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Research Reports |
SM Baker, PT, DPTSc, GCS, is Coordinator, Distance Learning Physical Therapist Assistant Program, Loma Linda University–Oakwood College campus, Huntsville, Ala.
HH Marshak, PhD, is Associate Professor, School of Public Health, Loma Linda University, Loma Linda, Calif
GT Rice, RN, EdD, EdS, CHES, is Professor, Department of Physical Therapy, School of Allied Health Professions, Loma Linda University
GJ Zimmerman, PhD, is Associate Professor for Research and Professor of Biostatistics, School of Allied Health Professions, Loma Linda University
Address all correspondence to Dr Baker at 140 Taurus Dr, Harvest AL 35749 (USA) (smbakerpt{at}aol.com)
Submitted August 10, 1999;
Accepted November 22, 2000
 | Abstract |
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=76.4 years of age, SD=7.1, range=65–94). The audiotaped examinations were then scored using the Participation Method Assessment Instrument (PMAI) to determine the frequency of attempts made by therapists to involve patients in goal setting. Therapists and patients completed surveys following the examinations. Results. Therapists' use of participation methods during examinations ranged from a minimum of 1 to a maximum of 19 out of 21 possible items on the PMAI. The therapists stated that they believed that it is important to include patients in goal-setting activities and that outcomes will be improved if patients participate. Patients also indicated that participation is important to them. Discussion and Conclusion. In most cases, the therapists did not fully take advantage of the potential for patient participation in goal setting. Patient and therapist education is needed regarding methods for patient participation during initial goal-setting activities.
Key Words: Collaboration • Geriatric rehabilitation • Goal setting • Patient participation
| Introduction |
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Patient participation in goal setting is emphasized in order to enhance patient management and the effectiveness of treatment. Participation, in our view, should improve outcomes and could be used to identify benefits that may result from the treatment. These benefits include greater goal attainment, increased patient satisfaction, gains in function, better adherence to treatment regimens, decreased depression in patients, and reduced burnout rates among physical therapists.5,6
Regardless of the recommendations of professional organizations and accrediting bodies and the benefits of patient participation, physical therapists in clinical practice may face obstacles as they endeavor to establish a collaborative relationship with their patients. These obstacles may affect their attempts to involve patients in goal setting. Northen et al7 examined whether occupational therapists attempted to gain patient participation, in keeping with the occupational model of rehabilitation. They found that occupational therapists did seek patient participation in setting goals, but they concluded that opportunities for participation were not maximized. They cited theoretical application, time constraints, and the patient's age and cognitive status as factors that affect participation.
Payton and Nelson6 interviewed 20 patients to determine their perceived level of participation in goal setting, treatment planning, and outcome assessment. They found that the patients had a weak sense of participation in goal setting and described their role in this activity as indirect. The patients felt that goals were established as a result of a tacit consensus between them and their physical therapists.
Patients, we believe, enter the treatment setting with diverse values, beliefs, expectations, and personalities. Are patients prepared to assume an active role in goal setting? Or, because of historic medical paternalism, do they generally lack the preparation, motivation, or background needed to be active participants? Windom,8 in an unpublished master's thesis, reported that she interviewed 14 patients in the rehabilitation unit of a teaching hospital. Her study focused on whether patients were prepared to take an active role in their physical therapy, and she found that most patients perceived their role to be that of a passive participant.
In a study conducted with 109 patients receiving physical therapy services, Payton and colleagues9 found that 68% of the patients indicated that they would have preferred to be more involved in goal setting with their physical therapists. In another study,10 65 patients in a cardiac rehabilitation program indicated that they preferred to set their own treatment goals and that this preference was largely unmet. Male participants identified what they perceived as arbitrary goal setting as the area of their greatest dissatisfaction with the program.10
Despite the fact that patient participation in goal setting is recommended in practice guidelines,1 there appears to be a paucity of research focused on this aspect of patient management. The purpose of this study was to examine whether physical therapists seek patient participation in goal setting and, if so, what methods they use. We also wanted to explore the relationship between patient participation in goal setting and satisfaction with the examination and to determine the attitudes of physical therapists toward patient participation in goal setting.
| Methods |
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The physical therapists recruited 81 patients to participate as they were referred for examination. The inclusion criteria were: (1) the subjects were 65 years of age or older, (2) the subjects had a non-neurologic primary diagnosis, (3) the subjects had a functional cognitive level (as determined by the physical therapist's observational assessment) and had the ability to follow instructions with 3 to 5 or more steps, (4) the subjects spoke English as their primary language and had the ability to verbally communicate and read at an eighth-grade level, and (5) this examination was their initial one by this physical therapist.
Informed consent was given by each subject, and confidentiality was maintained by the use of data coding. Participants were provided with the title of the study and told that we were investigating patient examination methods.
Study Instruments
The Participation Method Assessment Instrument (PMAI) was used to record attempts by therapists to involve patients in goal setting. It consists of 21 items that are supposed to reflect various aspects and levels of patient participation. The PMAI was adapted, with permission, from the Patient Participation Evaluation Form, which was developed by Northen et al7 for use in a study of occupational therapists. Adaptations included adding several items that, we believe, reflect physical therapist practice and goal-setting activity. Northen and colleagues' documentation items were not used in the PMAI because our study did not include a chart review. In an effort to determine whether we had face validity for the PMAI, we distributed it to 3 physical therapists who were board-certified geriatric specialists and who were not associated with the study. These therapists were asked to review the PMAI and comment on whether they thought that it included the basic areas that would be covered in a typical initial physical therapy examination. The specialists were also asked to recommend additional items or indicate items that they thought may be invalid, arcane, or outside the scope of a typical examination. In the final version of the PMAI, we incorporated the suggestions that we received.
The physical therapists and patients each completed an opinion survey. The patient opinion survey instrument contained 10 items that we designed to elicit their perspective on the examination (Tab. 1). The therapist opinion survey instrument contained 12 items that we structured to assess attitudes about patient participation (Tab. 2). These survey instruments were designed for this study and were not studied for reliability or validity.
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The physical therapists invited patients to participate in the study. After the examination was completed, the patients were given a sealed envelope containing the patient opinion survey instrument. When they finished the survey, the patients were asked to place the survey instrument in another envelope, seal it, and return it to the physical therapist. Patients were told that the survey instrument would be forwarded to the researcher and that the therapist would not know how they had responded.
Review of data.
After the research packets were returned, the primary researcher (SMB) reviewed each audiotaped examination and scored it with a PMAI data sheet. Items were scored as "attempted," "not attempted," or "not applicable." In ex post facto analysis, we rescored PMAI items as either "attempted" or "not attempted" and did not use the "not applicable" category because "not applicable" called for the reviewer to make a decision. Such a decision could, in our opinion, be in error because the reviewer did not know the patient or have access to his or her medical or demographic information. In an effort to control for bias and develop a scoring framework, 2 physical therapist reviewers who were not involved in the study were told the purpose of the study, taught how to use the PMAI (the primary researcher reviewed the PMAI and discussed its use with the reviewers), and asked to review a random sample of 20 audiotapes each.
After a trial test, each reviewer's scores were compared with the primary researcher's scores. The reviewers and the primary researcher then established guidelines for scoring the PMAI. To develop the guidelines, we listened to a sample audiotape and discussed scoring of each PMAI item until 100% agreement was reached. Following this session, reviewers resumed listening to their sample of audiotapes. Agreement between the reviewers and primary researcher was 80.0% on the "patient preparation" items, 70.0% on the "concerns clarification" items, and 86.0% on the "goal-setting processes" items. We believed that these levels were acceptable for us to proceed with our research.
Statistical analysis was performed using SPSS 7.0.* Descriptive statistics were calculated for demographic variables. Nonparametric correlations were computed using Spearman rank correlation coefficients. An analysis of variance (ANOVA) was applied to the therapist and patient data.
| Results |
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=9.0) (Tab. 3).
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Patients
Audiotaped examinations were conducted with 81 patients. Due to recording errors involving 8 patients, data were available for analysis on 73 patients. The mean patient age was 76.4 years (SD=7.1, range=65–94). The majority of patients were women (67.6%, n=56), Caucasian (86.3%, n=63), and had an orthopedic diagnosis (71.2%, n=52). Educational level data were obtained because of our belief of the possible effect of education on the expectation for participation. However, it is difficult for us to report the educational level of our patients because of the data that were missing (54.8%, n=40). We speculate that many physical therapists did not collect data on education because it is not information they typically gather during the examination. From the data that we have, most patients had an elementary-or high school–level education (32.8%, n=24) (Tab. 4).
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=3.3 tapes, SD=1.55, range=1–5). In an attempt to decrease bias due to unequal submission of data, data were averaged over subjects for each therapist and then analyzed. The largest number of audiotapes were received from physical therapists working in rehabilitation centers (24.6%, n=18), and the smallest number were received from therapists in acute care settings (9.6%, n=7). The mean amount of time taken for all examinations was 30.4 minutes (SD=13.0, range=15–90). Therapists with mid to high use of PMAI items had a mean examination length of 31.7 minutes, and therapists with low use had a mean examination length of 29.2 minutes. Based on the statistical analysis, there was no difference in examination length between the 2 groups of therapists.
Extent of Patient Participation
We were able to quantify the physical therapists' attempts to involve their patients in goal setting by their use of the 21 PMAI items. Each therapist attempted to involve his or her patients to some extent during the examination. The minimum number of PMAI items used by therapists during an examination was 1. The maximum number of PMAI items used during an examination was 19. The mean number of PMAI items used during the typical examination was 10 items (mid to high use =13.1, low use =4.0). Every PMAI item was used at least one time.
Use of Patient Preparation Methods
The most frequently used group of PMAI items was "patient preparation" items, which received greater use than the "concerns clarification" or "goal-setting process" items (=47.71%, =33.04%, =31.30%, respectively). Table 5 shows the frequency of attempts for each PMAI item, along with the number of therapists who used each item. When use of PMAI items was analyzed as a whole, those items used frequently (
60%) by the physical therapists included: (1) discussion of assessment findings with the patient or family (item 5) (69.2%), (2) discussing the findings in a manner that was appropriate for the patient's level of understanding (item 6) (64%), (3) presentation of assessment purposes and procedures to the patient or family (item 3) (60.4%), and (4) elicitation of the patient's concerns (item 10) (59.5%).
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20%) by the therapists included: (1) confirmation of the patient's major concerns (item 14) (19.4%), (2) collaboration with the patient or family to establish goals (item 17) (18.9%), (3) introduction of physical therapy services (item 1) (12.7%), (4) introduction of concerns exploration (item 9) (10.4%), (5) discussion of how the patient may participate in goal setting and treatment planning (item 7) (6.8%), (6) explanation of cooperative role of the patient in identifying goals (item 16) (5.9%), and (7) asking the patient to prioritize concerns (item 13) (3.2%).
Patient Opinion Survey
Patient responses for all of the patient opinion survey items ranged from 3 to 5 on a 5-point Likert scale (1=strongly disagree, 5=strongly agree) (Tab. 1). Generally, patients felt very comfortable with the evaluating therapist (item 1), and they believed that physical therapy would be helpful to them (item 9). They also stated that they knew what benefits they wanted to receive from physical therapy (item 6). Following the examination, the patients recorded a high level of overall satisfaction (item 10) with all therapists, and there were no statistically significant differences in levels of satisfaction.
Patients responded that they and the therapist worked together to set the goals for their course of treatment (item 8). This response by patients was not compatible with the analysis of PMAI item 17 (Collaborates with patient and family to establish goals), because the audiotape analysis revealed that only 6 therapists collaborated with 19 patients in goal setting.
As part of the data analysis, we correlated all survey items with overall satisfaction with the examination. Patients rated all items high on the scale, and therefore there was a lack of variability in the responses. One item correlated with patient satisfaction: item 4 in which the therapist explained to the patient how physical therapy would help with the problem(s) that he or she was having (r=.43, P=.05).
Therapist Opinion Survey
All of the therapists indicated that they were able to establish initial rapport with their patients (item 1), and most therapists found that geriatric patients were as easy to talk to as patients in other age groups (item 12). Fifty percent of the therapists agreed that most patients had the ability to collaborate with them in establishing goals (item 8). Although the therapists believed that patients have the ability to collaborate, they had mixed opinions about whether patients are able to set realistic goals (item 9).
Regardless of their doubts about the patients' collaborative abilities, therapists asserted that collaborative goal setting is important (item 5). Furthermore, the therapists stated they believed that patients will be more successful in reaching treatment goals if they help to set these goals (item 7). Within that context, 95.5% of the therapists stated that they attempt to involve their patients in goal-setting processes (item 6) (Tab. 2).
| Discussion |
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The physical therapists in this study did seek to achieve patient participation in goal setting, much like the occupational therapists in the study by Northen et al.7 However, because the average physical therapist used only 10 of the 21 PMAI items during examinations, it appears that the therapists did not fully take advantage of the potential for patient participation in goal setting that exists, as measured by the instrument in this study.
The therapists indicated that they believed patient participation to be an important part of high-quality care. Furthermore, they associated patient participation with successful treatment outcomes. These beliefs appeared to be firm based on the strength of their responses; however, they were not consistently applied during the examination, as demonstrated by the PMAI data.
The "patient preparation" items of the PMAI are largely educational in nature. Therefore, the relatively frequent use of these items shows that the therapists are providing patient education, which can form the basis for patient participation. However, the less frequent use of the "concerns clarification" and "goal-setting processes" items may reveal that therapists are uncomfortable providing the type of patient education that demands greater interaction with the patient than "patient preparation" education does. Chase et al11 found that 80% to 100% of physical therapists reported that they did some teaching with their patients. May,12 however, discovered that many therapists felt poorly prepared to assume the role of patient educator. In regard to the PMAI items, it may be that, as the educational activities become more complex (such as in the "concerns clarification" and "goal-setting processes" items), therapists may avoid them, perhaps feeling that they are unprepared for these tasks. Nevertheless, therapist comfort with exploring and then addressing patients' concerns, in our opinion, is necessary to achieve collaboration in goal setting.
In this study, we focused on goal-setting processes and found that approximately 50% of the examinations did not include a statement of the treatment goals by the therapist to the patient. We believe there are 2 views that may help put this in perspective. One view is that the process of goal setting is developmental and, as such, proceeds along a continuum based on factors that indicate the patient's readiness and ability to collaborate.13
The other view is that, during the examination, unstated agreements about goals may occur between the patient and therapist. These agreements may be based on the deficits of the patient that are present during the course of the examination. If this is the case, neither the therapist nor patient may regard a formal statement of goals as necessary; they both know what needs to be done.9 Nonetheless, in our opinion, some type of goal statement is useful to clarify intentions and create a basis for mutual understanding.
We speculated that time constraints might affect patient participation. However, physical therapists who used a high number of participation methods did not have appreciably longer examination times than therapists who used fewer methods. Arguably, the additional 5 minutes of examination time spent by high-use therapists could result in an increase in treatment time over the course of a day. After listening to the audiotapes, however, we believe that, if participation is woven into the fabric of the examination from the start, collaborative goal setting becomes an integrated part of the examination and not a separate, time-consuming activity.
We noted earlier that patients positively rated therapists in all areas of the survey. In several areas, their positive responses were incompatible with the audiotape data. The majority of patients indicated that they collaborated with the physical therapist to set treatment goals. In addition, the majority of therapists stated that they seek to involve patients in goal setting. Audiotape analysis, however, showed that only a few therapists (6) engaged in collaborative goal setting that we could detect with several patients (19). There are a number of possible explanations for this result. Perhaps patients and therapists had differing definitions, perceptions, or attitudes regarding participation. The survey instruments may not have been sensitive enough to detect the nuances of participation issues. It may be that what therapists intend to do may not match what they actually do, to the extent that our instrument measured this activity.
Although the overwhelmingly positive patient opinion of their therapists in the survey was gratifying, it does raise questions. Did the patients give socially desirable responses? Do elderly people generally hold health care professionals in high regard, thus biasing their answers toward favorable responses? Did the patients believe that their answers were confidential and would not affect their treatment? Future research could address these questions, questions that may be relevant to the geriatric population.
Five questions (questions 1, 5, 6, 7, and 8) were embedded in the patient opinion survey that served to reflect the patient's ability to collaborate with the therapist in goal setting. Although this was a self-report measure and subject to the problems mentioned previously, the patients' responses to these key collaboration items indicated that they believe they have the ability to participate in goal setting.
Finally, while listening to the audiotaped examinations, we recognized that some level of patient participation can occur regardless of the patient's age, educational level, or prior experience with physical therapy. Gaining participation takes effort and skill on the part of the physical therapist, and assuming a participatory role takes willingness, readiness, and effort on the part of the patient. This was particularly evident as we listened to and scored the examinations of the subset of 3 therapists who used a high number of PMAI items (15–21). Although our study design did not allow this subset to be analyzed separately, we observed in their methods potentially distinctive practices.
| Conclusion |
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The subject of patient participation in treatment planning is multifactorial. Our focus was on the initial examination, which is only one area where patient participation can occur. Although we recognize that the examination does not include collaboration, that does not mean that it can never happen. Participation can be accomplished over time as the therapist-patient relationship is developed. We collected data from the examination simply because it is the correct place for patient participation to begin. Indeed, therapists who communicate their expectation for patient participation during an examination may set the stage for collaboration throughout the course of intervention.
In light of the potential benefits of patient participation in goal setting, we believe the following are needed: (1) patient and therapist education regarding the potential advantages of participation, (2) the enhancement of patient readiness to assume greater responsibility in their care, and (3) the development of models for use in achieving patient participation, because models for patient participation traditionally have not been used in physical therapist practice.
Future research may include: definitions of key concepts related to patient participation, the identification and development of effective and efficient models to increase participation in goal setting, the examination of attributes that enable therapists to use collaborative approaches, outcome studies that track participation over the course of treatment, models to assess patient readiness for participation, and education in participation methods in both professional and continuing education settings.
| Footnotes |
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This study was approved by the Institutional Review Board of Loma Linda University.
* SPSS Inc, 444 N Michigan Ave, Chicago, IL 60611. 
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