what the phenomenon is. The phenomenographic approach, on the other hand, uses a second-order perspective that describes (not interprets) people’s non-reflected conceptions of various perspectives of the phenomenon. People conceive the everyday world in different ways and this, in turn, leads to differences in how they conceptualise phenomena. The aim is to identify some of the qualitatively different conceptions of a phenomenon that exist within a population and describe these differences [16,17]. Ten physiotherapists were selected strategically to participate in the study. They were selected with consideration to variation in gender, number of years in the profession, sectors of physiotherapy and cultural background. Three men and seven women with a median working experience of 18 years (range 0.3–30 years) were chosen. They worked in different sectors of physiotherapy: neurology; respiratory; orthopaedics; habilitation; psychiatry; elder rehabilitation; primary health care and education and research. One was born, raised and educated in another European country. One
111
was born abroad, but raised and educated in Sweden. One was Swedish but educated elsewhere in Europe. The two respondents with a foreign background spoke Swedish fluently. The other seven respondents were born and educated in Sweden. Interview An interview guide was constructed consisting of the following open, semi-structured questions. • • • •
How do you conceptualise knowledge? What is physiotherapeutic knowledge in general? How have you obtained your knowledge? What is the content of professional physiotherapeutic knowledge? • How should this knowledge best be communicated to others? • What knowledge is valuable within physiotherapy? • What knowledge is necessary to become a professional physiotherapist? A pilot interview was conducted but did not result in any changes in the interview guide. The first author interviewed the respondents. The questions were addressed to the respondents in the same order. The interviewer followed up what was said through additional questions, such as ‘That is interesting, can you tell me more?’ or ‘What do you think about that?’, in order to obtain additional information. The interviews were conducted at the respondents’ workplace in all cases except one. Each interview lasted about 45 minutes, was tape recorded and subsequently transcribed. Analysis The transcribed material was analysed in seven steps according to accepted phenomenographic procedure [18]. The first author analysed the first three steps. In the following steps, the second author and another physiotherapist, experienced in qualitative methods but not involved in this study, assisted. Steps 4 and 5 were repeated several times before the analysis was deemed to be satisfactory. 1. Familiarisation. First the transcription of the interviews was read carefully several times in order for the assessor to become acquainted with the text. 2. Condensation. The answers from the interview were then reduced to significant statements. 3. Comparison. These statements were compared to identify sources of variation or agreement. 4. Grouping. Statements with similar condensed content were then assigned to groups for preliminary classification. 5. Articulation. The essence of the similarities within each group was described by a limited and central content for each qualitatively different and non-overlapping category. 6. Labelling. Each category was assigned a tailored linguistic expression.
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7. Contrasting. Finally, the categories were compared, in a more abstract way with regard to similarities and differences, based on the first author’s perspective.
Results Four qualitatively different categories were identified in this study. The same physiotherapist expressed a range of different conceptions within a specific interview. Category A: interaction The conception of physiotherapy knowledge is described in terms of how different types of knowledge are used to collaborate and interact with patients. This interaction is influenced by theoretical and practical knowledge. From the patient-oriented perspective, the physiotherapist is conceived as a coach, and patient participation is conceived to increase through sharing knowledge on how to manage problems as a prerequisite for good clinical assessment and treatment. ‘Lots of people don’t have the ability to establish contact with others; they only have a lot of theoretical knowledge. They may also have a lot of experience but not the ability to cooperate or interact empathetically. A physiotherapist can’t be like that. As you work alone with a patient for a long time, the ability to cooperate and interact must be there . . ..’ (Respondent 7) ‘Yes, I must be able to adapt, to get my message across to different people. There is no single answer. All the people I meet are different, so I must adapt to different patients and relate to them in a way that suits them. So first I must be aware of how they perceive the situation based on their own knowledge and understanding of what I say . . .. And from there I have to find an appropriate level for communicating with the patient.’ (Respondent 10) Category B: personal competencies Physiotherapy knowledge is conceived to be tacitly and individually related to practice and experience. Scientific areas and clinical practice are conceived to be strongly related to each other as a complex entity or process, which is influenced more by practical knowledge. The statements have a physiotherapist-oriented perspective, and knowledge development is conceived as being dependent on time, interest and the person’s ability to understand. ‘This knowledge regarding what you’re . . . doing . . . and why you’re doing something . . . and the background as to why you do what you do. Partly to provide as good-quality treatment or care as possible. And also for your own wellbeing and self-esteem . . . To, in a way, not do things routinely without having something in the back of your mind that . . . tells you what you’re doing, you know. You recognise that
you know anatomy, physiology, you know about different types of disease. You understand what’s going on and what you want to accomplish.’ (Respondent 5) ‘Bit by bit things have fallen into place . . . so I’m sometimes surprised over the fact that I see things in the movement analysis—that I sometimes catch myself seeing why the patient has trouble moving his leg; if it’s the result of weak hip flexion or if they can’t bend their knee so that they can swing their leg back and forth, or whatever it is. And it’s fun to discover that you see something yourself . . .. But it’s sort of fallen into place bit by bit.’ (Respondent 9) ‘People are interested in different things . . .. So I don’t think its possible to train anyone as a fully fledged physiotherapist . . .. It’s just something you have to try . . . once you’ve, sort of, tried various bits and pieces. Then you just have to do it by trial and error.’ (Respondent 6) ‘During training, you do each bit, but you don’t really go into it . . .. So, I don’t think you really learn how to do it . . . until afterwards.’ (Respondent 3) Category C: professional demands Physiotherapy knowledge is conceived as being related to the professional demands that education, healthcare units, society and the influence of different workplaces and cultural traditions place on the profession. The conception is more influenced by theoretical knowledge as a conviction that knowledge mirrors reality and can be defined. The perspective is oriented towards the physiotherapist. ‘To be a professional in a surgical department I have to establish good relationships in a short period of time, and I have to be good at everything that may be required of me. To be good in home care, I have to be good at communicating with the elderly, have patience, and know a lot about how they function. I have to be good at what I do. I have to be good at relating to others in the relevant context.’ (Respondent 1) ‘So we have to stick to the rules of the profession . . . and we have laws and regulations we have to obey. We keep to what . . . what we’ve been trained to do, and what it says in the rules.’ (Respondent 4) ‘And then . . . there’s the business of always learning something new . . .. I think that’s important. Always taking a step forward, and . . . you know . . . improving.’ (Respondent 8) Category D: scientific areas The conception of physiotherapy knowledge is described as a well-defined area of knowledge that can be separated into different scientific areas strongly influenced by theoretical tradition. This knowledge can be accumulated and put into practice. The perspective is oriented towards the patient, and the physiotherapist is conceived as an expert.
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‘It’s fundamental knowledge in physiology, anatomy, biomechanics, social science, and psychology of learning and general teaching practice. Physiotherapists usually use their expertise when they meet an individual who has a dysfunction . . .. Where the physiotherapist hopefully can take their preclinical knowledge regarding physiology and anatomy . . . and can then combine this knowledge with biomechanics and, hopefully, with their enthusiasm . . . to convince the individual to participate in rehabilitation.’ (Respondent 2) ‘Yes, it’s about the prerequisites for human movement . . . using one’s ability to move. I can perform a movement analysis on a patient . . . no other professional group can do that. Many groups think they can. But to put together prerequisites for movement with abilities for movement and movement behaviour in a special situation . . . I’m the one who can say whether the patient is able to go to the toilet herself. I can assess whether she doesn’t want to or if she doesn’t have the ability to.’ (Respondent 1) Discussion This study attempted to describe how 10 Swedish physiotherapists conceive physiotherapy knowledge using a qualitative phenomenographic approach. The results are in accordance with previous qualitative studies, which demonstrated that people vary in their conception of a certain phenomenon [15–18]. In Category A, knowledge is described as an interaction and an active collaborative process in which dialogue with the patient is fundamental. Edwards et al. [10] described this type of clinical reasoning as narrative reasoning, i.e. understanding of patient stories, and collaboration reasoning, e.g. a consensual approach to goals and interventions. A fundamental factor in interaction is the physiotherapist’s ability to correctly identify the problem from both the patient’s and the physiotherapist’s perspective. Rehabilitation through the service that professionals provide is not always what patients perceive as their need. It may therefore be beneficial to establish both users’ and providers’ views of rehabilitation and goal setting [11,19]. The patient is an important source of knowledge [9], and even if it is sometimes difficult to achieve full patient participation, it is nonetheless necessary [20] as the goal of rehabilitation is to encourage active participation and autonomy [21]. An empowerment strategy such as involving patients in goal setting and allowing them to make their own decisions is fundamental [22]. To assess impairment in body function, activity limitations and participation restrictions and to discuss goals and life situations requires interaction skills, tolerance and acceptance of individual goal setting [23]. This multi-dimensional conception of knowledge relates to what Molander [6] described as knowledge in action, as an ability to observe what is going on and understand the situation and traditions. It is also in accordance with how Jensen et al. [9] described expert practice in physiotherapy.
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In Category B, knowledge is described as a process that occurs within each individual. As competence and interest can be seen as determining the individual’s ability to master a situation, the development of knowledge depends on how the individual physiotherapist perceives the world and his or her views of life [6]. Experience in practicing physiotherapy develops professional skills, but there is a risk that the knowledge will remain tacit if the process only occurs within each person [6,7]. Even if the development of knowledge is guided by the ability to be innovative and creative in clinical practice, it is important that it is verbalised. According to Rolf [7], tacit knowledge can be categorised and verbalised from three different perspectives: the content, the function and the origin of knowledge. This requires an ability to analyse, value and reflect over the way things are done, what treatment strategy is used and how this is related to current scientific knowledge. In Category C, knowledge is described as originating from demands that are placed on the profession. In order to function as a physiotherapist in different situations and contextual environments, it is necessary to gain the knowledge required [6,7,24]. Professional intervention requires the use of rules and ethical principles in accordance with science and clinical practice. Research reports and articles have to be read, used and reflected upon, and must therefore be written in such a way that they can be easily understood. Theories that cannot be tested or evaluated, or which are not relevant or useful in busy clinical settings, will seldom be implemented. Although randomised studies based on scientifically sound, credible, evidence-based practices are imperfect, they are nevertheless necessary [25]. Physiotherapy intervention must be based on individual responsibility as well as on a high degree of competence and high-quality clinical decision-making. In Category D, the conception of knowledge is related to specific areas of science. The patient is implicitly described as a passive consumer of physiotherapy. According to the respondents and the literature, knowledge in physiotherapy is described as including the ability to analyse human movement behaviour, and to focus on making individuals aware of the importance of body movements, and of how experience and habits influence body movements [1,2]. This fundamental area of knowledge is believed to distinguish the physiotherapy profession from other clinical healthcare professions. Each profession has a tendency to look at problems and interventions from their own discipline’s point of view and regard themselves as experts [26]. Since the aim of intervention is to empower the patient’s self-awareness and self-esteem [22,27,28], the physiotherapist has to know how to use his or her expertise. Instead of merely focusing on treatment and problem-solving that require professional expertise, focus can be directed towards the patient’s own competence, resources and goals in optimising their physical function in daily life. Perhaps it is time to regard different conceptions as a challenge in the dynamic process that knowledge develop-
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ment constitutes. The World Health Organisation (WHO) International Classification of Functioning, Disability and Health (ICF) [29] has been used to explain and understand the relationship between theories and patients’ problems [30,31]. The WHO classification describes health as a dynamic process that integrates body function/structure, activity and participation in a relationship with contextual and personal differences, and provides views on disabilities from different perspectives. Physiotherapy requires understanding of the social and contextual environment in which the patients live their lives, and how activity and participation are affected by their disability. The ICF can provide a conceptual model that can help physiotherapists to be aware of which perspective of health they use, and to describe how and within which component of the ICF they intervene.
Conclusions This study has resulted in four different conceptions of physiotherapy knowledge based on different knowledge traditions, different perspectives and a variety of experiences that affect the interaction with the patient and the development and use of knowledge. The implications of this study are relevant from an educational perspective. Quality of learning can be improved if students become aware of how different conceptions of physiotherapy knowledge and different paradigms interact within physiotherapy. Marton [16] argued that the way in which people conceive a phenomenon influences their way of thinking and acting. In education, students’ conceptions are altered as their experience and knowledge grow. Students learn to analyse and discuss different physiotherapy interventions. Is it the movement components in the patient’s performance, related to the ICF body function/structure component [29], or the way in which the patient uses his or her abilities in everyday life, related to the ICF activity/participation component [29], that is important? Does the student take on the role of a coach (i.e. Category A) or an expert (i.e. Category D)? Which assessment and evaluation instruments are used? Do they choose to assess patients in the same way as their tutor in the clinic because he or she is their role model, an expert in the area who has a great deal of experience (i.e. Category B)? Do they only choose valid and reliable instruments because it is always ‘the right thing to do’ (i.e. Category C)? Is one perspective always right and the others always wrong, or does it depend on the patient, the disability and the physiotherapist? Learning physiotherapy is a challenge. To be a physiotherapist is to use different scientific areas according to the demands placed on the profession and to use personal competencies in interactions with the patient. Being able to describe how physiotherapists conceive physiotherapy knowledge can perhaps also be a way of bridging the gap between theory and practice. Further studies are necessary.
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