- Email: [email protected]
The perceived knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation
Physical Therapy in Sport 4 (2003) 74–81 www.elsevier.com/locate/yptsp
The perceived knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation Simon Matthew Jevona,*, Lynne Halley Johnstonb,1 a
MD Meridian Sports (UK) Ltd, BASES Accredited Sport and Exercise Psychologist, Bolton Arena, Arena Approach, Bolton BL6 6LB, UK b University of Gloucestershire, Oxstalls Campus, Oxstalls Lane, Gloucester GL2 9HW, UK
Abstract Objectives. This study investigated the knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation, their perceived need for training and reported access to an accredited sport psychologist or chartered clinical psychologist for onward referral. Methodological Approach. The methodological approach adopted was a constructionist revision of the Grounded Theory approach. Semistructured interviews were conducted with 19 governing body chartered physiotherapists. QSR N-Vivo (Fraser 1999) was employed to assist with the mechanical aspects of text coding, search, retrieval and theoretical modelling. A Grounded model was developed to represent the key themes. Results. Results concur with previous research, demonstrating an unequivocal and important role for practitioners in the psychological support provided to the injured athletes. Although practitioners reported conflicts regarding the nature and depth of this role, they are assuming responsibility for the provision of psychological support, even if not self-acknowledging this role. Practitioners have an extensive implicit knowledge base on the psychology of the injured athlete garnered through experiential learning. This implicit knowledge is not supported by an understanding of underpinning psychological theory, or formal education and training in psychology or psychology of sport and sports injury. Conclusions. Questions exist regarding the efficacy of psychological support in clinical practice. Professional training and application of reflective and evidence based practice principles to this area of clinical practice are strongly recommended. q 2003 Elsevier Science Ltd. All rights reserved. Keywords: Psychological Interventions; Injury; Physiotherapists; Training needs
1. Introduction
1.1. Practitioners’ role in the psychology of athletic injury
Both quantitative and qualitative research has demonstrated that injury can have a profound psychological impact on athletes (Gould et al. 1997a,b; Johnston & Carroll 1998a, b, 2000a,b; Quinn & Fallon 1999; Rose & Jevne 1993; Smith et al. 1993; Udry et al. 1997a,b). Practitioners providing healthcare to elite athletes are best placed to identify these problems and can often be the most influential people in the emotional support of injured athletes (Ford & Gordon 1997; Gordon et al. 1991; Hemmings & Povey 2002; Larson et al. 1996; Wiese & Weise, 1987; Ray & Wiese-Bjornstal, 1999).
Several studies have confirmed that physiotherapists and athletic trainers are acutely aware of the negative psychological impact of injury upon athletes (Ford & Gordon 1997; Hemmings & Povey 2002; Larson et al. 1996; McKenna et al. 2002). Ford & Gordon (1997) reported that physiotherapists in Australia, New Zealand and Canada found negative emotional responses were frequently observed among injured athletes and that non-compliance to the rehabilitation programme was problematic. Larson et al. (1996) reported that 90% of athletic trainers, rated psychological support as relatively or very important in the rehabilitation of an injured athlete, with 47% believing that every athlete they treated presented with some form of psychological issue as a result of their injury. In two recent British studies, Hemmings and Povey (2002) confirmed that more than 90% of physiotherapists surveyed felt athletes
* Corresponding author. E-mail addresses: [email protected] (L.H. Johnston), matt.jevon@ meridiansports.co.uk (S.M. Jevon). 1 Tel.: þ 44-1452-876638; fax: þ 44-1452-876601.
1466-853X/03/$ - see front matter q 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1466-853X(03)00034-8
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
were psychologically affected by injury; while McKenna et al. (2002) noted that physiotherapists treating elite athletes reported reactions ranging from ‘slight setback’ to ‘life has fallen apart’. Despite the recognition that psychological factors can play a substantial role in the rehabilitation of the injured athlete and that psychological skills training could facilitate treatment (Kolt 2000), a number of studies have shown that physiotherapists do not feel adequately equipped to deal with the psychological impact of injury (Ford & Gordon 1997; Gordon et al. 1991; Hemmings & Povey 2002; McKenna et al., 2002). Gordon et al. (1991) reported that 84% of sports physiotherapists in New Zealand and Australia reported limitations in their ability to deal with psychological factors, and 87% would welcome further training in the field. Hemmings & Povey (2002) found that although physiotherapists in the UK reported using a variety of psychological techniques alongside physical treatment they also articulated a need for training in such techniques. McKenna et al. (2002) note that although physiotherapists believed psychological interventions to be outwith their professional competencies, basic interventions were being used. McKenna et al. (2002) further suggest that training in psychological interventions could be included in continuing professional development sessions. An arguably more disturbing finding is that the referral pathway or access to an accredited sport or clinical psychologist may be uncertain. Larson et al. (1996) found that only 24.5% of athletic trainers reported having a sport psychologist available to them. Hemmings and Povey (2002) noted that less that 10% of UK physiotherapists surveyed, had access to a British Association of Sport and Exercise Sciences (BASES) accredited sport psychologist for referral. To date, no previous work in the UK has examined, from a qualitative perspective, the knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation, their perceived need for training in psychological interventions, or their access to and ability to refer to a British Psychological Society (BPS) chartered clinical psychologist or BASES accredited sport and exercise psychologist. The aim of the current study is to address these issues.
2. Methodological approach The methodological approach adopted is a constructionist revision (Yardley & Savage 1998 in Johnston et al., 1999: 268) of the Grounded Theory Approach (Glaser & Strauss 1967). The lack of theory and knowledge specific to practitioners working with elite athletes, and the small sample size of UK physiotherapists working with Olympic athletes created a demand for a study that was exploratory in nature, accounting for the methodological paradigm adopted.
75
‘Pure’ Grounded Theory requires the data collection process to drive the research, implying an innocence of the subject matter by the researcher, and an evolutionary process of discovery that is both open ended and unstructured. The richness of data generated by this approach is desirable. However, the practical aspects inherent in working with a geographically disparate population of research participants heavily involved in applied clinical work, prevents the adoption of the original approach proposed by Glaser and Strauss (1967). Further, the purity of the researcher is tainted by experience, previous research and exposure to anecdotal information, both on entry into the research area and throughout the evolution of the study. Strauss and Corbin (1990, 1998) have suggested that Grounded Theory should meet four central criteria: fit, understanding, generality and control. This implies that the evolution of new theories and models utilising this methodology should fit a substantive area that is faithful to the every day reality of that area. It should make sense and be comprehensible to the researcher, participants in the study, and those practicing in the area. It should be general enough that a variety of concepts applicable to the area under consideration are well related to the emergent theory, and the emergent theory should ‘provide control with regard to action toward the phenomenon’. An acknowledgement of the benefits that the researcher’s experience brings to the study, a ‘bracketing’ (Rose & Jevne 1993) of conceptions and values, particularly through the use of a research diary during data collection and analysis, is an essential part of the research process. Yardley and Savage (cited in Johnston et al. 1999: 268) propose that three core strands are intertwined through the constructionist revision of the Grounded Theory process: reflexive, resonant and generative. Resonance is defined as interest, engagement and commitment generated by the broad focus of initial Grounded Theory enquiry. The research methodology should generate self-reflection and co-learning commitments. Reflexive elements encompass the researcher’s own self reflection on decisions made through the research process. Generativity refers to the potential to generate meaningful insights within applied and practical applications. These strands can readily be justified by reference to the inherent values within pure Grounded Theory (Strauss & Corbin 1990, 1998) whilst enhancing the research process through inclusion of the researcher’s interpretive knowledge, albeit controlled through the bracketing process and subjected to audit via memos, diagrams and the research diary. 3. Method of data collection 3.1. Interview guide and demographic survey A semi-structured interview guide was developed, based on the work of Ford and Gordon (1993) and Ford et al.
76
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
Table 1 Interview themes and sample questions
Table 2 Research participants’ age, qualification and experience
Theme
Partici pant
Age
Years experience total since qualification
Years experience working with international athletes
Average contact time per year with elite athletes
Post graduate qualifica tions
Alpha Bravo Charlie Delta Echo Foxtrot Golf Hotel India Juliet Kilo Lima Mother November Oscar Papa Quebec Romeo Sierra
INS INS 38 42 INS 37 59 INS 46 INS 42 INS INS 42 34 42 INS INS INS
INS INS 12 20 17 16 38 INS 25 INS 21 INS INS 16 13 20 INS INS INS
INS INS 5 6 16 4 25 INS 11 INS 12 INS INS 8 6 12 INS INS INS
INS INS 130 days 80 days 5 days 12 days 180 days INS 58 days INS 355 days INS INS 60 days 86 days 38 days INS INS INS
No No Masters Masters Masters No Masters No No No No No No No No No No No No
Sample question
The role of the Can you describe your role as a governing governing body chartered body chartered physiotherapist? physiotherapist What sort of environments/locations do you find yourself working in? Psychological response What positive/negative psychological to injury or emotional responses to injury do you observe? Can you provide some examples of observable signs/symptoms at each stage in rehabilitation? Factors influencing What observations can you make regarding rehabilitation adherence poor/positive attitude towards rehabilitation protocols from the athletes behaviour? What are the main barriers associated with optimal rehabilitation? Return to training/ Can you define what you mean by recovered? competition What are the main challenges in the final stages of recovery? The athlete/physio If an athlete is overly optimistic/pessimistic therapist relationship about their outcome what do you say/do? Are you aware of any psychological interven tion techniques? Can you give examples? The role of other people Can you describe positive/negative during the treatment and experiences with a coach/sport scientist/rest rehabilitation process of team/media/other medical personnel? Other models of Are you aware of models of healthcare for healthcare the physically active in other countries (e.g. USA, Canada, Australia)? What educational standards and clinical /practical experience would you feel is required in such a professional? Preparation for Do you feel that your physiotherapy training current role prepared you fully for your current role? What other steps have you felt it necessary to take to reach your current role?
(1993) (see Table 1). An additional demographic and educational survey was also developed. 3.2. Recruitment of participants and data collection Participants were governing body Chartered Physiotherapists who were members of the British Olympic Association (BOA) Steering Group. This group is composed exclusively of Chartered Physiotherapists who work with Great Britain Olympic athletes. Each prospective participant was contacted by letter and asked to confirm their willingness to participate ðN ¼ 22Þ: Nineteen governing body Chartered Physiotherapists agreed to take part, completed informed consent forms, and were interviewed at various locations throughout the UK. The available demographic information is shown in Table 2. Interview times ranging from 53 to 86 min. Interviews were transcribed verbatim and sent to each participant for
INS, information not supplied.
member checking (Rose & Jevne 1993; Strauss & Corbin 1998). On completion of the transcription, the interviews were edited to provide anonymity for participants, their professional colleagues and clients. Rich Text files were imported into QSR NUD*IST Vivo (N-Vivo) software (Fraser 1999). This programme is designed to assist with the mechanical aspects of text coding, search, retrieval and theoretical modelling (Richards 1999). To ensure anonymity, no demographic details of participating BOA physiotherapists are reported. All references to particular sports have been edited from the results reported. 3.3. Emergence of core data themes Data were coded from the open-ended interview questions according to the principles outlined by Glaser and Strauss (1967). Initially meaning units were coded at ‘nodes’ created in N-Vivo to encapsulate broad themes within the data. Once the theme was borne out by further data, it was transferred into one of a number of relevant sets of nodes. Within these working sets modelling of relationships between data themes (nodes) was examined and further more extensive themes were developed. N-Vivo helps to facilitate the process of axial coding as both source and derived data documents, together with memos and diagrams can be viewed concurrently and compared. Coding was judged to be complete when no new themes or concepts emerged from the data (Glaser & Strauss 1967). This point is referred to as theoretical saturation (Udry et al.
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
1997a). The inductive Grounded Theory process described earlier was instrumental in developing credible themes represented by the data.
4. Results and discussion The emergent themes highlighted a disparity between the participant’s perceived effectiveness and the predicted effectiveness suggested within the existing literature regarding the provision of psychological support to injured athletes. Physiotherapists placed a greater emphasis on vicarious knowledge and experience, whereas the existing literature suggests a combination of formal and vicarious knowledge (Ray & Wiese-Bjornstal, 1999). A range of themes influenced these beliefs. Participants suggested that a number of factors also influence the physiotherapist and athlete independently (influencing factors) and their interaction (athlete/physio interaction). 4.1. Formal training in psychological theory or practice The interviewees described a lack of formal training in psychology theory or practice (undergraduate or diploma), although some physiotherapists who had qualified more recently did report some training in communication skills. The training reported in undergraduate programmes was described as basic and minimal. Postgraduate training in psychology or associated subjects (communication/management, etc.) formed less than five percent of all postgraduate practicum courses taken by the participants. Physiotherapists in the UK keep a continuing professional development record and attend learning and educational events in order to demonstrate that they are remaining current in their knowledge (http://www.csp.org/ lifelonglearning/cpd.cfm). A number of the participants in this study, although governing body Chartered Physiotherapists for Olympic sports, also have additional work commitments requiring appropriate emphasis on continuing professional development not related to sport. Only three of the participants in this study referred to taking practicum courses in sports psychology since qualifying, and none referred to sports psychology training from recognised accrediting bodies such as BASES or the BPS. Only four of the physiotherapists interviewed had a Masters level qualification and details of any psychological components were vague. Thus, conclusions regarding the overall level of formal training in psychology amongst the research participants are difficult to frame in positive terms. Continuing professional development requirements appear to be unclear for practitioners working in elite sport in the UK, this is in contrast to recommendations made for physiotherapists in Australia (Gordon et al. 1998) and to the clear guidelines set out for athletic trainers, the primary health care professional for injured athletes in the USA (http://www.nata.org).
77
The level of formal undergraduate training in psychology appeared to influence participants’ beliefs regarding their abilities in providing psychological support. Those participants who had some level of applied psychological training were more likely to value and use psychological support mechanisms and services. Those without this underpinning theoretical and applied knowledge appeared to underestimate the importance of psychological support from the therapist to the injured athlete, even though they were often providing this in an informal and intuitive format. Other influencing factors included formal postgraduate education/training in psychology, psychological training in professional development, experiences gained from working with a sports psychologist, any counselling training received, personally developed communication and rapport skills, teacher training, and experience in elite sport. 4.2. Vicarious knowledge and experience Participants reported feeling that the majority of their knowledge and skills regarding the psychological aspects of injury were developed through clinical practice. Further, the belief that the clinical experiences gave them an ability to support the athlete emotionally was consistent across all participants. Despite an acknowledged lack of formal knowledge of psychological skills, most participants felt able, particularly with experience and a long association with a group of athletes, to interpret an athletes psychological reaction to injury and to provide appropriate emotional, social and informational support: ‘…but we as physiotherapists end up doing quite a lot of sort of (pause), what do you call it, amateur psychology in that, you know, we’re sort of, (pause), there to listen to (the athlete) and deal with (their) emotions, etc.’ The following quote from a physiotherapist without formal training in psychology typifies the more intuitive approach: ‘I am mostly aware of some psychology technique but I mean I’m not claiming to be a psychologist and I, you know, I don’t think I really use any particular techniques’. Only one of the research participants described a formal goal setting process used with the athletes, and one other described combining physiotherapy skills in massage with relaxation. Without exception, all the participants described using some form of goal setting, though often with a didactic rather than a shared ownership approach. Other than goal setting and relaxation, visualisation was the only other intervention reported: Well certainly the goal setting. And I suppose sometimes the relaxation but if so that would be because somebody’s getting massively hyper immediately post injury, you know what I mean, I’d just want them to calm down. (Pause) the imagery and the visualisation I would know about it if they wanted to talk about it (pause), but I wouldn’t want to start teaching anybody in the first place really. (Pause), not my profession, you know and I’m
78
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
more frightened about what I could, could be imagining anything here. So if they had some insight into it and I might say well you know you might consider just thinking through the skills and doing it that way…I’d probably do that but I wouldn’t start anybody from scratch. None of the participants reported any counselling training or experience. Knowledge of counselling skills and techniques appeared to be limited and practitioner effectiveness was reported to be a function of the practitioners’ knowledge of the athlete, personal factors of the physiotherapist (good listener, sympathetic, experience in sport) and length of experience as opposed to formal training. However, many of the interviewees acknowledged a counselling role, particularly on an informal basis: This is, I think this is back to the sort of counselling realism and timings for them and, you know, this is what you have to do…I never sort of ask people directly what they, what they feel they’re, the outcome is going to be but I think you always listen to the way people are talking about their injury and say oh hang on a minute you know that, that’s, you know that’s not necessary the case. You can do that or no you can’t do that, and no you won’t be able to do that so its, its just bringing, either drawing people in or pushing them along a little bit No other interventions or psychological techniques were formally described although informally a wide variety of techniques were reported including dissociative strategies for pain management, healing imagery, reflective listening skills and social support. In light of the importance of counselling skills to effect an effective interaction between the athlete and practitioner (Flint 1998; Ray & Wiese-Bjornstal, 1999; Smith et al. 1990) this is an area that may require considerable development. Participants reported that they found it difficult to separate good communication skills from providing emotional or psychological support. In a recent study examining physiotherapists’ and athletes’ views regarding psychological skills for rehabilitation, Francis et al. (2000) found good communication skills to be the highest related construct by both athletes and practitioners. However, Francis et al. (2000) focussed specifically on the communication methods as opposed to the interaction between athlete and practitioner. Practitioners in the current study were unable to describe their use of psychological interventions, or to describe any practice in this area in psychological terms. This is consistent with Francis et al. (2000) who postulated that lack of application of psychological interventions stemmed from a lack of knowledge of underpinning theory and therefore application and use. A review of publications aimed at developing excellence in practice for the sports medicine practitioner (Arnheim &
Prentice 1997; Flint 1998; Ray & Wiese-Bjornstal, 1999; Taylor & Taylor 1997) establishes consensus in the importance of using a variety of psychological intervention techniques. A lack of understanding of these issues may well negatively impact upon clinical practice and effective treatment (Myers & Midence 1998). Use of psychological interventions within an appropriate framework, underpinned by a theoretical knowledge base, is held as an exemplar of best practice, and is included in the competencies for USA trained Certified Athletic Trainers (http:// www.nata.org) and UK educated BASRaT Certified Sports Rehabilitators and Certified Sports Trainers (http://www. basrat.org). 4.3. Athlete/physiotherapist interaction Participants described a number of factors that influenced the quality of the relationship between the athlete and physiotherapist. Participants reported that successful treatment was based on effective communication with the athlete, adherence by the athlete to treatment and rehabilitation work, and the ability of the physiotherapist to engender confidence in the athlete. In particular, the ability of the physiotherapist to determine whether an athlete is covering up ‘impression management’ (Leary 1995) or being honest in their emotional reactions was essential. Individual analysis of athletes’ psychological and emotional responses to injury appeared to guide the physiotherapist’s subsequent action in treatment and rehabilitation. Without exception, all participants described using implicit psychological skills or interventions, even if they did not perceive themselves as having a formal role: ‘we’re physiotherapists, yes we use psychology in our job because we have to, but we’re not trained psychologists.’ and: ‘… the problem with say elite athletes is your (psychological) role is never defined in that you’re just going to be doing that, because you find yourself doing a lot of other things.’ Participants reported that this was a part of their ‘bedside manner’ and that the roles they assumed were a vital aspect of their practice, even if they themselves did not label these roles as psychological: I think any time that we (pause) end up in open discussion with the athlete about their injury from the type of thing that you’re talking about, we are involved psychologically so there’s always got, we’ve always got to be positive, realistic and setting goals, timescales and things like that. But again we’ve got to be careful we don’t move outside our remit. Participants that implicitly provided psychological support to athletes were least likely to acknowledge a formal role for physiotherapists in such provision. Those with more formal knowledge reported that they felt they had an awareness of professional boundaries, had a formal role and responsibility to provide psychological support and were
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
more likely to have access to a named psychologist to whom they could make a referral. All participants articulated a willingness to refer, although only three physiotherapists said that they had ever done so formally. Only five participants stated that they had a named sports or clinical psychologist to whom they would refer. One participant described strict criteria regarding the characteristics of an appropriate psychologist for referral. This included the need for sports specific knowledge, a personality match of the psychologist with the athlete, and practical as opposed to academic credibility. Interestingly, practitioners stated that they wanted to maintain a professional separation between their roles and the role of the psychologist, and despite much of the literature pointing to the importance of the practitioner providing this type of support (Flint 1998; Kolt 2000; Taylor & Taylor 1997), they reported an unwillingness to do so. McKenna et al. (2002) also noted that although physiotherapists working with elite athletes recognise the need for psychological interventions and implicitly deliver foundation level support, they do not view the delivery of psychological interventions as part of their remit. The results of the current study therefore demonstrate that a conflict was created within many practitioners regarding appropriate boundaries and role assumptions. Practitioners appear to be struggling between the roles they are assuming on an informal basis (e.g. emotional support) their acknowledgement of the importance of effective communication skills and a good ‘bedside manner’, and the desire to avoid extending beyond self interpreted professional boundaries. Much of this conflict may be engendered within terminological difficulties, caused by lack of underpinning knowledge, rather than a genuine unwillingness to assume this role. Further, this perceived conflict regarding the use of psychological techniques in the rehabilitation of elite athletes might account for the lack of demand for postgraduate training in the psychological aspects of injury. 4.4. Influencing factors Participants identified a number of factors that they felt had an influence on the athletes’ psychological response to the injury. In addition, they reported that these factors had an impact upon the practitioner, resulting in an indirect impact on the quality of the athlete/physiotherapist interaction. Practitioners stated that they were often asked to work in different environments, including hotel bedrooms, changing rooms, track or pitch side, and custom designed well-equipped facilities. Many insisted that the different physical environments did not affect their treatment of the athlete; however, they did emphasise the need to create a professional setting for treatment. Claims of practical achievement by the practitioner in negating the effects of the environment are difficult to understand in the light of lack of facilities and equipment, restrictions placed
79
on clinical practice and drug use in other countries and the difficulties described by the practitioners in creating appropriate treatment settings. The venue does (affect the athletes psychological response). In so far as what competition is on, so if it’s a world cup competition, an important one, then yes they, they certainly do get a lot more em pissed off about it all if it happens there. If it’s a minor event they’re not too, too bothered because they’ll focus, they’ll focus at different times in the season and different events so they’ll have their three or four key events that they must do and as part of that if they miss out on one lesser event it doesn’t bother them too much so I mean if I’m out there and it happens to be leading up to a key event which is usually when I do go out there, then an injury then is pretty traumatic for them. Practitioners also described the effects of differences between sports cultures and the psychological reaction of the athlete to injury. In some sports, particularly endurance sports, where a high level of athlete body awareness was reported, an injury was an immediate issue, requiring attention and seen as a critical threat to preparation, training and competition. In other sports with a power or contact base, injuries were accepted as an inevitable fact of life and viewed as something to be managed, not as an immediate barrier to competition. These cultural variations produced responses that were perceived as reasonably predictable and stable by the practitioners. Practitioners with a participation background in the sport in which they worked reported that cultural understanding was important in allowing them to cope well with athletes’ reactions to injury. Some practitioners described departures from these cultural expectations in situations where the athlete was no longer under the direct influence of team members, management or significant others and no longer had to ‘put a brave face on it’. In these instances the practitioners described individual differences within the reactions, suggesting that within sports environments practitioners need to be aware of the influence of peer and sports culture on the athlete. Practitioners working in particular sports may need to be aware of the culture of a particular sport, but should be wary of discounting individual differences and preferences by making predictions about athlete response based on cultural factors. Athletes may well ‘impression manage’ (Leary 1992) in public groups but in reality their psychological response may be influenced more by individual differences, environmental, and situational factors (Wiese-Bjornstal et al. 1998). Participants suggested that the proximity of and the importance of competition also had a significant and predictable effect on the athletes’ responses and the resultant stress on the practitioner.
80
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
…the ones that have been really negative have tended to, its either been because they think its put them, or its going to put them out of a major event, (pause) or, I mean even if that major event is selection (pause) but most of them, that’s where I hope you know just sit down and you talk with them long enough you should at least be able to talk them round. But yes, you know, and you can you can understand why as well really. The ability of the practitioner to spend time with the athlete, and the nature of the communication established was viewed as essential to this process, and is consistent with research in the psychology of injury (Heil 1993; Flint 1998; Rungapadiachy 1999; Taylor & Taylor 1997). Physiotherapists who described the provision of psychological support as part of their role tended to deliver this in a reactive way, i.e. when athletes presented with such serious emotional issues or problems that the need for intervention was obvious. None of the practitioners had any method of undertaking any psychological needs analysis with the injured athlete. The participants suggested that injured athletes, for a number of reasons, including environment, competition valency and nature of interaction with the practitioner, tend to ‘impression manage’ (Leary 1992) in the interaction between themselves and the practitioner. This tendency to impression manage by the athlete, possibly heavily influenced by culture and timing of competitions, may well be difficult for the practitioner to both recognise and overcome. Therefore without appropriate needs analysis techniques and underlying training, practitioners may well only surface treat the image or impression the athlete wishes to project and may miss more serious psychological needs and thereby not provide appropriate support or onward referral.
5. Conclusions and recommendations Current knowledge and practice by governing body Chartered Physiotherapists in providing support to elite athletes regarding psychological issues associated with injury could benefit from further in service training. The educational and professional gaps in practice may well impact negatively on effective clinical application. Substantial work is needed to identify and express an appropriate role in this area and to support that role with high quality education and professional development. In the context of criteria proposed by Sackett et al. (1996); Greenhalgh (1996), and by reference to the physiotherapy evidence based healthcare model reported in Bury & Mead (1998), none of the participants in the current study reported knowledge of or adoption of an evidence based approach to practice in psychological aspects of injury to elite athletes. The need to adopt an evidence based approach may have been moderated by
the perceptions of the majority of the physiotherapists in the current study, who felt that they did not have a formal role in the provision of psychological support, in contrast to the informal role so often assumed. Greenhalgh (1996); Bury and Mead (1998) emphasise the importance of reflection as a critical part of evidence based practice. McKenna et al. (2002) noted that physiotherapists who described practicing ‘real physiotherapy’ when treating elite athletes, were ‘motivated by learning’ and that their understanding of treatment was developed through reflective practice. Whilst practitioners in the current study certainly have the capacity and ability to be highly reflective, and have garnered high levels of experiential learning, these are not placed within a continuous improvement or applied framework of reflective practice. The results of this study and from the existing literature (e.g. Francis et al. 2000; Larson et al. 1996) have shown that there is a vital and important role for the sports medicine practitioner in the psychological support provided to injured athletes. Whilst conflict exists regarding the exact nature and depth of this role, practitioners are assuming responsibility for its provision, even if not self-acknowledging this. The current study raises a number of suggestions for further research. First, there is a need to triangulate the perceptions of the BOA Chartered Physiotherapist regarding their role in the psychological support of injured elite athletes with the perspective of the injured athletes themselves, physicians and other members of the athlete support team (e.g. BASES and BOA accredited sport psychologists and BPS chartered clinical psychologists). Second, there are now a number of allied healthcare professions in the UK, including BASRaT Certified Sports Trainers and Graduate Sports Rehabilitators, as well as USA trained Certified Athletic Trainers. It would be interesting to conduct similar research with such groups and to note any differences in practice. The influence of the environment on both athlete and practitioner remains largely unexplored at elite level. Many of the participants in this study intimated that the variety of environments in which they worked affected both the athlete and themselves. Of further interest are some of the additional emergent themes within this study pertaining to the actual psychological reactions of elite athletes to injury, differences observed between acute and chronic injuries, the influence of sports cultures, social support, practitioner interaction, and practitioners’ own psychological coping skills and stressors. Professional development, recognising the implicit knowledge and addressing the lack of formal knowledge, is required, generally in psychology of sport and specifically in the psychology of sports injury in elite athletes. As practitioners move from a broad base engendered by traditional physiotherapy training, development of psychological knowledge must be given a priority. It should follow a developmental pathway that will allow the practitioner to
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
ground their practice and experiences within an applied framework supported by theory. This continuing professional development should lead into a clearly expressed role, with appropriate support structures and referral pathways for practitioners. Finally, the professional development programme should be subject to an objective assessment procedure that measures both formal knowledge and the ability to apply that knowledge in an environment that reflects societal demands for evidence based and reflective practice.
References Arnheim, D.D., Prentice, W.E., 1997. Principles of athletic training, Ninth ed., Brown and Benchmark, Madison. Bury, T.J., Mead, J.M. (Eds.), 1998. Evidence-based healthcare: a practical guide for therapists, Butterworth-Heinemann, Oxford. Flint, F.A., 1998. Integrating sport psychology and sports medicine in research: the Dilemmas. Journal of Applied Sport Psychology 10 (1), 83–102. Ford, I.W., Gordon, S., 1993. Social support and athletic injury: the perspective of sport physiotherapists. The Australian Journal of Science and Medicine in Sport, 17 –25. Ford, I.W., Gordon, S., 1997. Perspectives of sport physiotherapist on the frequency and significant of psychological factors in professional practice: implications for curriculum design in professional training. The Australian Journal of Science and Medicine in Sport 29 (2), 34–40. Ford, I.W., Gordon, S., Horsley, C., 1993. Providing social support for injured athletes: the perspective of elite coaches. Sports Coach, 13–19. Francis, S.R., Anderson, M.B., Maley, P., 2000. Physiotherapists’ and male professional athletes’ views of psychological skills for rehabilitation. Journal of Science and Medicine in Sport 3, 17– 29. Fraser, D., 1999. QSR NUDpIST Vivo: Reference Guide, Qualitative Solutions and Research Pty. Ltd, Melbourne, Australia. Glaser, B., Strauss, A., 1967. The Discovery of Grounded Theory, Aldine, Chicago, IL. Gordon, S., Milios, D., Grove, J.R., 1991. Psychological aspect of the recovery process from sport injury: the perspective of the sport physiotherapist. The Australian Journal of Science and Medicine in Sport 23 (2), 53–60. Gordon, S., Potter, M., Ford, I.W., 1998. Toward a psychoeducational education for training sport injury rehabilitation personnel. Journal of Applied Sport Psychology 10, 140 –156. Gould, D., Udry, E., Bridges, D., Beck, L., 1997a. Coping with seasonending injuries. The Sport Psychologist 11, 379 –399. Gould, D., Udry, E., Bridges, D., Beck, L., 1997b. How to help elite athletes cope psychologically with season-ending injuries. Athletic Therapy Today 2 (4), 50 –53. Greenhalgh, T., 1996. Is my practice evidence-based? British Medical Journal 313, 656–657. Heil, J. (Ed.), 1993. The Psychology of Sport Injury, Human Kinetics, Champaign, IL. Hemmings, B., Povey, L., 2002. Views of chartered physiotherapists on the psychological content of their practice: a preliminary study in the United Kingdom. British Journal of Sports Medicine 31 (1), 61–64. Johnston, L.H., Carroll, D., 1998a. The context of emotional response to athletic injury: a qualitative analysis. Journal of Sport Rehabilitation 7, 206–220. Johnston, L.H., Carroll, D., 1998b. The provision of social support to injured athletes: a qualitive analysis. Journal of Sport Rehabilitation 7, 267–284.
81
Johnston, L.H., Carroll, D., 2000a. The Psychological impact of injury: effects of prior sport and exercise involvement. British Journal of Sports Medicine 34 (6), 436–439. Johnston, L.H., Carroll, D., 2000b. Coping, social support, and injury: changes over time and the effects of level of sports involvement. Journal of Sport Rehabilitation 9 (4), 290–303. Johnston, L.H., Corban, R.M., Clarke, P., 1999. Multi-method approaches to the investigation of adherence issues within sport and exercise: qualitative and quantitative techniques. In: Bull, S.J., (Ed.), Adherence Issues in Sport and Exercise, Wiley, Chichester, pp. 263–288. Kolt, G.S., 2000. Doing sport psychology with injured athletes. In: Andersen, M.B., (Ed.), Doing Sport Psychology, Human Kinetics, Champaign, IL, pp. 223 –236. Larson, G.A., Starkey, C., Zaichkowsky, L.D., 1996. Psychological aspects of athletic injuries as perceived by athletic trainers. The Sport Psychologist 10, 37–47. Leary, M.R., 1992. Self-presentational processes in exercise and sport. Journal of Sport and Exercise Psychology 14, 339 –351. Leary, M.R., 1995. Self-presentation: Impression Management and Interpersonal Behavior, Westview Press, Boulder, CO. McKenna, J., Delaney, H., Phillips, S., 2002. Physiotherapists’ lived experience of rehabilitating elite athletes. Physical Therapy in Sport 3 (2), 66–78. Myers, L.B., Midence, K. (Eds.), 1998. Adherence to Treatment in Medical Conditions, Harwood Academic Publishers, Amsterdam, The Netherlands. Quinn, A.M., Fallon, B.J., 1999. The changes in psychological characteristics and reactions of elite athletes from injury onset until full recovery. Journal of Applied Sport Psychology 10, 210– 229. Ray, R., Wiese-Bjornstal, D.M. (Eds.), 1999. Counselling in Sports Medicine, Human Kinetics, Champaign, IL. Richards, L., 1999. Using Nvivo in Qualitative Research, Qualitative Solutions and Research, Melbourne, Australia. Rose, J., Jevne, R.F.J., 1993. Psychological processes associated with athletic injuries. The Sport Psychologist 7, 309 –328. Rungapadiachy, M., 1999. Interpersonal Communication and Psychology for Health Care Professionals: Theory and Practice, ButterworthHeinemannn, Oxford. Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., 1996. Evidence-based medicine: what it is and what it isn’t. British Medical Journal 312, 71– 72. Smith, A.M., Scott, S.G., Wiese, D.M., 1990. The psychological effects of sports injuries: coping. Sports Medicine 9, 352– 369. Smith, A.M., Stuart, M.J., Wiese-Bjornstal, D.M., Milliner, E.K., O’Fallon, W.M., Crowson, C.S., 1993. Competitive athletes: pre-injury and postinjury mood state and self-esteem. Mayo Clinic Proceedings 68, 939– 947. Strauss, A., Corbin, J., 1990. Basics of Qualitative Research: Grounded Theory Procedures and Techniques, Sage, London. Strauss, A., Corbin, J., 1998. Basics of qualitative research: techniques and procedures for developing grounded theory, Second ed., Sage, London. Taylor, J., Taylor, S., 1997. Psychological Approaches to Sports Injury Rehabilitation, Aspen, Gaithersburg. Udry, E., Gould, D., Bridges, D., Tuffey, S., 1997a. People helping people? Examining the social ties of athletes coping with burnout and injury stress. Journal of Sport and Exercise Psychology 19, 368–395. Udry, E., Gould, D., Bridges, D., Beck, L., 1997b. Down but not out: athletic responses to season ending injuries. Journal of Sport and Exercise Psychology 19, 229–248. Wiese, D.M., Weise, M.R., 1987. Psychological rehabilitation and physical injury: implications for the sport medicine team. The Sport Psychologist 1 (4), 318 –330. Wiese-Bjornstal, D.M., Smith, A.M., Shaffer, S.M., Morrey, M.A., 1998. An integrated model of response to sport injury: psychological and sociological dynamics. Journal of Applied Sport Psychology 1, 46– 69.
The perceived knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation Simon Matthew Jevona,*, Lynne Halley Johnstonb,1 a
MD Meridian Sports (UK) Ltd, BASES Accredited Sport and Exercise Psychologist, Bolton Arena, Arena Approach, Bolton BL6 6LB, UK b University of Gloucestershire, Oxstalls Campus, Oxstalls Lane, Gloucester GL2 9HW, UK
Abstract Objectives. This study investigated the knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation, their perceived need for training and reported access to an accredited sport psychologist or chartered clinical psychologist for onward referral. Methodological Approach. The methodological approach adopted was a constructionist revision of the Grounded Theory approach. Semistructured interviews were conducted with 19 governing body chartered physiotherapists. QSR N-Vivo (Fraser 1999) was employed to assist with the mechanical aspects of text coding, search, retrieval and theoretical modelling. A Grounded model was developed to represent the key themes. Results. Results concur with previous research, demonstrating an unequivocal and important role for practitioners in the psychological support provided to the injured athletes. Although practitioners reported conflicts regarding the nature and depth of this role, they are assuming responsibility for the provision of psychological support, even if not self-acknowledging this role. Practitioners have an extensive implicit knowledge base on the psychology of the injured athlete garnered through experiential learning. This implicit knowledge is not supported by an understanding of underpinning psychological theory, or formal education and training in psychology or psychology of sport and sports injury. Conclusions. Questions exist regarding the efficacy of psychological support in clinical practice. Professional training and application of reflective and evidence based practice principles to this area of clinical practice are strongly recommended. q 2003 Elsevier Science Ltd. All rights reserved. Keywords: Psychological Interventions; Injury; Physiotherapists; Training needs
1. Introduction
1.1. Practitioners’ role in the psychology of athletic injury
Both quantitative and qualitative research has demonstrated that injury can have a profound psychological impact on athletes (Gould et al. 1997a,b; Johnston & Carroll 1998a, b, 2000a,b; Quinn & Fallon 1999; Rose & Jevne 1993; Smith et al. 1993; Udry et al. 1997a,b). Practitioners providing healthcare to elite athletes are best placed to identify these problems and can often be the most influential people in the emotional support of injured athletes (Ford & Gordon 1997; Gordon et al. 1991; Hemmings & Povey 2002; Larson et al. 1996; Wiese & Weise, 1987; Ray & Wiese-Bjornstal, 1999).
Several studies have confirmed that physiotherapists and athletic trainers are acutely aware of the negative psychological impact of injury upon athletes (Ford & Gordon 1997; Hemmings & Povey 2002; Larson et al. 1996; McKenna et al. 2002). Ford & Gordon (1997) reported that physiotherapists in Australia, New Zealand and Canada found negative emotional responses were frequently observed among injured athletes and that non-compliance to the rehabilitation programme was problematic. Larson et al. (1996) reported that 90% of athletic trainers, rated psychological support as relatively or very important in the rehabilitation of an injured athlete, with 47% believing that every athlete they treated presented with some form of psychological issue as a result of their injury. In two recent British studies, Hemmings and Povey (2002) confirmed that more than 90% of physiotherapists surveyed felt athletes
* Corresponding author. E-mail addresses: [email protected] (L.H. Johnston), matt.jevon@ meridiansports.co.uk (S.M. Jevon). 1 Tel.: þ 44-1452-876638; fax: þ 44-1452-876601.
1466-853X/03/$ - see front matter q 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1466-853X(03)00034-8
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
were psychologically affected by injury; while McKenna et al. (2002) noted that physiotherapists treating elite athletes reported reactions ranging from ‘slight setback’ to ‘life has fallen apart’. Despite the recognition that psychological factors can play a substantial role in the rehabilitation of the injured athlete and that psychological skills training could facilitate treatment (Kolt 2000), a number of studies have shown that physiotherapists do not feel adequately equipped to deal with the psychological impact of injury (Ford & Gordon 1997; Gordon et al. 1991; Hemmings & Povey 2002; McKenna et al., 2002). Gordon et al. (1991) reported that 84% of sports physiotherapists in New Zealand and Australia reported limitations in their ability to deal with psychological factors, and 87% would welcome further training in the field. Hemmings & Povey (2002) found that although physiotherapists in the UK reported using a variety of psychological techniques alongside physical treatment they also articulated a need for training in such techniques. McKenna et al. (2002) note that although physiotherapists believed psychological interventions to be outwith their professional competencies, basic interventions were being used. McKenna et al. (2002) further suggest that training in psychological interventions could be included in continuing professional development sessions. An arguably more disturbing finding is that the referral pathway or access to an accredited sport or clinical psychologist may be uncertain. Larson et al. (1996) found that only 24.5% of athletic trainers reported having a sport psychologist available to them. Hemmings and Povey (2002) noted that less that 10% of UK physiotherapists surveyed, had access to a British Association of Sport and Exercise Sciences (BASES) accredited sport psychologist for referral. To date, no previous work in the UK has examined, from a qualitative perspective, the knowledge and attitudes of governing body chartered physiotherapists towards the psychological aspects of rehabilitation, their perceived need for training in psychological interventions, or their access to and ability to refer to a British Psychological Society (BPS) chartered clinical psychologist or BASES accredited sport and exercise psychologist. The aim of the current study is to address these issues.
2. Methodological approach The methodological approach adopted is a constructionist revision (Yardley & Savage 1998 in Johnston et al., 1999: 268) of the Grounded Theory Approach (Glaser & Strauss 1967). The lack of theory and knowledge specific to practitioners working with elite athletes, and the small sample size of UK physiotherapists working with Olympic athletes created a demand for a study that was exploratory in nature, accounting for the methodological paradigm adopted.
75
‘Pure’ Grounded Theory requires the data collection process to drive the research, implying an innocence of the subject matter by the researcher, and an evolutionary process of discovery that is both open ended and unstructured. The richness of data generated by this approach is desirable. However, the practical aspects inherent in working with a geographically disparate population of research participants heavily involved in applied clinical work, prevents the adoption of the original approach proposed by Glaser and Strauss (1967). Further, the purity of the researcher is tainted by experience, previous research and exposure to anecdotal information, both on entry into the research area and throughout the evolution of the study. Strauss and Corbin (1990, 1998) have suggested that Grounded Theory should meet four central criteria: fit, understanding, generality and control. This implies that the evolution of new theories and models utilising this methodology should fit a substantive area that is faithful to the every day reality of that area. It should make sense and be comprehensible to the researcher, participants in the study, and those practicing in the area. It should be general enough that a variety of concepts applicable to the area under consideration are well related to the emergent theory, and the emergent theory should ‘provide control with regard to action toward the phenomenon’. An acknowledgement of the benefits that the researcher’s experience brings to the study, a ‘bracketing’ (Rose & Jevne 1993) of conceptions and values, particularly through the use of a research diary during data collection and analysis, is an essential part of the research process. Yardley and Savage (cited in Johnston et al. 1999: 268) propose that three core strands are intertwined through the constructionist revision of the Grounded Theory process: reflexive, resonant and generative. Resonance is defined as interest, engagement and commitment generated by the broad focus of initial Grounded Theory enquiry. The research methodology should generate self-reflection and co-learning commitments. Reflexive elements encompass the researcher’s own self reflection on decisions made through the research process. Generativity refers to the potential to generate meaningful insights within applied and practical applications. These strands can readily be justified by reference to the inherent values within pure Grounded Theory (Strauss & Corbin 1990, 1998) whilst enhancing the research process through inclusion of the researcher’s interpretive knowledge, albeit controlled through the bracketing process and subjected to audit via memos, diagrams and the research diary. 3. Method of data collection 3.1. Interview guide and demographic survey A semi-structured interview guide was developed, based on the work of Ford and Gordon (1993) and Ford et al.
76
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
Table 1 Interview themes and sample questions
Table 2 Research participants’ age, qualification and experience
Theme
Partici pant
Age
Years experience total since qualification
Years experience working with international athletes
Average contact time per year with elite athletes
Post graduate qualifica tions
Alpha Bravo Charlie Delta Echo Foxtrot Golf Hotel India Juliet Kilo Lima Mother November Oscar Papa Quebec Romeo Sierra
INS INS 38 42 INS 37 59 INS 46 INS 42 INS INS 42 34 42 INS INS INS
INS INS 12 20 17 16 38 INS 25 INS 21 INS INS 16 13 20 INS INS INS
INS INS 5 6 16 4 25 INS 11 INS 12 INS INS 8 6 12 INS INS INS
INS INS 130 days 80 days 5 days 12 days 180 days INS 58 days INS 355 days INS INS 60 days 86 days 38 days INS INS INS
No No Masters Masters Masters No Masters No No No No No No No No No No No No
Sample question
The role of the Can you describe your role as a governing governing body chartered body chartered physiotherapist? physiotherapist What sort of environments/locations do you find yourself working in? Psychological response What positive/negative psychological to injury or emotional responses to injury do you observe? Can you provide some examples of observable signs/symptoms at each stage in rehabilitation? Factors influencing What observations can you make regarding rehabilitation adherence poor/positive attitude towards rehabilitation protocols from the athletes behaviour? What are the main barriers associated with optimal rehabilitation? Return to training/ Can you define what you mean by recovered? competition What are the main challenges in the final stages of recovery? The athlete/physio If an athlete is overly optimistic/pessimistic therapist relationship about their outcome what do you say/do? Are you aware of any psychological interven tion techniques? Can you give examples? The role of other people Can you describe positive/negative during the treatment and experiences with a coach/sport scientist/rest rehabilitation process of team/media/other medical personnel? Other models of Are you aware of models of healthcare for healthcare the physically active in other countries (e.g. USA, Canada, Australia)? What educational standards and clinical /practical experience would you feel is required in such a professional? Preparation for Do you feel that your physiotherapy training current role prepared you fully for your current role? What other steps have you felt it necessary to take to reach your current role?
(1993) (see Table 1). An additional demographic and educational survey was also developed. 3.2. Recruitment of participants and data collection Participants were governing body Chartered Physiotherapists who were members of the British Olympic Association (BOA) Steering Group. This group is composed exclusively of Chartered Physiotherapists who work with Great Britain Olympic athletes. Each prospective participant was contacted by letter and asked to confirm their willingness to participate ðN ¼ 22Þ: Nineteen governing body Chartered Physiotherapists agreed to take part, completed informed consent forms, and were interviewed at various locations throughout the UK. The available demographic information is shown in Table 2. Interview times ranging from 53 to 86 min. Interviews were transcribed verbatim and sent to each participant for
INS, information not supplied.
member checking (Rose & Jevne 1993; Strauss & Corbin 1998). On completion of the transcription, the interviews were edited to provide anonymity for participants, their professional colleagues and clients. Rich Text files were imported into QSR NUD*IST Vivo (N-Vivo) software (Fraser 1999). This programme is designed to assist with the mechanical aspects of text coding, search, retrieval and theoretical modelling (Richards 1999). To ensure anonymity, no demographic details of participating BOA physiotherapists are reported. All references to particular sports have been edited from the results reported. 3.3. Emergence of core data themes Data were coded from the open-ended interview questions according to the principles outlined by Glaser and Strauss (1967). Initially meaning units were coded at ‘nodes’ created in N-Vivo to encapsulate broad themes within the data. Once the theme was borne out by further data, it was transferred into one of a number of relevant sets of nodes. Within these working sets modelling of relationships between data themes (nodes) was examined and further more extensive themes were developed. N-Vivo helps to facilitate the process of axial coding as both source and derived data documents, together with memos and diagrams can be viewed concurrently and compared. Coding was judged to be complete when no new themes or concepts emerged from the data (Glaser & Strauss 1967). This point is referred to as theoretical saturation (Udry et al.
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
1997a). The inductive Grounded Theory process described earlier was instrumental in developing credible themes represented by the data.
4. Results and discussion The emergent themes highlighted a disparity between the participant’s perceived effectiveness and the predicted effectiveness suggested within the existing literature regarding the provision of psychological support to injured athletes. Physiotherapists placed a greater emphasis on vicarious knowledge and experience, whereas the existing literature suggests a combination of formal and vicarious knowledge (Ray & Wiese-Bjornstal, 1999). A range of themes influenced these beliefs. Participants suggested that a number of factors also influence the physiotherapist and athlete independently (influencing factors) and their interaction (athlete/physio interaction). 4.1. Formal training in psychological theory or practice The interviewees described a lack of formal training in psychology theory or practice (undergraduate or diploma), although some physiotherapists who had qualified more recently did report some training in communication skills. The training reported in undergraduate programmes was described as basic and minimal. Postgraduate training in psychology or associated subjects (communication/management, etc.) formed less than five percent of all postgraduate practicum courses taken by the participants. Physiotherapists in the UK keep a continuing professional development record and attend learning and educational events in order to demonstrate that they are remaining current in their knowledge (http://www.csp.org/ lifelonglearning/cpd.cfm). A number of the participants in this study, although governing body Chartered Physiotherapists for Olympic sports, also have additional work commitments requiring appropriate emphasis on continuing professional development not related to sport. Only three of the participants in this study referred to taking practicum courses in sports psychology since qualifying, and none referred to sports psychology training from recognised accrediting bodies such as BASES or the BPS. Only four of the physiotherapists interviewed had a Masters level qualification and details of any psychological components were vague. Thus, conclusions regarding the overall level of formal training in psychology amongst the research participants are difficult to frame in positive terms. Continuing professional development requirements appear to be unclear for practitioners working in elite sport in the UK, this is in contrast to recommendations made for physiotherapists in Australia (Gordon et al. 1998) and to the clear guidelines set out for athletic trainers, the primary health care professional for injured athletes in the USA (http://www.nata.org).
77
The level of formal undergraduate training in psychology appeared to influence participants’ beliefs regarding their abilities in providing psychological support. Those participants who had some level of applied psychological training were more likely to value and use psychological support mechanisms and services. Those without this underpinning theoretical and applied knowledge appeared to underestimate the importance of psychological support from the therapist to the injured athlete, even though they were often providing this in an informal and intuitive format. Other influencing factors included formal postgraduate education/training in psychology, psychological training in professional development, experiences gained from working with a sports psychologist, any counselling training received, personally developed communication and rapport skills, teacher training, and experience in elite sport. 4.2. Vicarious knowledge and experience Participants reported feeling that the majority of their knowledge and skills regarding the psychological aspects of injury were developed through clinical practice. Further, the belief that the clinical experiences gave them an ability to support the athlete emotionally was consistent across all participants. Despite an acknowledged lack of formal knowledge of psychological skills, most participants felt able, particularly with experience and a long association with a group of athletes, to interpret an athletes psychological reaction to injury and to provide appropriate emotional, social and informational support: ‘…but we as physiotherapists end up doing quite a lot of sort of (pause), what do you call it, amateur psychology in that, you know, we’re sort of, (pause), there to listen to (the athlete) and deal with (their) emotions, etc.’ The following quote from a physiotherapist without formal training in psychology typifies the more intuitive approach: ‘I am mostly aware of some psychology technique but I mean I’m not claiming to be a psychologist and I, you know, I don’t think I really use any particular techniques’. Only one of the research participants described a formal goal setting process used with the athletes, and one other described combining physiotherapy skills in massage with relaxation. Without exception, all the participants described using some form of goal setting, though often with a didactic rather than a shared ownership approach. Other than goal setting and relaxation, visualisation was the only other intervention reported: Well certainly the goal setting. And I suppose sometimes the relaxation but if so that would be because somebody’s getting massively hyper immediately post injury, you know what I mean, I’d just want them to calm down. (Pause) the imagery and the visualisation I would know about it if they wanted to talk about it (pause), but I wouldn’t want to start teaching anybody in the first place really. (Pause), not my profession, you know and I’m
78
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
more frightened about what I could, could be imagining anything here. So if they had some insight into it and I might say well you know you might consider just thinking through the skills and doing it that way…I’d probably do that but I wouldn’t start anybody from scratch. None of the participants reported any counselling training or experience. Knowledge of counselling skills and techniques appeared to be limited and practitioner effectiveness was reported to be a function of the practitioners’ knowledge of the athlete, personal factors of the physiotherapist (good listener, sympathetic, experience in sport) and length of experience as opposed to formal training. However, many of the interviewees acknowledged a counselling role, particularly on an informal basis: This is, I think this is back to the sort of counselling realism and timings for them and, you know, this is what you have to do…I never sort of ask people directly what they, what they feel they’re, the outcome is going to be but I think you always listen to the way people are talking about their injury and say oh hang on a minute you know that, that’s, you know that’s not necessary the case. You can do that or no you can’t do that, and no you won’t be able to do that so its, its just bringing, either drawing people in or pushing them along a little bit No other interventions or psychological techniques were formally described although informally a wide variety of techniques were reported including dissociative strategies for pain management, healing imagery, reflective listening skills and social support. In light of the importance of counselling skills to effect an effective interaction between the athlete and practitioner (Flint 1998; Ray & Wiese-Bjornstal, 1999; Smith et al. 1990) this is an area that may require considerable development. Participants reported that they found it difficult to separate good communication skills from providing emotional or psychological support. In a recent study examining physiotherapists’ and athletes’ views regarding psychological skills for rehabilitation, Francis et al. (2000) found good communication skills to be the highest related construct by both athletes and practitioners. However, Francis et al. (2000) focussed specifically on the communication methods as opposed to the interaction between athlete and practitioner. Practitioners in the current study were unable to describe their use of psychological interventions, or to describe any practice in this area in psychological terms. This is consistent with Francis et al. (2000) who postulated that lack of application of psychological interventions stemmed from a lack of knowledge of underpinning theory and therefore application and use. A review of publications aimed at developing excellence in practice for the sports medicine practitioner (Arnheim &
Prentice 1997; Flint 1998; Ray & Wiese-Bjornstal, 1999; Taylor & Taylor 1997) establishes consensus in the importance of using a variety of psychological intervention techniques. A lack of understanding of these issues may well negatively impact upon clinical practice and effective treatment (Myers & Midence 1998). Use of psychological interventions within an appropriate framework, underpinned by a theoretical knowledge base, is held as an exemplar of best practice, and is included in the competencies for USA trained Certified Athletic Trainers (http:// www.nata.org) and UK educated BASRaT Certified Sports Rehabilitators and Certified Sports Trainers (http://www. basrat.org). 4.3. Athlete/physiotherapist interaction Participants described a number of factors that influenced the quality of the relationship between the athlete and physiotherapist. Participants reported that successful treatment was based on effective communication with the athlete, adherence by the athlete to treatment and rehabilitation work, and the ability of the physiotherapist to engender confidence in the athlete. In particular, the ability of the physiotherapist to determine whether an athlete is covering up ‘impression management’ (Leary 1995) or being honest in their emotional reactions was essential. Individual analysis of athletes’ psychological and emotional responses to injury appeared to guide the physiotherapist’s subsequent action in treatment and rehabilitation. Without exception, all participants described using implicit psychological skills or interventions, even if they did not perceive themselves as having a formal role: ‘we’re physiotherapists, yes we use psychology in our job because we have to, but we’re not trained psychologists.’ and: ‘… the problem with say elite athletes is your (psychological) role is never defined in that you’re just going to be doing that, because you find yourself doing a lot of other things.’ Participants reported that this was a part of their ‘bedside manner’ and that the roles they assumed were a vital aspect of their practice, even if they themselves did not label these roles as psychological: I think any time that we (pause) end up in open discussion with the athlete about their injury from the type of thing that you’re talking about, we are involved psychologically so there’s always got, we’ve always got to be positive, realistic and setting goals, timescales and things like that. But again we’ve got to be careful we don’t move outside our remit. Participants that implicitly provided psychological support to athletes were least likely to acknowledge a formal role for physiotherapists in such provision. Those with more formal knowledge reported that they felt they had an awareness of professional boundaries, had a formal role and responsibility to provide psychological support and were
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
more likely to have access to a named psychologist to whom they could make a referral. All participants articulated a willingness to refer, although only three physiotherapists said that they had ever done so formally. Only five participants stated that they had a named sports or clinical psychologist to whom they would refer. One participant described strict criteria regarding the characteristics of an appropriate psychologist for referral. This included the need for sports specific knowledge, a personality match of the psychologist with the athlete, and practical as opposed to academic credibility. Interestingly, practitioners stated that they wanted to maintain a professional separation between their roles and the role of the psychologist, and despite much of the literature pointing to the importance of the practitioner providing this type of support (Flint 1998; Kolt 2000; Taylor & Taylor 1997), they reported an unwillingness to do so. McKenna et al. (2002) also noted that although physiotherapists working with elite athletes recognise the need for psychological interventions and implicitly deliver foundation level support, they do not view the delivery of psychological interventions as part of their remit. The results of the current study therefore demonstrate that a conflict was created within many practitioners regarding appropriate boundaries and role assumptions. Practitioners appear to be struggling between the roles they are assuming on an informal basis (e.g. emotional support) their acknowledgement of the importance of effective communication skills and a good ‘bedside manner’, and the desire to avoid extending beyond self interpreted professional boundaries. Much of this conflict may be engendered within terminological difficulties, caused by lack of underpinning knowledge, rather than a genuine unwillingness to assume this role. Further, this perceived conflict regarding the use of psychological techniques in the rehabilitation of elite athletes might account for the lack of demand for postgraduate training in the psychological aspects of injury. 4.4. Influencing factors Participants identified a number of factors that they felt had an influence on the athletes’ psychological response to the injury. In addition, they reported that these factors had an impact upon the practitioner, resulting in an indirect impact on the quality of the athlete/physiotherapist interaction. Practitioners stated that they were often asked to work in different environments, including hotel bedrooms, changing rooms, track or pitch side, and custom designed well-equipped facilities. Many insisted that the different physical environments did not affect their treatment of the athlete; however, they did emphasise the need to create a professional setting for treatment. Claims of practical achievement by the practitioner in negating the effects of the environment are difficult to understand in the light of lack of facilities and equipment, restrictions placed
79
on clinical practice and drug use in other countries and the difficulties described by the practitioners in creating appropriate treatment settings. The venue does (affect the athletes psychological response). In so far as what competition is on, so if it’s a world cup competition, an important one, then yes they, they certainly do get a lot more em pissed off about it all if it happens there. If it’s a minor event they’re not too, too bothered because they’ll focus, they’ll focus at different times in the season and different events so they’ll have their three or four key events that they must do and as part of that if they miss out on one lesser event it doesn’t bother them too much so I mean if I’m out there and it happens to be leading up to a key event which is usually when I do go out there, then an injury then is pretty traumatic for them. Practitioners also described the effects of differences between sports cultures and the psychological reaction of the athlete to injury. In some sports, particularly endurance sports, where a high level of athlete body awareness was reported, an injury was an immediate issue, requiring attention and seen as a critical threat to preparation, training and competition. In other sports with a power or contact base, injuries were accepted as an inevitable fact of life and viewed as something to be managed, not as an immediate barrier to competition. These cultural variations produced responses that were perceived as reasonably predictable and stable by the practitioners. Practitioners with a participation background in the sport in which they worked reported that cultural understanding was important in allowing them to cope well with athletes’ reactions to injury. Some practitioners described departures from these cultural expectations in situations where the athlete was no longer under the direct influence of team members, management or significant others and no longer had to ‘put a brave face on it’. In these instances the practitioners described individual differences within the reactions, suggesting that within sports environments practitioners need to be aware of the influence of peer and sports culture on the athlete. Practitioners working in particular sports may need to be aware of the culture of a particular sport, but should be wary of discounting individual differences and preferences by making predictions about athlete response based on cultural factors. Athletes may well ‘impression manage’ (Leary 1992) in public groups but in reality their psychological response may be influenced more by individual differences, environmental, and situational factors (Wiese-Bjornstal et al. 1998). Participants suggested that the proximity of and the importance of competition also had a significant and predictable effect on the athletes’ responses and the resultant stress on the practitioner.
80
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
…the ones that have been really negative have tended to, its either been because they think its put them, or its going to put them out of a major event, (pause) or, I mean even if that major event is selection (pause) but most of them, that’s where I hope you know just sit down and you talk with them long enough you should at least be able to talk them round. But yes, you know, and you can you can understand why as well really. The ability of the practitioner to spend time with the athlete, and the nature of the communication established was viewed as essential to this process, and is consistent with research in the psychology of injury (Heil 1993; Flint 1998; Rungapadiachy 1999; Taylor & Taylor 1997). Physiotherapists who described the provision of psychological support as part of their role tended to deliver this in a reactive way, i.e. when athletes presented with such serious emotional issues or problems that the need for intervention was obvious. None of the practitioners had any method of undertaking any psychological needs analysis with the injured athlete. The participants suggested that injured athletes, for a number of reasons, including environment, competition valency and nature of interaction with the practitioner, tend to ‘impression manage’ (Leary 1992) in the interaction between themselves and the practitioner. This tendency to impression manage by the athlete, possibly heavily influenced by culture and timing of competitions, may well be difficult for the practitioner to both recognise and overcome. Therefore without appropriate needs analysis techniques and underlying training, practitioners may well only surface treat the image or impression the athlete wishes to project and may miss more serious psychological needs and thereby not provide appropriate support or onward referral.
5. Conclusions and recommendations Current knowledge and practice by governing body Chartered Physiotherapists in providing support to elite athletes regarding psychological issues associated with injury could benefit from further in service training. The educational and professional gaps in practice may well impact negatively on effective clinical application. Substantial work is needed to identify and express an appropriate role in this area and to support that role with high quality education and professional development. In the context of criteria proposed by Sackett et al. (1996); Greenhalgh (1996), and by reference to the physiotherapy evidence based healthcare model reported in Bury & Mead (1998), none of the participants in the current study reported knowledge of or adoption of an evidence based approach to practice in psychological aspects of injury to elite athletes. The need to adopt an evidence based approach may have been moderated by
the perceptions of the majority of the physiotherapists in the current study, who felt that they did not have a formal role in the provision of psychological support, in contrast to the informal role so often assumed. Greenhalgh (1996); Bury and Mead (1998) emphasise the importance of reflection as a critical part of evidence based practice. McKenna et al. (2002) noted that physiotherapists who described practicing ‘real physiotherapy’ when treating elite athletes, were ‘motivated by learning’ and that their understanding of treatment was developed through reflective practice. Whilst practitioners in the current study certainly have the capacity and ability to be highly reflective, and have garnered high levels of experiential learning, these are not placed within a continuous improvement or applied framework of reflective practice. The results of this study and from the existing literature (e.g. Francis et al. 2000; Larson et al. 1996) have shown that there is a vital and important role for the sports medicine practitioner in the psychological support provided to injured athletes. Whilst conflict exists regarding the exact nature and depth of this role, practitioners are assuming responsibility for its provision, even if not self-acknowledging this. The current study raises a number of suggestions for further research. First, there is a need to triangulate the perceptions of the BOA Chartered Physiotherapist regarding their role in the psychological support of injured elite athletes with the perspective of the injured athletes themselves, physicians and other members of the athlete support team (e.g. BASES and BOA accredited sport psychologists and BPS chartered clinical psychologists). Second, there are now a number of allied healthcare professions in the UK, including BASRaT Certified Sports Trainers and Graduate Sports Rehabilitators, as well as USA trained Certified Athletic Trainers. It would be interesting to conduct similar research with such groups and to note any differences in practice. The influence of the environment on both athlete and practitioner remains largely unexplored at elite level. Many of the participants in this study intimated that the variety of environments in which they worked affected both the athlete and themselves. Of further interest are some of the additional emergent themes within this study pertaining to the actual psychological reactions of elite athletes to injury, differences observed between acute and chronic injuries, the influence of sports cultures, social support, practitioner interaction, and practitioners’ own psychological coping skills and stressors. Professional development, recognising the implicit knowledge and addressing the lack of formal knowledge, is required, generally in psychology of sport and specifically in the psychology of sports injury in elite athletes. As practitioners move from a broad base engendered by traditional physiotherapy training, development of psychological knowledge must be given a priority. It should follow a developmental pathway that will allow the practitioner to
S.M. Jevon, L.H. Johnston / Physical Therapy in Sport 4 (2003) 74–81
ground their practice and experiences within an applied framework supported by theory. This continuing professional development should lead into a clearly expressed role, with appropriate support structures and referral pathways for practitioners. Finally, the professional development programme should be subject to an objective assessment procedure that measures both formal knowledge and the ability to apply that knowledge in an environment that reflects societal demands for evidence based and reflective practice.
References Arnheim, D.D., Prentice, W.E., 1997. Principles of athletic training, Ninth ed., Brown and Benchmark, Madison. Bury, T.J., Mead, J.M. (Eds.), 1998. Evidence-based healthcare: a practical guide for therapists, Butterworth-Heinemann, Oxford. Flint, F.A., 1998. Integrating sport psychology and sports medicine in research: the Dilemmas. Journal of Applied Sport Psychology 10 (1), 83–102. Ford, I.W., Gordon, S., 1993. Social support and athletic injury: the perspective of sport physiotherapists. The Australian Journal of Science and Medicine in Sport, 17 –25. Ford, I.W., Gordon, S., 1997. Perspectives of sport physiotherapist on the frequency and significant of psychological factors in professional practice: implications for curriculum design in professional training. The Australian Journal of Science and Medicine in Sport 29 (2), 34–40. Ford, I.W., Gordon, S., Horsley, C., 1993. Providing social support for injured athletes: the perspective of elite coaches. Sports Coach, 13–19. Francis, S.R., Anderson, M.B., Maley, P., 2000. Physiotherapists’ and male professional athletes’ views of psychological skills for rehabilitation. Journal of Science and Medicine in Sport 3, 17– 29. Fraser, D., 1999. QSR NUDpIST Vivo: Reference Guide, Qualitative Solutions and Research Pty. Ltd, Melbourne, Australia. Glaser, B., Strauss, A., 1967. The Discovery of Grounded Theory, Aldine, Chicago, IL. Gordon, S., Milios, D., Grove, J.R., 1991. Psychological aspect of the recovery process from sport injury: the perspective of the sport physiotherapist. The Australian Journal of Science and Medicine in Sport 23 (2), 53–60. Gordon, S., Potter, M., Ford, I.W., 1998. Toward a psychoeducational education for training sport injury rehabilitation personnel. Journal of Applied Sport Psychology 10, 140 –156. Gould, D., Udry, E., Bridges, D., Beck, L., 1997a. Coping with seasonending injuries. The Sport Psychologist 11, 379 –399. Gould, D., Udry, E., Bridges, D., Beck, L., 1997b. How to help elite athletes cope psychologically with season-ending injuries. Athletic Therapy Today 2 (4), 50 –53. Greenhalgh, T., 1996. Is my practice evidence-based? British Medical Journal 313, 656–657. Heil, J. (Ed.), 1993. The Psychology of Sport Injury, Human Kinetics, Champaign, IL. Hemmings, B., Povey, L., 2002. Views of chartered physiotherapists on the psychological content of their practice: a preliminary study in the United Kingdom. British Journal of Sports Medicine 31 (1), 61–64. Johnston, L.H., Carroll, D., 1998a. The context of emotional response to athletic injury: a qualitative analysis. Journal of Sport Rehabilitation 7, 206–220. Johnston, L.H., Carroll, D., 1998b. The provision of social support to injured athletes: a qualitive analysis. Journal of Sport Rehabilitation 7, 267–284.
81
Johnston, L.H., Carroll, D., 2000a. The Psychological impact of injury: effects of prior sport and exercise involvement. British Journal of Sports Medicine 34 (6), 436–439. Johnston, L.H., Carroll, D., 2000b. Coping, social support, and injury: changes over time and the effects of level of sports involvement. Journal of Sport Rehabilitation 9 (4), 290–303. Johnston, L.H., Corban, R.M., Clarke, P., 1999. Multi-method approaches to the investigation of adherence issues within sport and exercise: qualitative and quantitative techniques. In: Bull, S.J., (Ed.), Adherence Issues in Sport and Exercise, Wiley, Chichester, pp. 263–288. Kolt, G.S., 2000. Doing sport psychology with injured athletes. In: Andersen, M.B., (Ed.), Doing Sport Psychology, Human Kinetics, Champaign, IL, pp. 223 –236. Larson, G.A., Starkey, C., Zaichkowsky, L.D., 1996. Psychological aspects of athletic injuries as perceived by athletic trainers. The Sport Psychologist 10, 37–47. Leary, M.R., 1992. Self-presentational processes in exercise and sport. Journal of Sport and Exercise Psychology 14, 339 –351. Leary, M.R., 1995. Self-presentation: Impression Management and Interpersonal Behavior, Westview Press, Boulder, CO. McKenna, J., Delaney, H., Phillips, S., 2002. Physiotherapists’ lived experience of rehabilitating elite athletes. Physical Therapy in Sport 3 (2), 66–78. Myers, L.B., Midence, K. (Eds.), 1998. Adherence to Treatment in Medical Conditions, Harwood Academic Publishers, Amsterdam, The Netherlands. Quinn, A.M., Fallon, B.J., 1999. The changes in psychological characteristics and reactions of elite athletes from injury onset until full recovery. Journal of Applied Sport Psychology 10, 210– 229. Ray, R., Wiese-Bjornstal, D.M. (Eds.), 1999. Counselling in Sports Medicine, Human Kinetics, Champaign, IL. Richards, L., 1999. Using Nvivo in Qualitative Research, Qualitative Solutions and Research, Melbourne, Australia. Rose, J., Jevne, R.F.J., 1993. Psychological processes associated with athletic injuries. The Sport Psychologist 7, 309 –328. Rungapadiachy, M., 1999. Interpersonal Communication and Psychology for Health Care Professionals: Theory and Practice, ButterworthHeinemannn, Oxford. Sackett, D.L., Rosenberg, W.M.C., Gray, J.A.M., 1996. Evidence-based medicine: what it is and what it isn’t. British Medical Journal 312, 71– 72. Smith, A.M., Scott, S.G., Wiese, D.M., 1990. The psychological effects of sports injuries: coping. Sports Medicine 9, 352– 369. Smith, A.M., Stuart, M.J., Wiese-Bjornstal, D.M., Milliner, E.K., O’Fallon, W.M., Crowson, C.S., 1993. Competitive athletes: pre-injury and postinjury mood state and self-esteem. Mayo Clinic Proceedings 68, 939– 947. Strauss, A., Corbin, J., 1990. Basics of Qualitative Research: Grounded Theory Procedures and Techniques, Sage, London. Strauss, A., Corbin, J., 1998. Basics of qualitative research: techniques and procedures for developing grounded theory, Second ed., Sage, London. Taylor, J., Taylor, S., 1997. Psychological Approaches to Sports Injury Rehabilitation, Aspen, Gaithersburg. Udry, E., Gould, D., Bridges, D., Tuffey, S., 1997a. People helping people? Examining the social ties of athletes coping with burnout and injury stress. Journal of Sport and Exercise Psychology 19, 368–395. Udry, E., Gould, D., Bridges, D., Beck, L., 1997b. Down but not out: athletic responses to season ending injuries. Journal of Sport and Exercise Psychology 19, 229–248. Wiese, D.M., Weise, M.R., 1987. Psychological rehabilitation and physical injury: implications for the sport medicine team. The Sport Psychologist 1 (4), 318 –330. Wiese-Bjornstal, D.M., Smith, A.M., Shaffer, S.M., Morrey, M.A., 1998. An integrated model of response to sport injury: psychological and sociological dynamics. Journal of Applied Sport Psychology 1, 46– 69.