This research note describes a pilot study that examined the meaning of caring from the perspectives of patients undergoing physical therapy. METHODS: A phenomenological methodology was used to explore the essential meaning of caring behaviors from the experiences of patients undergoing physical therapy. Patients were asked to describe caring interactions they have experienced with their physical therapists. RESULTS: The responses of the participants were inductively analyzed for themes and sub-themes that explained physical therapy caring. Based on that analysis, a central theme of mindful caring emerged from participants' responses. The theme of mindful caring reflected the physical therapist and patient relationship. Further analysis uncovered four sub-themes that gave a clearer picture of caring behaviors experienced by the participants. These included personal values, patient empowerment, open communication and exceptional service. CONCLUSION: The results of this pilot study demonstrate the dimensions of caring in healthcare practice from the unique perspectives of patients. J Allied Health 2010; 39:e43- e47.
ALLIED HEALTH PROFESSIONALS cultivate relationships that are guided by the value of caring. Caring has been identified in many healthcare professions as a core value of their professional ethos.1-13 Contemporary healthcare disablement models such as the International Classification of Impairment, Function and Disability (ICF),14 emphasize patient-centered caring to uncover and integrate patients' personal values into decisions about clinical care. The nature of caring in clinical practice is based on psychosocial literature,15,16 professional education literature,17-20 normative ethical theory,21 feminist ethics,22,23 and qualitative exploration.8,12,13,24-34 Most of that data about caring, in turn, are based on the experiences and the perspectives of ethicists, educators, and clinicians and little from the perspectives of patients.
Caring has been described in healthcare literature through several different and conflicting frameworks, including: virtue of caring8,35, ethics of caring6,20,36,37, novice and expert caring24,31,34,38, and rules based caring39,40 (Table 1 provides a summary of caring frameworks) An American Physical Therapy Association (APTA) consensus panel developed a document, Professionalism in Physical Therapy, to assist the profession in its transition to a doctoring profession. This document listed several core values of professionalism including caring. The consensus panel defined caring as concern, empathy, and consideration for the needs and values of others.41 The document lists sample indicators of caring behaviors including:
(1) understanding an individual's perspective,
(2) being an advocate for patient's/client's needs,
(3) empowering patients/clients to achieve the highest level of function possible and to exercise self-determination in their care, and
(4) embracing the patient's/client's emotional and psychological aspects of care.
Because caring is considered a core value of clinical practice, researchers in healthcare continue to explore caring behaviors from multiple perspectives. The purpose of this study was to explore the nature of caring from the perspectives of patients undergoing physical therapy to determine the behaviors that reflect caring. Based on the purpose of this pilot study, we sought to answer the following questions. Are therapists exhibiting caring behaviors? Second, is our caring consistent with the sample indicators set forth by our professional organization? Third, is caring the same across all clinical settings and patient conditions?
This study was approved by the Institutional Review Board at Emory University. To develop a deeper understanding of caring behaviors in clinical practice from the perspectives of patients, a phenomenological research design was used. Phenomenology was the methodology of choice because this method helps us explore and understand human interactions within the context in which they occur. 42 Phenomenological researchers analyze experiences through interviews or narratives, and categorize the information into themes and sub-themes that will eventually explain the data. 43 Phenomenology has been used in previous studies that examined caring in clinical practice. 24, 31
Purposeful sampling44 was used to recruit participants from a list of approved clinical affiliation sites used by the Division of Physical Therapy at Emory University. Sampling yielded 9 participants-3 from acute care, 1 from rehabilitation and 5 from outpatient orthopedic clinics (Table 2). The list of clinical sites was provided to the investigators by the Academic Coordinator of Clinical Education. All 9 participants were attending physical therapy for at least 4-6 sessions at the time of the interview to ensure that each had the opportunity to establish therapeutic relationships with their physical therapists.
RECRUITMENT OF PARTICIPANTS
An introductory letter was mailed to the physical therapists and clinic administrators in each selected clinical site. The letter introduced the investigators, explained the purpose of the study, and requested assistance to help recruit potential participants. The physical therapists and/or administrators who agreed to participate provided a list of potential participants who expressed interest in contributing to the study. Potential participants were subsequently mailed letters, to introduce the investigators and briefly explain the study. The patients verbally communicated to their physical therapist whether they accepted or declined participation in the study. Once the patients accepted participation in the study, they were contacted by the investigators to set up a time and place for an interview.
TYPE OF INTERVIEW
Prior to the interview, demographic data about each participant was obtained from his/her physical therapist. Concurrently, the participants were screened for cognitive impairments using the Mini Mental Status Examination (MMSE), a 30-point questionnaire used to assess cognition. 45 Most widely used to screen for dementia, the MMSE standard cutoff for a cognitive impairment of 24 was used in this study. No participants were excluded due to MMSE scores. After cognitive screening, each participant was provided additional information about the study and his/her roles. A consent form and a Health Insurance Portability and Accountability Act (HIPAA) waiver were signed by each participant acknowledging an understanding of the research study and patient confidentiality. One investigator conducted the interview. Each interview was audio-taped and lasted approximately 10 to 15 minutes. Probe questions were asked, as needed, to encourage elaboration about specific experiences
The following semi structured interview questions, taken from a previous phenomenological study that examined the meaning of caring in nursing from the perspectives of their patients were used in this study. 46
1. Describe a personal interaction you had with your physical therapist that you felt was caring.
2. Try to describe how you felt in that interaction.
3. Please do not stop until you feel that you have discussed your feelings as completely as possible.
Pilot testing of the interview process was performed prior to data collection. The purpose of the pilot test was to practice the interview process. Two separate pilot studies were conducted. For each pilot study, an investigator volunteered to interview a patient undergoing physical therapy recruited from Emory list of clinical sites. The interviews were audiotaped. The remaining investigators including the principal investigator (BHG- with substantial experience in qualitative research) were present during the pilot interview. After each interview, the entire investigative team listened to the audiotape while providing feedback. Feedback was directed in two crucial areas consistent with good phenomenological interviews- minimizing interviewer bias by eliminating leading questions, and promoting the proper use of probe question about concrete instances of caring experiences.
Each member of the research team was systematically assigned by the PI to interview participants. As a result, each investigator interviewed at least 2 participants. Six copies of each transcribed participant interview were made. The original copy of the transcript, including participant and therapist demographic information, was locked in the principal investigator's file cabinet and was assigned a code number. Each remaining copy of the transcript was identified by code number only for the remainder of the study in order to maintain patient confidentiality.
A phenomenological approach for data reduction was taken from Creswell 43 and adopted by Riemen 46. This approach emphasized an inductive process toward the development of themes and sub-themes that were common to all the participants based on their responses. All of the transcripts were read twice by each researcher independently. During the second reading of each transcript, significant statements were extracted from each transcript. Significant statements were phrases and sentences that directly related to the investigated phenomena (caring attitudes and behaviors). Investigators wrote memos along the borders of the transcripts to explain to the entire investigative group their arrival at each significant statement. The memos provided an additional "layer" of analysis to the interpretation.
Peer checking was employed during the collective review of significant statements to come to a consensus that the statement closely reflected the phenomenon of caring. Ongoing negotiation occurred among all the investigators about the inclusion of significant statements until consensus was reached 47
Collectively, the investigators grouped significant statements that contained similar ideas about caring behaviors to form meaning statements. The investigators clustered significant statements with similar meanings together to remove overlapping and repetitive statements.
In final step in the analysis the investigators identified the central idea or theme about caring based on the meaning statements from all the participants. After the major theme was identified, the investigators identified sub-themes that reflected components of the major theme. Phenomenologists' characterize sub-themes as the essences or essential variations of the major phenomenon (theme), in this case mindful caring. These clusters of sub -themes were referred back to the transcripts in order to validate them. The memos were useful during this step to revisit the investigators' thought processes.
CREDIBILITY OF THE RESULTS
Several methods used throughout data collection and analysis helped to enhance credibility of the results. First, the inclusion of memos ensured that the meaning statement did not lose its connection from the original statement. Secondly, peer checking ensured that individual biases were accounted for and controlled.
Participants were given the opportunity to verify their interview transcripts, and the significant statements extracted from it, to determine if the investigators had interpreted their experiences correctly. However, no participants elected to verify their transcripts or significant statements. Reflexivity, or bias, was controlled initially by a process of bracketing. Bracketing was achieved through ongoing peer checking and discussion of the investigators' biases about caring frameworks during the development of meaning statements and themes. 43
The investigators used an audit trail to focus on the data and the experiences of participants during physical therapy to describe their own perceptions of caring behaviors. A pilot study helped to ensure that the use of leading questions or the imposition of our own perceptions of caring on the participants' stories was minimized. During initial coding of significant statements, there was flexibility in including all statements that the investigators believed may be relevant, regardless of their own perceptions.
Mindful caring emerged as the major theme of this pilot study.Mindful caring consisted of the following sub - themes: (1) personal value, (2) patient empowerment, (3) open communication and (4) exceptional service. (Table 3)
This pilot study indicated that patients undergoing physical therapy valued ongoing caring behaviors in their therapists. We used the theme of mindful caring to best reflect the type of caring described and valued by the participants. Langer48 described mindfulness as being engaged in the present moment, noticing new things and being sensitive to context and perspective. This type of caring occurred across the clinical setting we sampled. In this particular study, the participants described the caring behaviors of their physical therapists as deeply committed to their own personal welfare. The result was that many of the participants felt valued as patients as well as individuals. Patient R1 for instance, spoke about how she appreciated being cared for by her physical therapist as an "individual versus a number". Similarly, participant A1 said about her physical therapist "Well she took an interest in things that have happened to me and told me of her experiences and things of that nature".
What was notable about the type of caring behaviors valued by the participants was their therapists' willingness and engagement in assuring their overall well being. For example participant 02 commented that his physical therapist "does things beyond the medical stuff". Participant A2 described an incident
Yesterday some kind of a thing, uh attachment they had, it came loose and I was bleeding and it came loose and I was upset because it got all over me, and I could hardly move to clean it up and [my therapist] helped me out and they helped me out
The result of this type of non judgmental and compassionate behavior created a deep bond of trust between the therapist and patient. Participant 05 tells a remarkable story that illustrates the trustful bond she developed with her therapist.
Pam, now she, she go way, way out yonder to make things work for ya. And uh, she very compassionate. She understands. A while back my son locked his keys in his car. We were at a party and we didn't have nobody to call. So my wife is looking through my phone and all of a sudden here is pam. She said "I bet she'll look up a number for us." So we called her and she was tickled to death and she said she would be glad to. She looked it up for us. Now you can't beat that.
Mindful caring as a concept has been reported elsewhere in the literature. According to Epstein49, the goal of mindfulness is "compassionate informed action in the world, to use a wide array of data, make correct decisions, understand the patient, and relieve suffering" (p. 839). The idea of compassion associated with caring may reflect that mindful caring experienced by these patients was more than actionable responses toward their well being as patients, but rather as a deeply felt commitment by their therapists to their overall welfare as human being. Mindful caring in this sense can be thought of both as a virtue (a character trait of compassion) as well as a caring behavior.50 In thinking about mindful caring as compassionate caring, we can begin to understand the limitations of either alone.
This study contains several limitations. Most of the participants interviewed were undergoing outpatient physical therapy at the time of interview. Perceptions of caring might differ fromone setting to another, such as fromacute care to outpatient. Future studies should explore differences in perceptions of caring among three practice settings.
Additionally, future studies might examine the patienttherapist dyad to determine how physical therapist characteristics may have influenced the patient's perceptions of their caring. This study did not investigate whether caring experiences from the patient's perspective differ according to gender of physical therapist. Future studies should investigate perceptions of caring among different genders of therapists.
Although the data in this study is preliminary, the findings suggest some answers to the questions we posed in the Background section. In response to the first question are we, in fact, exhibiting good professional behaviors including caring? The results of this pilot study indicate that physical therapists have embraced caring as a core value in clinical practice that reflects a deep commitment to patient-centered care. Second, is our caring consistent with the sample indicators set forth by our professional organization? Most certainly the results of this study indicate that physical therapist are guided by compassionate care and embrace, and indeed cultivate the relational nature of clinical practice. Third, is caring the same across all clinical settings and patient conditions? Based on the preliminary results, it seems so that mindful caring was exhibited by all of the therapists.
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Bruce Greenfield, PT, PhD, OCS
Erin Keough, DPT
Sydney Linn, DPT
Derek Little, DPT
Christine Portela, DPT
Dr. Bruce Greenfield is Associate Professor and Drs. Keough, Linn, Little, and Portela were formerly students in the Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA.
RN842 - Received Oct 6, 2008; accepted Nov 19, 2009.
Address correspondence to: Dr. Bruce Greenfield, Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, 1462 Clifton Rd NE, Atlanta, GA 30322, USA. Tel 404 712 4139. email@example.com.
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