A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation

The aim of this study was to develop an implementation intervention that could be
used to promote physiotherapist behaviour change in primary care. Specifically, the
intervention was developed to support physiotherapist’s enhanced use of theory-informed,
evidence-based communication skills in clinical practice. Our development approach
was systematic and allowed us to choose behaviour change techniques and delivery modes
informed by theory and evidence that addressed some of the specific barriers and enablers
identified by key stakeholders in the local context. The subsequent pilot-study with
two physiotherapists, allowed us to consider how this intervention could be optimized,
tailored and refined prior to a more detailed testing of effectiveness.

Refinements

During the pilot-testing we found that, on the whole, both physiotherapists were positive
regarding the success of the KEDS intervention in addressing the barriers of knowledge,
skills, beliefs about capabilities and behavioural regulation; particularly, the coaching
process in general and specifically the goal and action sheets and audio-recording
review. For example, one physiotherapist noted in the follow-up interviews that “the
one on one coaching was fantastic and I think really helped to cement all the learnings”.
However, they felt the barrier of limited social support was not addressed effectively
through the chosen intervention components; primarily due to wider environmental constraints,
of working in isolation with few opportunities to discuss, support and encourage their
peers. This is illustrated by the following physiotherapist comment, “we wouldn’t
really be sharing our work practices as such, I don’t think I would have the opportunity
to sit down with them (i.e. colleagues) and ask them about their experience with the
communication skills”. Lastly, in terms of acceptability, both physiotherapists considered
the intervention to be relevant and, beneficial to their practice and signalled a
desire to continue using these skills in their daily interactions with patients. For
example, one of the physiotherapists stated, “I would see myself going forward and
using it (i.e. autonomy supportive communication style) the overall benefit to me
is the sense of being in partnership with the patient”. Thus, as a result of these
initial findings, we intend to use most of the selected strategies but would recommend
enhancing the continuing education meeting to further address social support.

In addition, preliminary assessment of physiotherapist behaviour change with the HCCQ
revealed an important finding. As part of promoting autonomy supportive behaviour,
the KEDs intervention also addresses how to identify and reduce controlling behaviours
(e.g. contingent reward or conditional acceptance) which has been negatively associated
with long-term behaviour change 35]. Feedback from the semi-structured interviews reinforced the discussion and recognition
of controlling behaviours as a useful part of the intervention. Unfortunately, the
HCCQ only measures autonomy supportive behaviours. Therefore, based on this finding
and in line with recent health related research 36], we would refine the intervention assessment to include measures of autonomy supportive
and controlling behaviours to fully assess change in physiotherapist communication behaviour.

Strengths

The MRC guidelines for design and evaluation of complex (e.g. behaviour change) interventions,
recommend that researchers fully describe the rationale underpinning the development
process and map intervention components to theory and outcome to allow for meaningful
evaluation which we have done using the TDF. Thus, our study differs from many previous
implementation interventions which did not rely on theory to design interventions
37] and expands on the limited number of theory-informed, tailored interventions developed
using a rigorous methodological approach. Moreover, by tailoring the intervention
to address specific TDF barriers/enablers and linking those with specific behaviour
change techniques, we ensured a better understanding of how change within the intervention
might be achieved 38] and increased the opportunity to change clinical practice.

Recommendations for future research

This intervention only addressed barriers and enablers at the intra and interpersonal
levels. For example, at the intrapersonal (physiotherapist) level, feedback from interviews
indicated that this intervention was acceptable in enhancing the knowledge, skills
and self-confidence of participants. This was likely due to specific components of
the intervention that addressed these barriers, such as information provision at the
continued education meeting and goal-setting, problem solving and feedback through
the coaching process. Whereas, at the interpersonal (therapist-to-therapist) level,
it seemed the barrier of lack of social support was not addressed adequately by the
intervention components. Specifically, the process of encouragement and support through
the continued education meeting did not enable support networks to be created within
the primary care sites. Operationally, this intervention could also be further challenged
by: (i) organisational barriers related to time and workload and (ii) patient expectations,
which were originally identified in focus groups but deemed beyond the scope of this
intervention. Indeed, both participants in the semi-structured interviews reported
the ongoing negative effect of these barriers.

Consequently, future research should consider strategies to further enhance the intervention
to address barriers beyond those at the physiotherapist level 39]. For example, participants in the focus groups highlighted the challenges of working
with patients who expected passive rather than proactive treatment. This could perhaps
be addressed by additional communication with referring primary care GPs about the
scope of physiotherapy in chronic pain management as well as eliciting patient expectations
and then managing them more effectively using a range of communication modes (e.g.
introductory information advising patients what physiotherapy is and what they can
expect prior to attending a consultation, this could be provided via postal, telephone
or online methods).

Lastly, while we found that individualized coaching was acceptable and likely to provide
a positive impact on behaviour; a one-to-one in person approach is costly and perhaps
impedes opportunities for wider dissemination. Thus, exploration of providing this
component in other formats and at different levels tailored to the individual could
also be considered 40]. For example, the use of educational technology such as the virtual environment of
Second Life 41] might be an alternative method for training HCPs and improving self-efficacy for
the behaviour along with skill development. Additionally, the use of intermediaries
such as, local opinion leaders 42] could be an alternative for targeting barriers related to professional role and identify
and social influence. Both avenues may be promising and pragmatic ways to support
clinician behaviour change.