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Research Reports |
BH Greenfield, PT, PhD, OCS, is Assistant Professor, Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1441 Clifton Rd NE, Atlanta, GA 30322 (USA)
A Anderson, PT, DPT, is employed with ATI Physical Therapy–Beverly, Chicago, Illinois. He was a student in the Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, at the time of this study
B Cox, PT, DPT, was a student in the Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, at the time of this study
MC Tanner, PT, DPT, is employed with Benchmark Physical Therapy, Hiram, Georgia. She was a student in the Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, at the time of this study
Address all correspondence to Dr Greenfield at: bgreenf{at}emory.edu
Submitted November 12, 2007;
Accepted June 25, 2008
 | Abstract |
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Subjects: Seven novice physical therapists (with less than 1 year of clinical experience) working in either an outpatient or an inpatient facility were recruited.
Methods: A qualitative method (phenomenology) was used, with data being obtained from retrospective interviews of the novice physical therapists regarding their experiences in the clinic.
Results: Three common themes relating to the nature of caring emerged: learning to care (with the following subthemes: barriers to caring, the "difficult" patient, finding a balance, and time constraints), patients as subjects, and the culture of the clinic.
Discussion and Conclusion: The novice physical therapists in this study expressed difficulty in dealing with difficult patients, with time management, and with balancing their professional and personal lives. However, despite the barriers to caring, many of these participants viewed caring not just as a rules-based approach but as a core value and, in some cases, a moral orientation that guided their first year of clinical practice. The findings suggest that caring requires certain skills and attitudes that accrue over time and that physical therapist education programs should integrate learning experiences (including clinical experiences) throughout the curriculum that foster caring behaviors in order to prepare students for the first-year transition in the clinic. In addition, experienced clinicians should appreciate how their clinic's culture and their behaviors can help model caring attitudes in novice physical therapists.
| Introduction |
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Caring has been identified as a rules-based approach to good patient care, as a core value in physical therapist professional behavior, as part of experienced and expert practice, as a virtue, and as a moral orientation. Most people would agree that caring is a fiduciary responsibility that guides physical therapists to act according to the principles and rules contained in their basic core and consensus documents. For example, principle 1 in the APTA "Guide for Professional Conduct" states, "A physical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care."6 Davis, however, identified this type of care as simple rules-based beneficence involving minimal obligations to care for patients, "but does not admonish us to care or act beyond our contractual obligations as health care providers."7(p216)
In contrast to rules-based beneficent caring, compassionate caring, or benevolence, is often viewed as a virtue that implies doing good (promoting health and well-being versus rightful action, which involves avoiding basic harms, such as pain, injury, loss of freedom, and loss of pleasure) out of genuine care or concern. Virtue ethics was described originally by Aristotle as being related to one's moral character and is generally viewed as an internal state of being properly motivated and experiencing appropriate feelings, such as sympathy and regret.8 Virtuous practitioners are thought to possess a characteristic self-motivation to care, to empathize, and to act altruistically toward their patients. Beauchamp and Childress9 warned, however, that one can act rightly but not virtuously (from the wrong motives) or be properly motivated but act wrongly. Compassionate caring, by extension, may be viewed as the proper balance of motive and action.
Recognizing the problematic nature of defining caring behaviors, an APTA consensus panel developed a document, "Professionalism in Physical Therapy," to assist educators by defining compassion, along with caring, as concern, empathy, and consideration for the needs and values of others.10 The document lists sample indicators of caring behaviors, including: (1) understanding an individual's perspective, (2) being an advocate for a patient's or client's needs, (3) empowering patients or clients to achieve the highest level of function possible and to exercise self-determination in their care, and (4) embracing the emotional and psychological aspects of patient or client care.
Caring as a moral orientation has been the focus of much thinking and research in the medical professions in recent years. The original description of caring as a moral orientation is based on the theory of an ethic of care from a feminist perspective of morality and ethical decision making. Gilligan11 and Noddings12 provided the philosophical basis of an ethic of care that influenced moral judgment. In her landmark study, Gilligan described the moral orientation of women, observing that they solved ethical dilemmas by seeking ways to maintain relationships. Those practicing an ethic of care believe that connection to others is central to an individual's moral orientation and that ethical decisions are made on a case-by-case basis. As a moral theory, an ethic of care is based on the desire to be receptive and responsible for others. According to Branch,5 a receptive physician listens to a patient with empathy and concern. A responsible physician transforms his or her feelings into actions that specifically meet the needs of the patient. Therefore, according to Romanello and Knight-Abowitz,13 an ethic of care focuses rehabilitation on patients’ concerns, making them active participants in rehabilitation and thus facilitating recovery.
The growth of nursing ethics in the 1980s provided impetus for the examination of caring and caring ethics in health care. Benner and Wrubel,14 Fry et al,15 Benner et al,16 Leners and Beardslee,17 and Dinkins and Sorrell18 all reported an ethic of caring in nursing. Branch5 reported that an ethic of caring is underappreciated in medicine. Practitioners in other health care fields reported the influence of patient-centered care in promoting a health care climate that facilitates intrinsic motivation, adherence, and positive outcomes in patients.16,19,20
Raz et al21 examined the influence of gender on professional values and behaviors in physical therapy and reported that female physical therapists described caring as a primary value that influenced their behaviors toward their patients. Central to the clinical practice of these physical therapists were the development and preservation of trusting and reciprocal relationships with their patients that were characterized by interpersonal sensitivity, receptiveness, and responsiveness. The authors reported that the female physical therapists sought ongoing input from their patients about their rehabilitation goals in order to negotiate mutually agreeable decisions. Greenfield22 examined the meaning of moral practice in physical therapy from the perspectives of 5 physical therapists with more than 7 years of experience. He reported that moral issues and dilemmas were ubiquitous in clinical practice and that experienced physical therapists used an ethic of caring to help make ethical decisions. In that study, physical therapists who practiced an ethic of caring were responsive to the unique needs of each patient, assumed responsibilities to address those needs, and were creative in findings ethical solutions to health care problems.
Jensen and colleagues23 examined the clinical practice of expert physical therapists, observing that they were consistently able to communicate a sense of commitment and caring toward their patients. The strong sense of commitment of experts toward the overall well-being of their patients resulted in a health care climate that emphasized collaborative and reciprocal decision making between physical therapists and patients. Resnik and Jensen24 found that primary goals of expert physical therapists in caring for their patients were the empowerment of their patients and the establishment of good patient-therapist relationships.
Given that the APTA encourages physical therapist educators to foster compassionate attitudes and caring behaviors in physical therapist students across practice settings and patient conditions, it is particularly important to examine the meaning of caring in the experiences of newly graduated physical therapists. This information will add to an overall understanding of caring from physical therapists’ perspectives. In particular, this information will help clarify the framework of caring in novice physical therapist practice as a rules-based beneficent orientation, as a core value that influences clinical behaviors, as a type of virtue ethics, as part of a theoretical model of experienced and expert practice, as a moral framework characterized by an ethic of care, or as a combination of these factors.
The purpose of this study was to examine the experiences of novice physical therapists across inpatient and outpatient practice settings in order to understand the essential meaning of caring from their perspectives. We sought to answer the question: What is the meaning of caring in the clinical practice of novice physical therapists?
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The current study incorporated Creswell's approach to phenomenology.25 This approach allows for some interpretation of interview data by researchers as a way to organize and present the information that is collected. Using this approach, we developed "meaning statements" about the nature of caring that were related to the ongoing interpretation and analysis of the interview data. These meaning statements, in turn, formed the basis of themes and subthemes about caring.
Participants
Participants for our study were selected from 2 major clinical practice settings located in the Atlanta, Georgia, metropolitan area: inpatient facilities (hospital-based and rehabilitation-based centers) and outpatient facilities (freestanding clinics to which patients travel to receive therapy, usually 2 or 3 times weekly). Although we recognized that there are differences in types of inpatient and outpatient facilities and patient populations across physical therapist practice (home health, geriatric and pediatric practices, rehabilitation, and acute care), we expected that at the very least, from a broad perspective, inpatient and outpatient settings would present some basic differences in patient populations in terms of diagnoses, treatments, and length of rehabilitation.26
Purposive selection from all clinics was used to ensure representation of novice physical therapists across both practice settings. Novice physical therapists were defined as those with 1 year or less of clinical experience after graduation from an accredited physical therapist educational program. The criterion of 1 year or less was based on the findings of a phenomenological study by Benner et al,16 who examined the behaviors of novice and expert nurses during clinical practice.
Procedure
Participants for this study were identified by a multistep process. First, inpatient and outpatient rehabilitation facilities in the Atlanta area were selected through online and telephone book searches. These facilities were systematically contacted by telephone until all participants had been identified. After explaining the purpose of this study, we asked whether the facilities currently employed physical therapists who had 1 year or less of clinical experience. Facilities that had eligible physical therapists on staff were asked to encourage potential participants to contact us if they were interested in participating in our study. Once participation was agreed upon and written informed consent was obtained, a 45- to 60-minute interview session was conducted at a site convenient to the participant. At the end of this process, 7 participants agreed to participate in this study. Three participants were employed at outpatient facilities, and the remaining 4 participants were employed at inpatient facilities.
The study participants ranged in age from 26 to 32 years (Table). All participants had graduated from an accredited physical therapist educational program less than 1 year prior to the time of data collection.
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The junior research members alternated conducting semistructured interviews. This method of interviews was chosen to allow for greater exploration and definition of insights from the participants’ perspectives.16,22 We began each interview by asking open-ended questions about the participants’ reasons for choosing physical therapy as a profession and their particular clinical settings. These questions were followed by more-specific questions related to caring. This method allowed for flexibility during the actual interviews so that participants could talk freely about their experiences with caring for patients.
Questions about caring were selected on the basis of a series of pilot studies that were consistent with the purpose of this study. The first 2 questions were designed to examine the participants’ personal interpretations of the meaning of caring in general (question 1) and specifically in relation to clinical practice (question 2). Questions 3 and 4 related to the participants’ perceptions of caring in relation to the health and illness experiences of their patients during rehabilitation. Question 5 was designed to focus on possible personal, environmental, and societal barriers to caring previously reported in the literature. Questions 6 and 7 were designed to determine changes in caring in response to clinical practice experiences.
The questions were:
Data Analysis
All interviews were audiotaped and transcribed. Copies of each transcript were sent to each researcher, and participants received copies of their own interviews. All participants were given the opportunity to read and review their own transcripts and were allowed to make any additional comments to ensure the accuracy of their statements.
The analysis was based on the method described by Creswell27 and was carried out as follows. Each researcher individually highlighted significant statements in each interview that were relevant to caring, including barriers to caring. Once that step was completed, all of the researchers brought their findings to a group meeting, at which significant statements were carefully compared. The researchers discussed and compiled a master list of significant statements for each participant. A master copy of each participant's interview transcript with the highlighted significant statements was developed in order to keep a detailed audit trail for future reference and coding. Each participant's list of significant statements for each setting was consolidated, individually by the researchers and then in a group meeting, and similar statements were grouped together to form meaning statements. Once meaning statements were derived from each participant's data, 2 general lists were compiled: one for inpatient physical therapists and one for outpatient physical therapists. Each general list was consolidated further, and similar meaning statements were grouped together to form themes by all of the researchers. Once themes were identified, subthemes accommodating all of the meaning statements emerged. Final themes for data analysis included those that researchers identified as pertaining to caring as well as those that represented barriers to caring.
Methodological Rigor
Methodological rigor was established during data collection and analysis in the following ways. The interview format used in this study involved first asking general, open-ended questions about the participants’ clinical experiences. Researcher control over the interview, therefore, was minimized, and participants were allowed to speak freely of their experiences. This strategy reduced any potential researcher bias and allowed for rich, detailed descriptions. All narratives were collected and later confirmed by the participants for accuracy in order to improve the credibility of the study. None of the participants requested changes to the transcripts. Peer checking, reflexivity, and bracketing were used to minimize individual biases during data analysis and to improve both the confirmability and the credibility of the study.28 Reflexivity involves reflecting on one's own biases. Biases must be identified before they can be eliminated. Because we were addressing the potential for many different frameworks of caring, each researcher attempted to determine his or her biases prior to this study, either through self-reflection or through examination of the literature. Once biases were identified, they were discussed as a team so that they could be appropriately bracketed and set aside. The awareness of potential biases allowed for a more objective approach to data analysis. This process was ongoing during data analysis.
All data were meticulously maintained and recorded to ensure an accurate audit trail to improve the dependability of the study. This process involved the establishment of a method for referencing all statements and themes to the original documents from which they were drawn (the interview transcripts). Significant statements were color coded in the original interview transcripts from which they were drawn and labeled on subsequent documents by both participant name and transcript location or paragraph number. Meaning statements included accurate references to the significant statements from which they were drawn, and the same process was followed for themes. This method allowed for quick and accurate location of the data in the original transcripts during analysis. Finally, to reduce researcher bias and to ensure that emerging themes were representative of the data, researchers processed and analyzed the data independently prior to meeting as a group to discuss findings. Individual findings were then compared so that interpretation of the data was not influenced by bias.
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Learning to Care
All of the participants reported that caring for their patients was important to their clinical practice and for successful outcomes. However, the participants described difficult adjustments to full-time clinical work that presented challenges to their abilities to spend time listening to, talking with, and caring for their patients. The sources of these difficulties ranged from communicating with "difficult" patients to efficiently and effectively balancing the demands of limited time and work with leisure activities. The theme of learning to care included 3 subthemes that were shared by the physical therapists in both the inpatient and the outpatient settings: the difficult patient as a barrier to caring, finding a balance between home and work, and time constraints.
A barrier to caring: the difficult patient.
The participants experienced difficult patients as those who were not receptive to therapy, were resistant to therapy, or were unmotivated to participate in therapy. Participants described their difficult patients as "uncooperative," "noncompliant," "not taking the therapist's advice," "repeatedly declining therapy," "not responding to therapy," and "giving the therapist a hard time." In many instances, the participants blamed their patients for a breakdown in communication. For instance, Matthew, an inpatient physical therapist working in rehabilitation, described his response to difficult patients:
I mean, I try and if they repeatedly decline and refuse I really get to the point where I'm like, you know, when there is nothing else I can do, and I shut off a little bit—I guess that's when caring kind of goes out the window. I mean if you don't care about yourself, then why should I care about you?
An issue frequently encountered was trying to provide effective care to unmotivated patients. Kendra, an outpatient orthopedic physical therapist, commented:
It's really hard to show someone, it's hard to care for someone [when] they're just mean and nasty. I mean flat out ... it's almost fake... . If [the patients] don't want to improve, they're not going to improve."
Sam, an inpatient physical therapist working in an acute-care setting, stated:
You can only do so much sometimes, that sometimes patients just don't respond and those are difficult patients. It's like some of those patients that, you're telling them how to move or what they need to do to not be in pain and yet they're yelling at you ... and sometimes patients don't respond and you just move in ... you deal with it, so personality can be a barrier.
In some instances, family members of patients present difficulties for therapists. Melissa, an outpatient pediatric physical therapist, described the challenge of caring for children of difficult parents:
I think when you make recommendations that you feel are good recommendations but the parents are resistant. Or a lot of times there are marital problems when children have disabilities, especially long-term disabilities. Mom and dad are going through a divorce and mom had one viewpoint and dad another, so, no, I am not going to get in the middle of that.
Finding a balance.
In addition to barriers toward caring resulting from interactions with difficult patients or parents, the novice physical therapists expressed frustrations concerning the stress and fatigue that they experienced while taking care of their patients and balancing a busy work schedule. At certain points in their professional development, many of the participants recognized that caring for themselves was an important part of effectively caring for their patients in professional practice. As a result, many of the participants in both inpatient and outpatient settings recognized the importance of learning to take care of themselves by balancing work and home life to reduce stress associated with caring for their patients. One aspect of learning to take care of themselves was recognition of the demands and energy of caring for their patients without a guarantee of successful outcomes. For instance, Bryan, an outpatient orthopedic physical therapist, expressed difficulty in accepting his personal limitations during patient care:
The down part is sometimes it can be frustrating when you give all you can give. Sometimes knowledge has its limits, and you apply everything you learn in school, and you do all you know to do to the best of your ability, and sometimes that's just not enough for some patients. That's hard, and you have to recognize your limits, especially as new physical therapists.
Melissa also expressed her frustration as a novice physical therapist:
When you're brand new ... you don't have any experience in handling those situations. You don't know what you'd do because it's never happened.
Additionally, Kendra spoke of her limitations as a physical therapist:
I just don't think physical therapy helps everybody, and that's something that is hard at first to realize ... you can't cure everybody.
The participants used different strategies for taking care of themselves to avoid stress. Sam, for instance, felt that self-reflection was crucial to leaving the day's stressors behind:
I'm a big proponent of down time, especially at the end of the day, especially if it's been a stressful day or if it's been an enjoyable day. [I just] take time and sort of reflect back on the day.
Other participants tried to remain active within their communities in an effort to relieve stress. Bryan, who works in an outpatient orthopedic setting, credits his success in caring for himself to having a focus outside of the clinic:
I like to be physically active and I also like to be spiritually active. ... I try to go to the gym or run or bike or play soccer ... something that physically gets me releasing any tension in my body. ... If you don't care for yourself, how can you care for others? I try to do what everybody tries to do: that's spend time with my family, take care of my body, and take care of my mental health ... caring for yourself is so important because you have to draw a line somewhere.
At the end of the day, the participants tried their best to "leave work at work" in an effort to keep separate their professional and personal lives. However, this was a struggle. Bryan stated:
It's been tough, that whole work-home, work-self balance ... that's been a challenge. ... I haven't solved that puzzle yet. I think it's an ongoing thing.
Time constraints.
The novice physical therapists described how constraints on their clinical time affected their ability to care. They told stories about lack of time to spend with their patients because of administrative responsibilities and high patient case loads. Luke, an inpatient physical therapist in an acute-care setting, provided an example:
We're just overburdened I think ... we're not able to get to patients as often as we'd like. ... When you get to the point where we are right now, and you're not able to get to all the patients you want to see during the day, it definitely makes you kind of have to cut things short.
Bryan conveyed his frustration:
How can you show caring the more and more people you have and you have to divide your time?
Melissa felt that she struggled with completing administrative tasks quickly because of her inexperience:
There's a lot of times when I'm here until 7 PM at night doing paperwork, and you know I see my last kid at 5. ... I think that comes a lot with being a new therapist because you need to take a lot of extra time to make sure that you've dotted all your I's and crossed your T's.
Patients as Subjects
Despite barriers to caring, our participants were genuinely concerned about their patients and made concerted efforts to individualize their care to meet the specific needs of their patients. In addition, despite struggling with the burdens of caring, many looked beyond their patients’ diseases or injuries to their illness experiences (including their lived experiences related to their diseases or injuries) and considered these to be instrumental in patient care. The result is that many of the participants practiced an ethic of care by focusing on their connection to their patients as fellow human beings in order to help guide treatment; in most cases, this ethic of care went beyond rules-based beneficence. Bryan's report was typical of the holistic approach toward illness experiences:
What I try to do is to just really empathize, to really understand where they are at in their lives, what their biggest stressors are, what their biggest concerns are right now, and how I, as a physical therapist, address that. I try to see it holistically—not only physically—where their pain is and how it is working mechanically but also from their mental and emotional standpoints.
By viewing their patients holistically, or as subjects of illness rather than objects of disease, the participants were able to focus on the meaning of health and quality-of-life issues related to illness. For example, Sam said:
One of the best aspects of my job is getting to spend a lot of time with patients. Doctors and nurses may be going in and out very quickly, and patients don't really have time to really voice their concerns. There's a guy that I just worked with, and he had a severe aneurysm. The doctors were so focused on the fact he'd lived that there wasn't a lot of attention pain to the fact he was having a difficult time walking. We spent a lot of time talking about that and how much better it made him feel somebody was aggressively concerned.
Like Sam, other participants recognized the human connection with their patients and were able to extend their care to the emotional as well as the physical well-being of their patients. In this passage, Kendra's story evokes the core value of caring and the behavioral indicator of embracing the emotional and psychological aspects of patient or client care:
I really try to understand what the patients are saying. I really, truly think there are a lot of people who need that ... letting them talk. I mean it's amazing. Some people are in so much pain, and all of a sudden you just let them talk about things—what's going on in their lives, and all of this emotion comes out. I think it's not always a physical aspect of physical therapy. I think it's emotional, too—trying to get your patients to feel better whether it's physically better, emotionally, psychologically—whatever you got to do.
The novice physical therapists described this connection as a reciprocal relationship that involved mutual trust. Bryan explained this relationship:
[Patients] get into this mind-set once they've seen that people really do care about them ... that if they come here, to this clinic, or to certain therapists, they already have this preconceived feeling that someone cares about them, and that in itself is beneficial.
For some therapists, return of affection and care was an important part of their relationships with their patients. Melissa explained:
[Therapists] spill over into [patients] lives so much ... they really depend on me for guidance ... they have a genuine caring for me back, and they want to see me happy, too. ... I don't think that happens instantaneously, either, because it took a couple of months for me to realize that ... even when I discharge patients, it's a happy time, but it's a sad time, too.
Luke felt that caring as part of clinical practice was essential to developing a connection with a patient:
I think caring is one of the most important tricks you've got in your bag, and you use it all the time. Without [caring], you really just don't make a bond, and you really can't make an impact.
Interestingly, the novice physical therapists in this study appreciated the influence that touch had on their ability to communicate with their patients. Several of them commented on the importance of touch. Lauren stated:
You've already broken the barrier of touch, you know, because you're hands on with the patient, and I think that allows the patient to be way more open with you than any other practitioner. When you have a nurse or CNA [who comes] in and throw you around in bed ... you're not going to open up to them.
Bryan felt that touch is an essential aspect of caring:
Physical therapy, by nature, is a profession that we do a lot of touching and interaction and hands-on therapy, so the way you show caring is through touch a lot of the time.
Several of the participants described the importance of caring to outcomes and the empowerment of patients. Kendra stated, "I get better outcomes," with a commitment to caring. Sam described caring as an "art form":
Because if we, as professionals, are showing that we are caring, we're going to get a lot more from our patients when we ask them to do things ...that's sort of the art form. ... If we want a patient to respond to the things that we are asking them to do we have to ... be caring and have to establish sort of this trust [and] confidence in what we're doing so they can respond and give back.
Matthew stressed this partnership:
[Patient] involvement in making goals for themselves ... you just let them feel like they are a part of the whole process instead of [the physical therapist] being the boss. Be partners with them.
Culture of the Clinic
Finally, many of the participants reported how the attitudes, values, and behaviors of their colleagues influenced their caring interactions toward their patients. This theme relates to how the underlying culture of a clinic affects the caring attitudes, beliefs, and behaviors of impressionable novice physical therapists. Our participants indicated that the culture of their clinics influenced how they cared for their patients. The participants described elements that affected the culture of their clinics, including the values of their peers. Luke, an inpatient acute-care physical therapist, stated:
I mean, you'll get one [physical therapist] that's just in it for the paycheck, and you can definitely see a difference in their treatment and their respect for their patients versus somebody that's really in it to help people out and does do it for their patients.
Lauren also described how she is influenced by fellow staff members who are not focused on patients:
If you were to work at a place and you loved your job but worked with miserable people, I think it would ruin your day. ... [I don't enjoy] working with people who aren't willing to learn new things or aren't willing to help ... they really just want a paycheck every 2 weeks.
Interdisciplinary issues, such as interactions with coworkers and fellow health care professionals, were also barriers to caring for patients. Several of our participants reported that poor interdisciplinary communication on the part of other health care professionals made it difficult for them to adequately care for their patients. Sam stated:
Poor communication on the part of other professionals ... just in the sense that a failure to communicate to the patient from other professionals carries over into the things that I've been asked to do because it's not my role.
In the inpatient facilities, our participants also expressed irritation with fellow health care professionals who do not fully understand the role of a physical therapist. Mathew voiced his frustration about "the lack of understanding of other professionals in what physical therapists do ... we're not just people movers. We're not just cranes."
Compared with experienced practitioners, novice physical therapists appeared to require increased validation of their treatment choices. This validation can come from both mentors and coworkers and appears to play an important role in guiding these developing professionals in the field of physical therapy. For example, Bryan views his mentors as an invaluable source of knowledge:
I'll run [things] by other therapists that are more experienced ... get their opinion, give my thoughts, see if I'm on the right track, if my thinking makes logical sense, and if they need more immediate help. ... Being so new to the profession, I do like verification, especially on more-complex problems, by other physical therapists. That's what I was looking for when I was looking for my first job—a mentor ... someone who really loves what they do and really wants to help with the learning process. ... Even though you graduate with your doctorate, you still have a ton (chuckle) to learn.
Many of our participants reported a need for supportive and positive staff dynamics. They indicated that their ability to care for their patients was enhanced by the capacity of staff members to work well together as a team and maintain a positive clinic atmosphere. These participants noticed that their fellow physical therapists greatly influenced how they treated their own case loads as well as their quality of care. For instance, Bryan stated:
Well, I think you're very impressionable when you first come on your first job. You're going to take on the characteristics and the mentality and the behaviors of your coworkers ... they are modeling for you what you should and shouldn't be doing, in a sense. I know for sure I've been influenced by those around me. If they rushed through their patients, maybe I'd be more likely to rush through mine.
| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsReferences |
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The novice physical therapists in the present study reported struggling with caring for patients who were perceived to be difficult, including those whom they perceived as unmotivated, those who repeatedly refused therapy, and those who did not take their advice. Although many of the participants in this study blamed the difficult patients or their families for a breakdown in communication, researchers have acknowledged the fault of the health care provider as being equally important. For instance, Gallois et al29 showed that nonverbal messages sent by physical therapists in their interactions with patients may negatively affect communication and patient adherence and outcomes. Thornquist30 explored the initial encounter between physical therapists and their patients and observed the negative impact of subconscious behaviors on interactions with patients. Furthermore, Potter et al31 argued that difficult patients do not assume the roles that are expected by health care professionals, who may have beliefs and values or other personal characteristics that differ from those of caregivers and who cause caregivers to experience self-doubt.
Because novice health care professionals like our participants are more likely to experience considerable anxiety and frustration in the presence of first-time problematic and unpredictable patients, they may be more likely to blame the patients for failures in communication and less likely than experienced or expert physical therapists to approach difficult patients as challenges. Benner et al16 reported that beginner and advanced beginner nurses experienced considerable anxiety about their professional inadequacies and indicated that first-time critical situations can disable advanced beginners with fear and terror. Potter et al31 interviewed 17 experienced and inexperienced physical therapists to examine the attributes of difficult patients in private physical therapist practice. The attributes they identified included being passive, angry, or aggressive; thinking they "knew it all"; being dependent on the therapist or treatment; and being noncompliant, demanding, or manipulative. The less-experienced physical therapists perceived patients with long-term and chronic pain as being more difficult to deal with compared with the more-experienced physical therapists. The authors found that the less-experienced physical therapists identified more issues that were problematic for them as being related to what they perceived as difficult patients. These issues were not specifically injury related but involved the behavioral and psychosocial attributes and financial issues of their patients. In contrast, the more-experienced therapists did not identify as many behavioral problems of their patients as being problematic, most likely because they believed that certain behaviors were expected and were not as problematic for caring as the inexperienced therapists believed they were.
The challenge for young physical therapists dealing with difficult patients can be viewed in the context of the behaviors of more-experienced physical therapists in similar encounters. Jensen et al23 found that less-experienced physical therapists were more likely to be problem focused rather than patient focused and more uncomfortable with diagnostic uncertainty than experienced and expert physical therapists. Greenfield22 reported that experienced physical therapists care for difficult patients by recognizing that there are limits to caring for patients who refuse to assume responsibility for their health care. He observed, however, that experienced physical therapists did not easily stop caring for their difficult patients; rather, they attempted to find creative solutions to the patients’ problems regardless of the patients’ attitudes. One therapist in his study stated, "I tell the patient, let's find a constructive way out of this situation because you've got to continue to move forward." Another experienced physical therapist talked about what she learned about caring over the years:
When you are coming out of school, you have an idealistic view, but when you are in the clinic, you are trying to treat patients with constraints of your environment. The sixth sense, the ability to sit down and talk to a person and treat that person based on what's unique about that person, all are a little bit different.
Another barrier to caring faced by many novice physical therapists involves the time and energy expended caring for their patients. Learning to cope and balancing work and home life are important characteristics of caring that more-experienced physical therapists learn as their careers progress. Raz et al21 reported that female physical therapists used strategies such as leaving the clinic on time, choosing flexible job settings, and selecting convenient job locations in order to cope with the dual duties of career and home life. According to Romanello and Knight-Abowitz,13 caring for others on a daily basis in a job that is already taxing, challenging, and demanding requires a vast amount of time and energy. Experienced physical therapists reported that taking care of themselves and taking care of their patients had to be mutually inclusive behaviors in order to avoid burnout. Burnout can occur when the practitioner does too much for the patient, thereby minimizing the patient's role in the plan of care, rather than working collaboratively to meet the patient's goals. Greenfield22 reported stories of experienced physical therapists who struggled to support patients, emotionally and psychologically, even after all of their physical therapy goals had been met. Benner and Wrubel14 indicated that overinvolvement as a caregiver is, in fact, antithetical to an ethic of caring, reflecting instead a need to control and dominate a situation. Branch5 warned that physicians should always blend receptivity, compassion, and empathy for a patient's needs with responsible decision making.
The phenomenon of overcaring is detrimental to the mental health of the patient but also to that of the physical therapist. Leners and Beardslee17 found that nurses faced negative interpersonal emotional stress associated with ethical dilemmas. These nurses felt as though they often had to choose between getting involved in an ethical situation and their own emotional livelihood. Purtilo and Haddad32 advised physical therapists to practice an ethic of caring cautiously, taking care to define their limitations of caring in clinical practice. Experienced physical therapists have acknowledged the importance of combating emotional burnout by setting boundaries between their professional and personal lives such as curtailing long work hours and spending time with friends and family.22 Novice physical therapists must learn the boundaries of caring and how to implement these boundaries in their professional careers.
We believe that novice physical therapists have not yet learned to be efficient with their time and exhibit more difficulty with time management skills than experienced and expert physical therapists. Jensen et al33 reported that experienced physical therapists (with more than 13 years of clinical experience) were able to manage their time better than less-experienced therapists (with less than 2 years of experience) and make the best use of a patient's total treatment time by spending more time in direct hands-on care, seeking information, and educating the patient. The more-experienced physical therapists also were able to handle administrative tasks efficiently without disrupting the treatment session, whereas the less-experienced therapists were often distracted and lost focus during direct patient care.
Romanello and Knight-Abowitz13 argued that time constraints are becoming a greater and greater barrier to practicing an ethic of caring in clinical practice because of the increased documentation and authorization demands placed on practitioners by insurance companies, administrators and, ultimately, managed care. High demands are placed on physical therapists to be productive in direct patient care and to perform administrative obligations, such as documentation and insurance authorization. Physical therapists are forced to "work the system" to find creative ways both to meet the needs of the patient and to stay within the constraints of the health care system.
Implications
The results of the present study have professional and educational implications. Newly graduated physical therapists in contemporary health care practice settings will find many challenges that affect their abilities to develop caring for their patients. The fact that inexperienced therapists have to learn to care suggests that caring requires certain attitudes and skills that should be nurtured and developed during physical therapist educational training and during the initial year of clinical practice.
One strategy is to encourage inexperienced physical therapists to search for experienced physical therapists willing to serve as mentors during their first professional, clinical experiences. Mentors should be willing to meet with novice physical therapists periodically to discuss problematic patient cases and help these therapists develop strategies to care for these patients. Physical therapist educators should prepare students for potential risks and conflicts during their first year of clinical practice. Purtilo and Haddad32 recognized the difficulty of caring in clinical practice but advised that caring should remain central to clinical practice. Therefore, students should be taught to define the limitations of professional relationships and potential pitfalls of caring. Particularly effective in nurturing attitudes of caring is the use of simulated patient cases in which students are able to engage in situations that closely reflect some of the problems that they might encounter in future clinical care. Jensen and Richert34 advocated the integration of simulated patient cases followed by student reflection about that experience as a way to nurture values of caring associated with professional behavior.
The first year of clinical practice can be particularly daunting for novice physical therapists. We believe that without a formal internship in physical therapy like that in medicine, the first year of clinical practice for many physical therapists is akin to a medical internship. On the basis of the findings related to the culture of the clinic in the present study, experienced clinicians should recognize the importance of their values, attitudes, and behaviors to ethical and skill development in novice physical therapists. Mostrom35 described opportunities that clinical instructors have to enhance teaching students about the ethical and human dimensions of care in clinical settings by modeling humanistic and caring practice, creating a culture of respect, and facilitating mindful practice through critical self-reflection (by creating dialogue as conversation, inquiry, and instruction). These same strategies and behaviors can be directed toward novice physical therapists by experienced clinicians. In addition, Branch et al36 suggested that clinicians search for and take advantage of teachable moments—what they referred to as seminal events in clinical education.
Our novice physical therapists’ statements verified the importance of being surrounded with knowledgeable colleagues and mentors for frequent consultation. Resnik and Jensen24 reported that the experts interviewed had a rich knowledge base of colleagues to consult when faced with challenging cases, placing themselves in a supportive atmosphere that would augment professional growth. We believe that it is even more important that novice physical therapists seek such supportive environments when beginning their careers and ensure that the values of their clinics mirror the core values of the physical therapy profession.
Limitations
Only 7 participants were interviewed in the present study. Although this number is not unusually small for phenomenological examinations (Blau et al37 interviewed 5 participants in their phenomenological study), in relative terms the small sample size makes generalizability to all novice physical therapists problematic. Research is needed to determine whether the experiences of physical therapists in other settings and in other locations are similar to those of our participants.
For the present study, we collected data at one point in time. It would be useful to understand how caring in our participants evolved over several months. Future studies should examine caring in novice physical therapists by incorporating direct observations of clinical encounters as well. Future studies also could examine the perceptions of patients or other health care professionals as to what constitutes a caring practitioner in the physical therapy profession. Subsequent research also could examine demographics different from those examined in the present study, including more minorities and people of color. In addition, we did not collect data about the accredited educational programs in which our participants were trained. It is possible that our sample was composed of students from only 1 or 2 accredited programs. If so, then their perspectives may have been significantly influenced by only a few faculty or educational objectives in ethics and professionalism. Future studies should explore the perceptions of patients across more specific clinical settings, such as home health and outpatient settings.
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The findings of the present study suggest that caring requires certain skills and attitudes that accrue over time and that physical therapist education programs should integrate learning experiences throughout the curriculum to foster caring attitudes and behaviors in order to prepare students for the first-year transition in the clinic. However, the first year of clinical practice offers ample opportunities for learning experiences related to caring and caring behaviors that can be exploited by experienced physical therapists as mentors.
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The authors thank Jeanne Merkle Sorrell, PhD, RN, FAAN, Professor, School of Nursing, George Mason University, for her invaluable critiques and feedback on the manuscript.
This study was conducted with the approval of the institutional review board at Emory University School of Medicine.
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