Patient Satisfaction with Management of Back Pain Main

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Key Words Back pain, patient satisfaction, qualitative study, physiotherapy.

Patient Satisfaction with Management of Back Pain

by Stephen J May

Part 1: What Is Satisfaction? Review of satisfaction with medical management Summary This paper introduces readers to certain aspects of satisfaction. It reviews the reasons why patient satisfaction is important as an outcome, even though there is continuing debate about what exactly satisfaction represents. The best way to obtain information on what patients consider important is through the use of qualitative study designs. Previous research has found that significant dimensions of satisfaction relate to outcome, organisational issues, and interaction with health professionals. The key dimensions specific to back pain patients relate to information provision, empathy, and promoting self-care.

description of the aspects of care which patients, when interviewed, considered important in an episode of physiotherapy for low back pain. This section highlights some of the significant issues from the literature concerning satisfaction: ■ Why is satisfaction important? ■ What is satisfaction? ■ What do we know about satisfaction

that is relevant to this area?

May, S J (2000). ‘Patient satisfaction with management of back pain. Part 1: What is satisfaction? Review of satisfaction with medical management. Part 2: An explorative, qualitative study into patients’ satisfaction with physiotherapy’, Physiotherapy, 87, 1, 4-20.

Introduction Over the last few decades there has been a growing trend to investigate the views of health ser vice users. The degree of patient satisfaction is seen as a reflection of the quality of care, and as a worth-while outcome in its own right. The means of attaining users’ views is not straightfor ward, however. If patients simply tick boxes on questionnaires which have been designed by clinicians, are we truly getting patients’ opinions about their care? To know what users consider important in any aspect of the health service they must be asked directly. In this way the range of dimensions that are key to patients in their interaction with healthcare professionals can be mapped. Little work has been done to explore patient opinions about physiotherapy -Pound et al (1994) is a rare example -- or to explore the views of low back pain patients about their condition or their treatment in the UK. This is the first section of a two-part article which considers issues of patient satisfaction with physiotherapy care for low back pain. It introduces theoretical concerns relating to why we should ask about satisfaction and what it is, and also reviews what is already known about satisfaction with management of back pain. The second part presents a

Physiotherapy January 2001/vol 87/no 1

Satisfaction as an Outcome Measure Satisfaction is seen as an important outcome measure in its own right, being a reflection of the quality of healthcare (Fitzpatrick, 1990, 1997; Linder-Pelz, 1982). Concern for users’ views of the National Health Service (NHS) has been encouraged by several government reports in the last few decades (DHSS, 1984; DoH, 1989, 1997). Within these reports there has been criticism of the NHS for failing to obtain and act upon feedback from the users, and with the criticism has come a strong climate of opinion which seeks patient involvement in assessing the quality of healthcare (Fitzpatrick, 1997; Avis, 1997; Williams, 1994). There are suggestions that patient satisfaction has a significant effect on other important outcomes of healthcare (Fitzpatrick, 1990, 1997; Linder-Pelz, 1982). Various studies have shown it may have a role in predicting compliance with medical advice (Fitzpatrick and Hopkins, 1981; Stewart, 1984), re-attendance for further care (Orton et al, 1991), and even improvements in health status (Fitzpatrick et al, 1983). It is difficult to conceive of an effective method of judging many aspects of care without the perspective of the users

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(Fitzpatrick, 1990). Satisfaction is one way of assessing communication and information-giving between clinicians and patients. It is an area in which patients frequently express dissatisfaction with the inadequate provision of information (Savage and Armstrong, 1990; Locker and Dunt, 1978; Larsen and Rootman, 1976; Hall and Dornan, 1988). Finally, it is proposed that in the circumstances of chronic and on-going health problems, patients must be actively involved in the treatment process and not passive recipients of care (Boreham and Gibson, 1978; Brady, 1998); thus their satisfaction with this process is important to success. The epidemiological picture of back pain (Croft et al, 1997) is such that it should be seen as an on-going health problem that can intrude into people’s lives over long periods or with tiresome regularity. In recognition of this, recent guidelines for the management of back pain urge patient responsibility and self-management (Rosen, 1994). Clearly any attempt to achieve this has to be acceptable and convincing to patients. Collecting Data on Patient Satisfaction Patients’ views of quality may differ from those of clinicians and thus patients should define their own priorities and assessment criteria (Locker and Dunt, 1978). If the tool constructed to measure satisfaction is defined by clinicians rather than being framed in patients’ own terms the end result may be distorted. It may simply reflect the measuring tool rather than reflecting patients’ true concerns (Williams, 1994). In general, reports of overall satisfaction are high, frequently over 90% (Williams, 1994). However, poorly generated questionnaires may simply provide the illusion of user involvement by allowing respondents to express themselves, but in alien terms (Williams, 1994; Avis, 1997). In most studies concerning patient satisfaction their judgements were rarely used to construct the dimensions investigated (Hall and Dornan, 1988; Wensing et al, 1994), and generally it is the researchers who decide which aspects of care are to be included (Wensing et al, 1994). In a field in which no work has been done in elucidating patients’ concerns, the first task of research is thus to identify the ways that patients perceive healthcare and the terms in which they evaluate it,

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and whether some evaluate it at all (Williams, 1994). In order to discover this perspective on healthcare the use of qualitative research methods to access patients’ views is deemed essential (Avis, 1997). The interview is a more sensitive and flexible data-gathering tool than standardised questionnaires for ascertaining patients’ concerns (Fitzpatrick, 1991, 1997). Dimensions of Satisfaction It is clear from the literature that patients have opinions about satisfaction relating to different aspects of the healthcare process. Researchers have identified ten different dimensions of patient satisfaction besides an overall quality rating (Fitzpatrick, 1991; Linder-Pelz, 1982; Hall and Dornan, 1988; Ware et al, 1983): ■ Competence ■ Outcome ■ Humaneness ■ Informativeness ■ Attention to psychological problems ■ Continuity of care ■ Access/convenience ■ Facilities/surroundings ■ Cost ■ Bureaucracy

These aspects can be seen to reflect three key areas – clinical outcome relationships with professionals, and bureaucratic and environmental issues (Wensing et al, 1994; Gray, 1997). Thus satisfaction does not relate to a single aspect of care, but must reflect the multidimensional concerns that patients appear to have during an episode of healthcare.

Author Stephen J May MCSP DipMDT MSc is a senior physiotherapist, outpatients, at Walton Hospital, Chesterfield. This article was received on April 23, 1999, and accepted on June 27, 2000. Address for Correspondence Mr S J May, 219 Cemetery Road, Sheffield S11 8FQ. Acknowledgements This work was undertaken as part of an MSc in Health Services Research at Sheffield University. I would like to thank Ms Donna Luff for her numerous comments during the preparation of this work, and the assistance given to me by the North Derbyshire Clinical Audit and Research Team.

What is Satisfaction? It has been proposed that satisfaction is determined by comparison with existing perceptions and attitudes, and thus that expectations prior to service use are a vital aspect of ultimate satisfaction (LinderPelz, 1982). The role of this ‘expectancy theory’ in patient satisfaction has however been challenged as lacking empirical evidence (Williams, 1994). Patients may not always have clear expectations of a complex process of healthcare, or expectations may be fluid over time. Physiotherapy January 2001/vol 87/no 1

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Furthermore, satisfaction may simply reflect passive acceptance, rather than be the result of active evaluation (Williams, 1994; Avis, 1997). Although the theoretical basis of what patient satisfaction represents is still controversial, it is thought to include cognitive evaluations and emotional reactions to their care (Fitzpatrick, 1997; Baker, 1997). Baker (1997) has proposed a pragmatic model of patient satisfaction in general practice involving the following components: ■ An evaluative judgement or reaction to

care. ■ A continuous, not dichotomous

variable. ■ Multidimensional -- thus a measure of

general satisfaction may be insensitive to different aspects of care, and different patients may have different priorities. ■ Variety in different clinical settings. ■ Patient characteristics may influence

priorities and attitudes. ■ Satisfaction can influence subsequent

health behaviour. ■ Requirements for personal care.

Patient Satisfaction with Treatment for Low Back Pain Several studies in the United States have looked at patient satisfaction with medical management of low back pain (see table 1 for further details of studies mentioned in this section). Greenfield et al (1975) used satisfaction as one outcome measure when comparing nurse and physician management of back pain. Questions were posed that addressed overall satisfaction, empathy and understanding towards the patient, information, time, the clinician, and seeking other care. No details are given as to how this list was generated; it must be assumed it was designed for the study by the researchers. Dissatisfaction was most common concerning the information that had been given to patients. Deyo and Diehl (1986) based their satisfaction scale on the same list – patients were read nine statements and asked about their degree of satisfaction relevant to the different items. The most frequently cited area of dissatisfaction was an inadequate explanation of the Physiotherapy January 2001/vol 87/no 1

problem and poor understanding of what was wrong. They also had concerns about empathy from the clinicians, time spent with them and continuity of care. Across all these issues dissatisfaction was recorded in a minority of patients (less than 25%). It was also found that higher levels of satisfaction correlated moderately with medical compliance, self-rated improvement, and reduced desire for additional diagnostic tests. A satisfaction questionnaire was generated for a comparative evaluation of physician and chiropractor care for back pain patients (Cherkin and MacCornack, 1989). Thirty-two patients were invited to attend a focus group, and 20 agreed to participate. Information provision, belief in the reality of the patients’ pain, and showing of concern were the most notable findings. However, further details about the focus group discussion were not given, and the questionnaire was designed with input from the professionals involved. In a later study (Cherkin et al, 1991) the issues from the questionnaire were then used to construct and validate a patient satisfaction scale. Patients were read 17 statements about their care and asked about their level of agreement or disagreement. Factor analysis of their responses was used to construct key dimensions of patient satisfaction. Three distinct dimensions of care were identified from 10 of the statements – information, caring, and effectiveness. Studies from the United States have also looked at different providers of back care and shown that patients have preferences for certain management styles, especially those which encourage greater self-care, give them a better understanding of their problem, and show more empathy (von Korff et al, 1994; Overman et al, 1988). A physician management style that involved more bed rest and use of drug therapy compared to one that encouraged more self-care generated less satisfaction relative to the quality of information received, though the quality of medical care was deemed to be similar (von Korff et al, 1994). When management by physicians and physical therapists was compared, the latter produced considerably more satisfaction in the interest they showed in patients, time waiting and time with the clinician, and understanding of questions

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Table 1: Findings from previous studies concerning patient satisfaction with management of low back pain Reference

No of patients Country

Role of satisfaction in study design

Method of inquiry into satisfaction

Key findings relevant to satisfaction

Limitations of study for physiotherapy

Greenfield et al (1975)

419 USA

Satisfaction used as part of Nine questions assessment of nurse asked in telephone managementof back pain follow-up compared to physician

Dimensions included empathy, understanding, information, time, overall satisfaction, other care. Satisfaction not always related to outcome

List generated by researchers, no patient input. Medical management

Deyo et al (1986)

140 USA

Construction and validation of satisfaction scale, and correlation with other outcomes

Nine questions asked at follow-up (taken from Greenfield et al, 1975)

Same dimensions as above. Dissatisfaction especially related to information. Some association between satisfaction and compliance, outcome, and reduced wish for diagnostic tests

List generated by researchers, no patient input. Items generalised, not enough detail. Medical management

Fitzpatrick et al (1987)

72 England

Patient expectations before treatment, and satisfaction with these aspects after treatment

Asked about 15 aspects of management, plus satisfaction questionnaire

Main aspects of subsequent dissatisfaction: physiotherapy, personal worries, prognosis, investigations. Satisfaction common in those with persistent problems

Aspects of management selected by researchers. Medical management

Overman et al (1988)

106 USA

Satisfaction used as one outcome measure in comparison of physical therapist and physician as first-contact carer

Telephone follow-up using non-back pain model for questions

Physiotherapist preferred for interest shown, time spent waiting and questions being understood. Levels of very satisfied with physiotherapist 49%, physician 25%

Not exploring satisfaction. Dimensions not specific to back pain

Cherkin 705 USA and MacCornack (1989)

Satisfaction with aspects of care used as outcome measure in comparison of physicians and chiropractors

Satisfaction questionnaire designed from focus group with 20 patients and professional input

Key dimensions: Information, belief in reality of patient’s pain, concern. Statistically significant differences between providers across most dimensions

Findings from focus group not presented. Medical and chiropractor management

Cherkin et al (1991)

305 USA

Construction and validation 17 statements read Three distinct dimensions of care: Medical management. of satisfaction scale to patients Information, caring, effectiveness Items generalised, (part of larger study) not detailed

Bush et al (1993)

270 USA

Satisfaction rating relative to confidence of physician in treating back pain

Cherkin (1981) satisfaction scale used

Attitude of physican not related to satisfaction. Greater confidence of physician related to satisfaction with information

Medical management. Not exploring satisfaction

von Korff et al (1994)

911 USA

Satisfaction and other outcomes relative to different physician management styles

Patients asked about quality of medical care and patient education

Physicians with management style involving more bed rest and higher prescription rates generated less satisfaction with quality of education, poorer short-term outcomes and greater cost

Medical management. Not exploring satisfaction

Borkan et al (1995)

76 Israel

Qualitative study to gain understanding of patients’ perceptions, beliefs and experience of back pain

Focus groups, interviews and participant observation

General dissatisfaction with physicians – approach seen to be superficial and delegitimating patients’ suffering. Greater satisfaction with non-orthodox practitioners seen as more knowledgeable and effective

Not directly addressing dimensions of satisfaction

Skelton et al (1996)

52 England

Qualitative study to gain Semi-structured patients’ views about back interviews pain and its management in general practice

Only 20 patients satisfied by explanation about back pain and 22 satisfied with medical management. Dissatisfaction related to poor explanation, lack of skills, time or facilities

Medical management. Not directly addressing dimensions of satisfaction

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asked (Overman et al, 1988). However, the overall number of patients who were ‘very satisfied’ was low in both groups – 42% of those seeing therapists and 32% of those seeing physicians. Patients who had attended chiropractors were three times as likely as patients who had attended family physicians to report that they were very satisfied with the care they had received (Cherkin and MacCornack, 1989). There were statistically significant differences in satisfaction between the two provider types regarding information, prognosis, advice on self-care, time, the concern of the professional, and the professional’s confidence about treatment and diagnosis. Self-reported disability was also significantly greater in the physicianpatient group after treatment. More confident medical providers of care, compared to those who were less confident about back pain management, produced greater satisfaction with the information patients had received (Bush et al, 1993). Fitzpatrick et al (1987) followed 72 patients through a rheumatological back pain clinic in the UK, enquiring beforehand which aspects of the visit were important in terms of their expectations, and afterwards with which aspects they actually were satisfied. Over 50% expected information about back care (how to avoid strain, advice on posture and daily activities, and recommendations to rest), about prognosis, and about the reason for and details of any investigations. They also expected physiotherapy and discussion about personal worries. About threequarters of the patients recorded a decrease in disability following the intervention, and satisfaction ratings were high on most items. However, on five aspects of care some 30% of the patients expressed dissatisfaction. These related to discussion about prognosis and personal worries, the reasons for tests, and the provision of physiotherapy and further investigations. Dissatisfaction with these issues arose either because patients were not provided with these services; or if they were, they experienced them as unsatisfactory. When patients have been interviewed in more depth using qualitative research methods (Skelton et al, 1996; Borkan et al, 1995) similar concerns about the inadequacy of information provision, and Physiotherapy January 2001/vol 87/no 1

dissatisfaction with conventional medical management have been voiced. Conventional medical practitioners were seen as being superficial in terms of their understanding, assessment and treatment, whereas non-orthodox carers were perceived to be more knowledgeable, to have better diagnostic skills within the logic of their system, to be more empathetic, and to be more effective in treatment (Borkan et al, 1995). These studies also show that patients have a multi-dimensional perspective on back pain which considers the impact of the problem on their lifestyle, explanatory models of the pain, expectations about prognosis, varying degrees of commitment to secondary prevention, and varying degrees of willingness to seek allopathic or alternative health care (Skelton et al, 1996; Borkan et al, 1995). In summary, studies that have addressed the issue of patient satisfaction with management of back pain largely relate to medical care. Most of these studies have been conducted in the USA. The findings of these studies are not necessarily transferable to physiotherapy in the UK. The researchers involved have, on the whole, constructed the dimensions that patients have been asked about. No preliminary qualitative work has been done to explore the range of the phenomenon from the patients’ perspective, with the exception of the focus group in the study by Cherkin and MacCormack (1989). Unfortunately the full findings from these discussions are not presented. The final questionnaire also used issues raised by the physicians and chiropractors, and it is not clear how much the questionnaire reflected their concerns rather than those of the patients. Some of the studies have explored patients’ perceptions, beliefs and experience of back pain and treatment using qualitative research methodology (Borkan et al, 1995; Skelton et al, 1996), but these have not specifically addressed dimensions involved in satisfaction. Satisfaction has also been used as an outcome measure when comparing different healthcare providers or different styles of management (Overman et al, 1988; Cherkin and MacCornack, 1989; Bush et al, 1993; von Korff et al, 1994); these studies also are not exploring the nature of satisfaction.

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Nonetheless some consistent and pertinent issues related to patient satisfaction have been selected. These are empathy and understanding from clinicians, skills and effectiveness of clinicians, information provided about back pain and back care, and the time allowed. Patients appear to have preferences for a management style that encourages self-care, which is a dimension that has not been fully addressed. Interestingly, satisfaction does not always closely correlate with full resolution of symptoms (Greenfield et al, 1975; Deyo and Diehl, 1986; Fitzpatrick et al, 1987), demonstrating that patients’ judgements about the quality of care are based on more than the outcome. Conclusion Although there is ongoing theoretical debate about what exactly satisfaction is, its importance as an outcome measure is undeniable. Patients not only have the right to expect high quality care both in the process and the outcome of an episode of treatment, but also it is impossible to separate satisfaction from a successful outcome for any persistent condition. Back pain can certainly be classed as this (Croft et al, 1997), and thus part of the aim of management is to engender patient responsibility for back care. Appropriate information in order to achieve this has to be provided in a way

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that is acceptable and convincing to patients. Patient satisfaction with care is a complex multidimensional phenomenon in which outcome is only one of many concerns of patients. Others can be loosely classed as either to do with the ‘structures’ of healthcare (facilities, access, time, cost, bureaucracy) or to do with the ‘process’ of health care and particularly the quality of interaction with clinicians (humaneness, competence, continuity of care, information provision, attention to psychological problems). For back pain patients, key aspects of the provision of satisfactory care are the empathy and skills of the providers and the adequacy of their information-giving. This is partly so that patients can understand back pain, but also to give them ideas about prognosis and selfmanagement. Given the methodological argument that patients themselves should define their own priorities (Williams, 1994; Skelton et al, 1996) further research clearly needs to be undertaken in this area. No work has been done which seeks to explore the dimensions which patients consider important in an episode of physiotherapy. It is thus unclear if these dimensions will reflect those found in other health fields or will constitute a totally different agenda – part 2 of this paper addresses this issue.

Key Messages ■ Satisfaction is a multidimensional concept. ■ Satisfaction is a reflection of the quality and process of care, not only the outcome. ■ Back pain patients are frequently dissatisfied about the information they receive.

■ They want information that promotes self-care and prefer management styles that promote this. ■ Dimensions of satisfaction that concern back pain patients attending physiotherapy in the UK have not been explored.

References to parts 1 and 2 are combined at the end of this paper. Physiotherapy January 2001/vol 87/no 1

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Part 2: An Explorative, Qualitative Study into Patients’ Satisfaction with Physiotherapy Summary Objective To describe the aspects of physiotherapy care which back pain patients consider important. Study design Qualitative study, using semi-structured interviews. All interviews were transcribed and analysed using framework analysis to generate the key themes. Setting One community and one district general hospital in one town. Subjects One hundred and twenty-six patients who had had back pain and received physiotherapy for it during the previous year were invited to participate. Thirty-four interviews were conducted, mostly with patients with long histories of back pain. Results Patients were critical about the absence of certain characteristics of care, but equally were positive if these characteristics were present in an episode of physiotherapy. In this way the key dimensions were constructed. These related to the personal and professional manner of therapists, their role in providing information on different matters, making the treatment a consultative process, various aspects of the structure of provision, and the outcomes that ensue. Conclusions Patients’ needs relate not simply to the outcome of care, but also to the quality of the process of care. These needs are individualised, and in part reflect their history of back pain. Therapists ought to respond to these requirements, and have a key role in providing patients with appropriate information.

Introduction This study was undertaken to explore patients’ attitudes to and satisfaction with physiotherapy care for low back pain, as this form of management had not been evaluated from the patients’ perspective. The aim of the study was to generate the range of dimensions of care that patients believe are important in their satisfaction with an episode of physiotherapy. The use of qualitative methods has been advocated when research seeks to describe and understand patients’ experience of, and attitudes to, healthcare (Daly and McDonald, 1992; Ziebland and Wright, 1997; Ong, 1993; Britten, 1996; Faltermaier, 1997). Physiotherapy January 2001/vol 87/no 1

Method Sampling Patients were recruited from two hospital sites in one town. This was a purposive sample of those who had received physiotherapy for low back pain at some time in the previous year. A list was drawn up of patients who had been referred in a two-month period and every fifth name was selected. Subjects were invited to participate in the interview by letter; if interested they were asked to return a tear-off slip in a pre-paid envelope. Letters were sent out in batches of 25. Those who replied were then contacted by phone to arrange the details of the interview at their home, or an alternative venue, at their convenience. All but one took place at the patients’ homes. Over a threemonth period in 1998, 125 letters were sent and a total of 34 subjects volunteered to enter the study and were interviewed (table 2 shows demographic and clinical details of patients). Interview Process Interviews lasted from 15 to 25 minutes; one interview was carried out per subject. All inter views were done by the researcher, and were recorded and transcribed. Ethical approval was given for this study. The interviews were semistructured, a qualitative research method that uses open-ended questions related to the phenomenon of interest (Britten, 1996). A topic guide (see table 3), developed from a literature review and the aims of the study, was used to ensure that the same general areas were covered in each inter view. However, the conversation was flexible and responsive to issues as they arose, so that respondents’ individual experience and views could be explored as necessary (Taylor and Bogdan, 1984; McKracken, 1988). Inter viewing continued until ‘saturation point’ was reached (Taylor and Bogdan, 1984), that is no major new insights were being revealed and there was repetition of the same issues with different respondents.

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Table 2: Respondent details No

Sex

Age

55

Table 3: Topic Guide – issues derived from the literature History of condition

Previous therapy

The order of these issues is not significant.

1

F

Chronic >10 years, disabled/not working

y+

Expectations

2

M 55

Chronic intractable sciatica, 1 year /forced to retire

n

3

M 67

Chronic 30 years, episodic severe episodes/still working

y+

4

F

58

Episodic few years/working

n

About the treatment? (What it would involve) Where are these from? Met or disappointed? Have these changed?

5

F

58

Chronic 8 years, disabled/not working

n

6

F

41

Some lingering symptoms/mother

n

Expectations of prognosis

7

F

30

Episode fully resolved/mother

n

Is this different from before?

8

F

67

Episodic sciatica

o

9

M 55

One episode sciatica resolved/working

o

10

F

57

Chronic, severe episodes, for decades, disabled

y

11

F

64

Episodes

n

12

F

36

Persistent symptoms, 1 year working

y

Was it helpful at the time? What was most helpful? Has it helped you since? How?

13

M 56

Several episodes /working

y

Self-management

14

M 29

One episode resolved/working

o

15

F

Intractable leg pain, not clearly spinal

n

16

M 44

Two episodes back pain/working

n

17

F

67

Persistent problems > 10 years, severe episodes

n

Help to control your problem better? Allow you to manage problem independently of medical assistance? Do you feel you have control over the problem?

18

F

44

One episode back pain, resolved /working

y

Understanding

19

F

40

Several episodes back pain last 2 years/working

y+

20

F

56

Twenty-year history of back pain, severe episodes

n

21

F

35

Over 15-year history, severe episodes/mother

o

Did it help you understand your problem? Was the information adequate? Were you reassured about any problems?

22

F

77

Multiple pathologies, housebound

y+

Interaction with physiotherapists

23

M 73

Spinal problems for 20 years/multiple pathologies

y+

24

M 40

Persistent symptoms for 2 years/working

o

25

F

58

Severe episodes back pain > 20 years/not working

n

26

F

58

Single severe episode 1 year, not resolved

n

27

M 42

Improvement, not fully working again

y

28

M 49

One episode, resolved/working

n

29

M 55

Chronic history with severe episodes/working

y

30

F

Episodes for many years, getting worse last 2 years

n

31

M 57

Chronic, severe episodes

o

32

M 52

Chronic, episodes, previous surgery/working

y

Did they communicate well? Did they encourage you to be active and self-manage? Were they sympathetic and helpful? Did you have enough time? Any problems in doing what they asked you to do? How did they help you in this? Were there other ways in which you could have been helped? Anything particularly good/bad about their care? Did you agree with their approach to back pain?

33

M 73

Single persistent episode for > 1 year

n

Overall satisfaction

34

F

Episodic many years/working

o

Any other issues? How do you think care could have been improved?

71

65

37

n

= No previous physiotherapy

y

= Previous physiotherapy

Efficacy

y + = Several episodes of previous physiotherapy

Other treatments

o

How does it compare?

= Other previous therapy (chiropractic or osteopathy)

Analysis The data collected were subjected to framework analysis (Ritchie and Spencer, 1994). This involves initial familiarisation with the data, identification of a thematic framework, indexing of the data according to this framework, charting the dimensions of the main themes, and finally mapping and interpreting the data. This method was chosen as it is an explicit and visible research methodology in which analysis is grounded in the interview data and permitted to be a dynamic process.

While the data were still being collected, the researcher familiarised himself with transcripts already available and began to recognise recurrent themes. These initial themes were used to code some of the data and further develop the coding framework. The data were returned to on several occasions to refine and define the evolving themes further. Discussion with peers ensured that themes were comprehensive and inclusive. The thematic framework was thus developed out of the topic guide, emergent issues from the respondents, Physiotherapy January 2001/vol 87/no 1

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analytical themes arising from the data, and the aims of the study. This framework was then applied to all data that were relevant to the study aims, with some passages being indexed to several themes. In this way all relevant portions of text were grouped together according to thematic reference, so that transcripts were broken down and then reassembled by conceptual areas. These groups were then analysed to obtain the ranges and categories within each theme, and associations and patterns between

Table 4: Key themes identified from interview transcripts Final themes Expectations

Definitions Expectations about physiotherapy

Key examples of theme No expectations. Involve exercise

Perspectives on Beliefs and attitudes about low back pain low back pain

Learning to live with it. Not expecting a cure

Perspectives on Experience and attitudes relating management to management of the problem

Unsatisfactory management, slow referral to physiotherapy

Impact of low back pain

Impact of back pain on lifestyle

Enforced bed rest. Restriction of activities

Outcomes

Patients’ perceptions of outcome of therapy

Symptoms resolved, improved or unchanged. Gaining self-management strategies. Access to physiotherapy

Patient involvement

Patients’ attitudes to active involvement in managing their condition

Learning to live with it. Active involvement in self-management

Tools for selfmanagement

Self-management strategies that patients find useful

Consciousness of having a problem. Exercises. Awareness about postural stresses/ergonomics

Explaining and teaching

Physiotherapists’ roles in providing information

The problem. Self-management strategies. Process of treatment. Prognosis

Treatment as a consultative process

Involvement of patients within process of treatment so that it is responsive to their needs

Responsive to patients’ symptom behaviour, questions, and other concerns

Personal manner Personal characteristics of physiotherapists that patients appreciate or criticise

Friendly. Sympathetic. Good listener. Respectful

Professional manner

Skills of examination or treatment Thoroughness. Knowledge base. Manual skills

Structure

Issues relating to provision of physiotherapy

Waiting time. Open access. Having enough time

Previous physiotherapy

Critical comparisons between episodes of physiotherapy, osteopathy or chiropractic

Effective versus ineffective care. Personalised versus impersonalised care

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themes were then established to present the final interpretative analysis of the data. Findings Following this process the transcripts presented 13 separate key themes (table 4). Six of these themes described the aspects of physiotherapy care which patients considered important and are explored in this paper. The personal and professional manner of the therapist have been merged into one theme, thus making the five themes shown with bullet points below. The other themes related to patients’ opinions about back pain and its management – these form a separate subject and will be presented and published at a later date. Dimensions of Satisfaction In this study the dimensions that patients found important in an episode of physiotherapy care were: ■ The personal and professional manner

of the therapist. ■ The explaining and teaching which

occurred during the episode. ■ How much treatment was a consultative

process. ■ The structure that shaped access to and

time with the therapist ■ The outcome which ensued.

Personal and Professional Manner Respondents reported on a wide range of characteristics in the personal manner of physiotherapists. These could be generally seen to reflect two issues -- friendliness and empathy. Generally the respondents liked the physiotherapists’ friendly attitude, their ability to put people at ease, and their helpfulness: ‘There’s a certain way to talk to people, what I call a bedside manner. If they haven’t got that bedside manner, I think you rebel, I think "Ooh I don’t like her, I’m not doing, I’m not having this", but if you get a physio that is good with you...and find that they’re helping you it goes a long way’ (1).

The characteristic of empathy involved a range of skills which allowed patients to feel they were being dealt with in a sympathetic and respectful way. This

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involved listening to the patients’ concerns and being understanding of their situation: ‘It’s difficult to explain, but she did have that sympathy and empathy that.... I understood why people recommended her.... The young one was: "Sorry-I’m-just-another-case". Whereas I was welcomed: "Oh you poor dear, you must be in pain"’ (8). ‘You sometimes get the wrong impression of people, and I don’t mean this to sound nasty, but I didn’t know whether she was really listening to what I was saying was giving me grief, and where things were actually improving or not improving’ (24).

The professional manner represented a collection of perceived skills that inspired confidence. This was commented on, for instance, when patients felt positive about the physiotherapists’ knowledge base, thoroughness, or manual skills: ‘Just their confidence in knowing what they were doing really. I think that’s what it was. They knew exactly how to...where the problem was, they know exactly what to do with it, and it’s just their confidence that came across, and made me feel secure in them’ (28).

Although respondents highlighted a wide range of important characteristics about the physiotherapists’ personal and professional manner they relate primarily to three key areas -- friendliness and bedside manner (which allows patients to be relaxed); sensitivity to patients’ needs (which requires skills of listening and empathy from physiotherapists, as well as respect towards patients); and a professional approach (which inspires confidence in patients, and involves information giving). Explaining and Teaching A major segment of the data was about the physiotherapists’ role in explaining and teaching, which was a characteristic of an episode of care deemed important by nearly all respondents. This should not be seen as a straightforward transmission of knowledge to passive recipients, but an active process in which the patients gain a greater understanding of their condition, and as a consequence manage it better. There were four key areas in which patients generally appreciated information giving:

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■ The problem itself. ■ The patients’ role in back care. ■ The treatment process. ■ The prognosis of the condition.

The Problem The amount of explanation that people required varied, but being given some kind of anatomical information was frequently found to be useful, as was the use of drawings, charts and models. An explanation of the problem provided reassurance to some and also encouraged self-management: ‘They put your mind at rest, knowing what it is, and how to cope with it’ (19). ‘It’s like a motor car engine. We don’t particularly understand how it works, but we always jump behind the wheel and drive away in it. And the same goes for your body, you don’t really understand how it works. But when it’s explained to you in basic layman terms, then you start to understand and realise. It gives you the ability to do something about it’ (14).

Providing an explanation does not in itself make the pain better, however: ‘Doesn’t help a deal, understanding it. doesn’t make the pain any less’ (30). ‘Yes it’s nice to know what is basically wrong. Whether they can do owt or not, that’s another thing. At least they explain to you’ (9).

Patients’ Role in Back Care Both implicitly, by the prescription of exercises and postural advice, and explicitly, by the explanation of the patients’ ongoing responsibility for caring for their backs, physiotherapists frequently provided the rationale for selfmanagement. Their role as givers of expert advice in the realm of how to live with the problem and what to do to deal with it was thought by many to be a fundamental part of physiotherapy care. This often tied into the explanation of the problem, and provided reassurance and confidence. It involved giving specific exercises, as well as explanations of why, how many to do, how frequently and what to expect: Physiotherapy January 2001/vol 87/no 1

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‘Yes, she explained why I’d got to do them, to build my muscles up, to make your back strong, and you know, she explained it well, and said: "You’ve got to do them, it’s going to be part of your life now, you’ve got to do these or it’s back pain"’ (21).

It also involved advice about posture, ergonomics, and activities of daily living: ‘I’ve suffered with my back many years, and some of the things she told me this last time, nobody had bothered to tell me that, "Oh you shouldn’t reach like that", “You should sit down holding your muscles in", or "Stand up holding you muscles in". Nobody had ever consulted me over that. But this last time, she, she taught me quite a few things really…. I felt that the understanding was better as regards how I should perform certain activities during my lifetime’ (10).

Treatment Process Patients like to be given an idea of what is going to happen in the treatment process, why this is being done, and what response might be expected: ‘She explained things.... I think that’s very important, so you know just what they’re trying to do, and what is expected of you’ (18).

Prognosis of the Condition Patients also found helpful or wanted some explanation about the long-term implications of the problem, the limitations of any treatment, and the consequences of this in terms of their responsibility for their own on-going selfmanagement: ‘You should say what you hope to achieve at the end of it. Perhaps the physio should say: "Perhaps your goals are too high, don’t expect this, because it’s not going to happen"’ (12). ‘As he explained, he’d gone about as far as he could with me...."To be truthful there’s nothing more I can do for you. I can carry on keeping going for another two or three weeks, but it’s not gaining nothing".... So I said: "Great, I accept that".... personally felt, myself, at some stage you’re saying, that’s it, you can never do any more for me, it’s just me now keeping it in and doing my own exercises at home, and so on’ (13). Physiotherapy January 2001/vol 87/no 1

Consultative Process The third dimension of physiotherapy care that is mentioned widely concerns treatment which is seen to involve a level of consultation with the patient. This relates to some of the themes mentioned earlier, but nonetheless features frequently enough to stand as important in its own right. It includes such issues as listening and responding to patients’ questions, consulting with them about the effectiveness of therapy, and relating treatment to their individual self-help needs: ‘I mean whatever questions I asked, and I mean, we had kind of a dialogue. It was okay. I mean all my questions were answered’ (20). ‘So I usually go through what I’ve been doing through the week, discuss it with them. And then they might tell me to look at an activity a different way, or to tackle it in a different way’ (31).

The key issue of this dimension is the concern of patients to be listened to and involved in the treatment so that it is seen as a consultative, rather than a prescriptive, process. Structure Issues about the structure of provision of physiotherapy care were raised frequently. Patients appreciated quick and local access to a therapist when this occurred, and were equally critical of a protracted referral system when this was the case. Quite a number of respondents talked about the usefulness of being able to return to the therapist should the need arise, for instance during a flare-up of their problem. In fact in the NHS such open access to physiotherapy is not available, but clearly many patients would like it to be so. Respondents appreciated a flexible appointment system, not being kept waiting longer than five or ten minutes, having enough time with physiotherapists, and not feeling rushed: ‘I’d been going backwards and forwards to the doctor’s. In the June before I’d been to the osteopath, and it didn’t help, I went about four times, and I went to one of those chiropractors, and that didn’t help either.... It must have cost me about £150, and I ain’t getting any better.... And I went to the doctor’s, he says: "What do you want me to do?", and I

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says: "Well get rid of this pain, that’s all I’m bothered about", and he said: "Well, we’ll try physio as a last resort". And I would have thought the doctor would have said that was your first resort’ (9).

Outcome The final theme relating to the process of treatment is the outcome that ensues. Getting rid of the pain is a key concern: ‘And she made it work, which at the end of the day, that’s all you want isn’t it?‘ (9). ‘But as what she did suggest seemed to do the trick for me anyway, that’s all I was bothered about really’ (17).

With this though comes a reasonably eclectic perspective on the means of achieving this – patients do not have a firm commitment to a particular therapy, only to what works: ‘You tend to go with the person who does it, and helps you there and then…. I think what works for one person doesn’t always work for another. I know, my father was involved in a car accident, and he got terrible whiplash…. He had physiotherapy and he was over the moon with the service and the response he got.... ‘So I wouldn’t like to say that all physiotherapists are rubbish, because I don’t think that’s fair or true. But in my particular case it didn’t do me any good to go to the physio’ (14).

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‘It made it easier…. Yes, very liveable with at the moment … and I didn’t feel a need to go away and try something else. I was satisfied’ (20). ‘He was very good. He gave an idea of how you can do a lot more self-help rather than having to rely on keeping coming back to people like him, which I thought was very good, gave me lots of other ideas, did want to overcome various problems and how, how at the first sign of something else coming back, rather than having to go back to the doctor’s … so, yes, I was very pleased with that’ (6).

Discussion and Clinical Relevance The main findings from this study (table 5) are that patients are frequently able to make clear qualitative judgements about what they consider are good standards of physiotherapy care, and notice either the presence or absence of these characteristics. Patients appreciate a personal manner that is friendly and empathetic, and a professional manner that is skilled and inspires confidence. They wish to have information about the problem itself, advice on self-help for Table 5: Key dimensions of patient satisfaction with physiotherapy care for back pain Personal manner of the physiotherapist Friendly Sympathetic Listening Respectful Professional manner of the physiotherapist

Although the change in pain was an important issue this was not the only concern at the end of treatment, nor always the major concern. Many of these patients reported improvement, many also reported persistent symptoms or the condition unchanged, and only a few reported total resolution of the problem. Nonetheless many expressed overall satisfaction with care, suggesting that this did not relate simply to the outcome of pain. Although many patients had come to accept that the problem was not curable they frequently expressed satisfaction with strategies for self-help that they had learnt through physiotherapy. This was true even when these strategies simply improved their ability to manage the problem, but did not fully resolve it:

Skilled Thorough Inspired confidence Therapist’s role in providing information The problem Self-management Process of treatment Prognosis Treatment as a consultative process Involvement in treatment process Response to patients’ questions Responsive to self-help needs Structure of service provision Short waiting time Open access Enough time Outcome of treatment episode Treatment effectiveness Gaining self-help strategies

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back pain, explanation about the treatment, and be given some understanding about the prognosis of the problem. They desire a process of treatment that answers their questions, consults them about the efficacy of their treatment, and engages in their individual problems. Although effectiveness in terms of pain relief is a key outcome, gaining a good understanding of their problem and learning strategies of self-management is also a highly satisfactory outcome for many patients. From this study it is clear that satisfaction with physiotherapy, as with other healthcare processes (Fitzpatrick, 1991), is multi-dimensional. The dimensions of satisfaction that previous studies of back pain patients had highlighted, for medical care in the USA, related to information, caring, effectiveness, and time (Greenfield et al, 1975; Deyo and Diehl, 1986; Cherkin and MacCornack, 1989, Cherkin et al, 1991). Similar concerns were voiced in this study with the themes of information, the personal and professional manner of therapists, outcomes, and the structure of the provision of therapy. Information provision, a major theme in this study, has been highlighted as a key dimension of satisfaction generally (Ware et al, 1983; Fitzpatrick, 1991) and specifically related to back pain patients (Cherkin et al, 1991; Deyo and Diehl, 1986; Von Korff et al, 1994). This study found that information required by patients related to the problem, what patients could do about it, what treatment involved, and the prognosis. Some of these details have been raised in earlier studies (Cherkin and MacCornack, 1989; Cherkin et al, 1991; Fitzpatrick et al, 1987). It seems from this that issues of quality of care are reasonably similar across disciplines – with key concerns being information, relationship with professionals, structure of provision of service, and outcome. The theme of treatment as a consultative process is a novel dimension, and relates to patients’ desire to relinquish the role of passive recipients of care. Individualising Therapy This study defines some of these dimensions in more detail and begins to isolate some of the ways in which these Physiotherapy January 2001/vol 87/no 1

dimensions can be achieved in physiotherapy. For instance the information that patients want relates to their health problem and its prognosis, to what they can do to help themselves, and to what health professionals can do. This suggestion of an active patient role is further endorsed by other dimensions. Patients wished to see treatment as a consultative, rather than a prescriptive, process, and were satisfied with an outcome which gave them strategies of selfmanagement even if the problem was not resolved. To achieve adequate provision of information, therapists need to address all of these issues. However, patients’ particular requirements will vary, and their desire for empathy on the part of clinicians can be seen as a need to be dealt with on an individual basis. This researcher started the study with the rather naïve assumption that an episode of physiotherapy could be evaluated in a vacuum. It became clear very quickly that it was impossible to disentangle patients’ judgements about physiotherapy care from their past back pain history and their beliefs and attitudes concerning back pain and its management. As a consequence of these different histories and beliefs patients emphasised different dimensions in the range, and had their own particular concerns that they wanted to be addressed. Physiotherapists must clearly reflect this need to individualise care to the particular needs of the patients in front of them. Therefore it is appropriate to discuss with patients their individual needs so that therapy is tailored to their specific requirements. Clearly certain attributes of care, such as listening and being respectful, skilled or optimally effective, ought to be accorded to patients by right. However, the amount of information provided to patients in this study depended partly on their previous experience of back pain and therapy. The degree to which full resolution of symptoms or establishment of selfmanagement strategies was the main outcome depended on their back pain history. Altering Patients’ Attitudes Patients’ concerns though are not immutable, but can be open to change. Patients talked about their evolving beliefs and attitudes both over their history of

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back pain, and during the therapeutic encounter. Although their past experiences influenced their present belief structure, their future behaviour could be influenced by an episode of care. This demands an active and responsive attitude on the part of the therapist in which communication skills are more important than hands-on skills. To fail to provide the appropriate information and ideas about back pain is ultimately to fail the patients, and they are aware of this: ‘I think I’ve learnt more from what they’ve told me, and the exercises they’ve shown me, than actually going for weeks on end. And I think that that machine, I thought: "What can this machine do? What is it doing?" I think the exercises and just talking, what they felt about it, has made me accept more and understand more’ (34).

Certain of these dimensions interact with each other, and encouraging patients to adopt the self-management strategies, which are appropriate for the problem of low back pain, is not necessarily easy. Therapists cannot make the treatment a truly consultative process unless they are skilled listeners and can understand the patients’ problems. Unless therapists are convincing personally and professionally they are unlikely to get patients on side to test out fully the self-management strategies which they offer. Unless therapists provide adequate and appropriate information, patients may not be convinced of the need to adopt the intellectual and behavioural strategies necessary for self-management. Effective outcomes require therapists skilled in a wide range of interpersonal skills, not only good at certain techniques. Critique As a qualitative study this work addresses the nature of a phenomenon and seeks to describe its dimensions. It does not address issues of frequency, distribution or any other quantitative matter. Further research is needed both to confirm the importance of the dimensions here outlined and to survey their distribution in those receiving physiotherapy. Lincoln and Guba (1985) suggest that the conventional criterion by which the validity and reliability of quantitative data is ensured is inappropriate for qualitative

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data. Instead they propose the terms credibility, transferability, dependability and confirmability to ensure a rigorous and scientific qualitative approach. Credibility relates to how accurately the study has identified and described its subject matter. In this study the semistructured nature of the interview meant that the researcher was not tied to the topic guide -- this served only as a starting point from which to begin discussion of the subject. This allowed exploration of the patients’ perspectives as they arose; discovery of which was the key aim of the study. Towards the end of data collection no new themes were emerging. Credibility was enhanced by prolonged involvement in data collection and analysis. To ensure against any biases of the researcher influencing the analysis, the evolution of the themes went through five stages. At each stage the data were returned to and the evolving themes checked against them as described in the methods. As this was happening the research process was exposed to others so that ‘quality control’ occurred. An academic experienced in qualitative methods, involved in supervision of the project, and a fellow qualitative researcher helped to ensure that themes which arose were a true reflection of the data. The credibility of the final dimensions was strongly affirmed by positive and negative statements from patients that reinforced each other. For instance, respondents commented favourably about the provision of information and equally were critical about episodes of care in which information had been inadequate or lacking. In this way the dimensions that patients found important with an episode of physiotherapy were reaffirmed. Transferability corresponds to external validity. Readers need to be able to ascertain how transferable the sample is. In order to provide triangulation the patients were from two hospital sites. They were solely back pain patients with a preponderance of chronic problems. Other demographic and clinical details are given in table 2. Resources did not permit a wider sampling frame, for instance involving another town. Dependability corresponds to reliability. The fact that the patients were being Physiotherapy January 2001/vol 87/no 1

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interviewed by a therapist about physiotherapy might have been a problem in generating critical comments – in fact this did not stop respondents from offering negative comments. No patient who had been treated by the researcher was involved in the study. As outlined above, the data analysis was checked and rechecked by the researcher and peers to ensure that the final themes identified were comprehensive and all-inclusive. Good qualitative work should be in tune with previous studies. No previous work has been done to elucidate the dimensions of satisfaction relating to orthopaedic physiotherapy, so there is nothing with which to compare it directly. Previous work around satisfaction in the medical field suggests similarities (see part 1), thus endorsing the reliability of the study. Confirmability relates to the process of the qualitative data analysis – was it adequate and are the conclusions warranted by the data? A clear and visible audit trial of this process is available in the original dissertation. A formal external auditor was outside the time and resources available. Those who volunteered to be interviewed were about a quarter of those actually invited to attend, and were thus a self-selected group. Self-selection causes a potential bias in any study, but is an inevitable part of ethical research – patients cannot be compelled to participate. In terms of those who took part in the study compared to those who were invited to participate there were some slight differences. In those invited to be interviewed the average age was 44 years and 52% were women; in those who actually participated the average age was 53 and 59% were women. A high proportion of those interviewed had a long history of back pain, persistent or episodic, while few had had one brief episode of back pain. However an audit conducted at one of the participating units showed that 73% of those attending physiotherapy had ‘chronic’ symptoms (unpublished data). It is not possible to know if the participants in this study may have produced a biased perspective on patients’ views of physiotherapy. The critique of this study suggests that a sub-group of patients who attend outpatient physiotherapy may have been Physiotherapy January 2001/vol 87/no 1

involved. There was a predominance of women, and older individuals with a long history of back problems. Within the resources available everything was done to ensure a credible, dependable and confirmable collection and analysis of the data they offered. Compared to a suggested checklist (Greenhalgh, 1997) for evaluating quality of qualitative research this study performs reasonably highly. Conclusions This study shows that there is clearly a wide range of issues about which patients make judgements in relation to an encounter with a physiotherapist. They hope for someone who is friendly, sympathetic and offers them personalised care; they want someone who is skilled and knowledgeable; and is able to provide them with a wide range of information about back pain and selfmanagement. They want to be involved in the evaluation of treatment, and although they want symptomatic improvement other outcomes, such as improved levels of coping with the problem, are acceptable. Patients’ satisfaction with an episode of physiotherapy not only concerns the issue of quality of care, but also addresses the outcome of a therapeutic encounter. Given the epidemiological picture of back pain with its high prevalence and recurrence rates (Croft et al, 1997) patients need to have enough understanding of their problem in order to manage it in the best way. The therapists’ role is vital in providing information and working with patients to address their individual problems and concerns, not just to make particular episodes of care satisfactory, but in helping patients deal with their problem. The key outcome of an intervention for back pain should be the patients’ ability to self-manage their problem. This requires a good working relationship between patients and physiotherapists and the full involvement of patients in the resulting therapeutic alliance. Satisfaction is thus not a peripheral outcome measure, but can represent an integral part of the success of treatment – by meeting patients’ needs, by providing them with the appropriate information to help them manage their problem, and by working with patients to achieve greater understanding and control.

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Patient Satisfaction with Management of Back Pain References to Parts 1 and 2

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Fitzpatrick, R (1991). ‘Surveys of patient satisfaction. 1: Important general considerations’, BMJ, 302, 887-889.

Borkan, J, Reis, S, Hermoni, D and Biderman, A (1995). ‘Talking about the pain: A patient-centred study of low back pain in primary care’, Social Science and Medicine, 40, 7, 977-988.

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Key Messages ■ Patients make clear qualitative judgements about what they think is good or bad physiotherapy.

■ Patients prefer that treatment is a consultative rather than a prescriptive process.

■ Empathy and listening skills are key attributes in the personal manner of physiotherapists.

■ Communication with patients may achieve more than passive modalities or hands-on techniques.

■ Providing appropriate information is deemed an essential part of physiotherapy.

Physiotherapy January 2001/vol 87/no 1