Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage

Rationale, aims and objectives Innovative service delivery models are emerging using physiotherapists in the assessment and management of patients referred for orthopaedic consultation. The primary objective of this study was to compare the clinical recommendations of specially trained physiotherapists with those of an orthopaedic surgeon on: (1) appropriateness to be seen by an orthopaedic surgeon; and (2) candidacy and willingness to undergo total joint replacement (TJR) for patients with hip or knee problems. A secondary objective was to examine their recommendations for non‐surgical management and agreement on clinical diagnosis. Methods Physiotherapists and orthopaedic surgeons independently assessed patients with hip and knee problems referred for consideration for TJR and completed a standardized form on treatment recommendations. Agreement between providers was determined using the kappa coefficient and per cent agreement. Results Two physiotherapists and three orthopaedic surgeons participated in the study that included 45 and 17 patients with knee and hip problems respectively. In 91.8% (56/61) of cases, physiotherapists and orthopaedic surgeons agreed on the recommendation of appropriateness for the patient to see a surgeon (kappa 0.69). In discordant cases, the physiotherapists tended to refer for consultation. There was 85.5% (53/62) agreement on whether a patient was a candidate and willing to have TJR (kappa 0.70). The physiotherapists commonly recommended exercise and education for non‐surgical patients. Orthopaedic surgeons most commonly referred patients to rehabilitation services. Conclusions Patients with hip or knee pain referred to orthopaedic surgeons can be appropriately referred for orthopaedic consultation by physiotherapists working in extended roles. Further research is required to evaluate the value‐added and the most appropriate use of extended role physiotherapists.     

Comparing evidence-based practice of nurses and physiotherapists

Evidence-based practice has become an ubiquitous concept within nursing. However, there is little comparative data of nursing with other professions on attitudes to evidence-based practice. This article reports on a survey of nurses' and physiotherapists' sources of knowledge and perceived barriers to evidence-based practice within a large teaching hospital. A total of 324 questionnaires were sent to nurses and physiotherapists. The results showed that both physiotherapists and nurses accessed a wide variety of sources of knowledge. However, nurses were more likely than physiotherapists to use policy and procedure manuals and discussions with medical staff. Both professions have problems with overcoming the barrier of time. Nurses were more likely than physiotherapists to rate themselves as having poor evidence-based practice skills.     

Initiative to change ward culture results in better patient care

One of the main features of ward rounds is the professional conversation that occurs between doctors and nurses. Such conversation needs to be perfected to avoid iatrogenic harm and increase efficiency. This article looks at data collected from 146 consultant-led medical ward rounds at a hospital trust using the Caldwell considerative checklist process (Herring et al 2011) to identify the frequency and quality of such conversations. A total of 1,921 patients' reviews were undertaken. A nurse was present during preparatory discussions on 604 occasions (31 per cent) and during bedside review on 1,134 occasions (59 per cent). These data demonstrate an urgent need to change ward cultures to improve the professional conversations between doctors, nurses and patients. By increasing nurse presence as a result of this research patient care and safety has improved at ward level, increasing satisfaction for everyone involved.     

Problem drinkers among acute care inpatients

AIM: The objective of this study was to determine the prevalence of potential problem drinking among general hospital inpatients during a three-month period. METHOD: The study was conducted in a large Scottish teaching hospital. The wards involved were the general medical, general surgical, orthopaedic and short-stay wards as they had been identified as clinical areas with problem drinking among inpatients. Patients were interviewed using a structured interview schedule as a screening instrument to detect potential problem drinkers. RESULTS: Of the patients interviewed, 25 per cent were shown to drink in excess of the BMA's guidelines for low-risk drinking: 8 per cent had had previous treatment for alcohol problems; 2 per cent were bout or seasonal drinkers; and 15 per cent were newly identified potential problem drinkers. Of the newly identified group, 75 per cent were men and 25 per cent women. Those who were unemployed formed the largest group of potential problem drinkers according to occupation, and patients from the short-stay ward were more likely to have an alcohol problem than those from other wards in the study. CONCLUSION: The patients in this study found to be at risk of experiencing alcohol-related problems might not be routinely identified with current screening methods. This method of screening, by asking patients about their recent drinking patterns, will help nurses to identify those who are potential problem drinkers and enable them to provide relevant advice and education to these patients.     

Communication about sexual problems in male patients with multiple sclerosis

AIM: To explore the reasons given by a disability, assessment and rehabilitation team (DART) for perceived difficulties in discussing sexual problems with male patients with multiple sclerosis (MS), and to compare them with the views of a sample of patients. METHOD: Data were gathered from a multidisciplinary team who were responsible for assessment and rehabilitation of patients with MS, using a focus group and semi-structured interviews with 11 male patients. Data were analysed thematically, with reference to Annon's (1976) model of communication. FINDINGS: Patients felt a need to discuss problems with sexual dysfunction, and would welcome the introduction of the topic in a straightforward way. Health professionals were worried about intrusiveness and lack of information and training. Team members and the patients indicated that nurses are the best people to deal with these issues. CONCLUSION: Rehabilitation teams need training to deal with patients' sexual problems, and the nurse is likely to be identified as the specialist in this area.     

Goal Attainment Scaling: Is it appropriate for stroke patients and their physiotherapists?

Although much is known about the biological correlates of stroke there is a dearth of information regarding patients' expectations and physiotherapy outcomes in stroke units. Goal attainment scaling (GAS) is being used increasingly in the USA in rehabilitation facilities to measure outcome. This exploratory study aimed to determine the feasibility of physiotherapists and patients using GAS, and to discover the extent of congruence between patients' and therapists' goals. During a four-month period stroke patients and physiotherapists independently scaled goals. These were set and scaled successfully by all the patients in the pilot study, who were able to identify problems and scale goals with minimal guidance from a therapist. Physiotherapist-set goals related more often to a physical activity, whereas patients' goals related directly to functional outcome. Patients failed to reach their expected levels more frequently for their self-set goals, than for physiotherapist-determined goals. It is recommended that physiotherapists should explore further the use of GAS with stroke patients.     

The use and practice of body substance precautions in sports physiotherapy

This study examined the use of Universal Precautions in the management of bleeding sports injuries. A survey was used which asked questions on: demographics, hepatitis B vaccination, first aid practices and frequency of blood contact. The national sample consisted of 1800 Australian Physiotherapy Association National Sports Physiotherapy Group members. The response rate was 29.2 per cent. Eighty-five per cent of physiotherapists were exposed to bleeding injuries. The use of rubber gloves in the treatment of bleeding injuries was low (47 per cent using them always/frequently). Only 60 per cent disposed of sharp instruments appropriately. Eighty per cent reported being immunised against hepatitis B. Experience was strongly associated with appropriate first aid practices. The study suggests that physiotherapists in sport are not consistently adhering to Universal Precautions.     

Another look at polio and postpolio syndrome

Polio survivors will likely be accessing the health care system because of acute and/or chronic conditions as they age. Therefore, they will again be interacting with health care professionals, especially orthopaedic and rehabilitation nurses. A comprehensive understanding of polio and postpolio syndrome will give orthopaedic and rehabilitation nurses the knowledge they will need to help polio survivors and their families achieve their highest potential and quality of life.     

Subjective estimations of the treatment programmes offered in inpatient and outpatient orthopaedic rehabilitation

The survey of psychosocial, somatic and economic outcomes is regarded as standard in establishing the effectiveness of various rehabilitative forms of medical care. Another important part is the patient's perspective for the subjective valuation of the entire measure or different facets of the rehabilitation measure. During a comparison of the effectiveness of different forms of care of orthopaedic rehabilitation (inpatient, outpatient in the hospital, outpatient) 1176 patients were questioned in writing at 4 different time points. The results concerning the general measurement of the satisfaction with the rehabilitation measure showed a high level and a high acceptance in all forms of medical care at the end of and after the measure. The result relating to the selection of the correct hospital for the specific troubles of the patient was positive as well. This can also be stated for the patients' estimation of the contacts between the doctors and the physiotherapists. At the end of measure, all the patients in every form of care viewed these contacts as being helpful. The outpatient offers were viewed a bit better by the patients concerning the contacts to doctors and physiotherapists. The extent of the care specific to the different occupational groups was estimated by almost all patients of all forms as being just about right. Additionally, the course organization and the work of the administration had a good evaluation - with slight advantages for the inpatient forms.     

Exercise dependence: a problem for sports physiotherapists

Twenty-four postgraduate-trained sports physiotherapists were interviewed to investigate their experiences with exercise dependent patients. The respondents identified exercise dependent patients as likely to continue physical activity when injured. They were described in terms such as anxious, obsessive, overachieving and addicted to feelings. The majority of physiotherapists (71 per cent) reported problems in communicating with and gaining compliance from exercise dependent patients. Treatment approaches listed by the respondents included education, prescribing reduced or alternative activities, referral and psychological strategies. Most physiotherapists reported that they used combinations of these strategies. Within the limits of generalising from the present sample, it appears that sports physiotherapists are aware of the difficulties of managing exercise dependent patients and have developed specific techniques to cope with the problems of treating them.     

Physiotherapists and human immunodeficiency virus/acquired immune deficiency syndrome: knowledge and prevention: a study in Durban,South Africa

This study determined what physiotherapists in Durban, South Africa know about human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), their attitudes towards patients and how they cope as individuals. Data were collected using a validated questionnaire. One-hundred-and-fourteen physiotherapists in Durban hospitals participated in the study. Seventy-two per cent of the questionnaires met the criteria for analysis. Ninety per cent of the participants believed that they knew about HIV/AIDS, but only 78% could identify all viral transmission modes. Of the 38 physiotherapists who believed that they knew the stages of an HIV infection, only 11% actually knew the stages, 28% could not explain them and 61% were vaguely aware. Fifty-six per cent of the respondents had treated patients who had died from HIV/AIDS. Only 38% of physiotherapists were completely at ease when treating HIV/AIDS patients despite the fact that 98% believed that physiotherapy was an integral component of the management of an AIDS patient. Fifty-one per cent of the respondents were unaware of support structures provided by their employers. The authors conclude that the perceptions of physiotherapists about their knowledge about HIV/AIDS do not stand up to scrutiny. Significantly more attention should be paid to the development, implementation and evaluation of the effectiveness of educational programmes on HIV/AIDS for physiotherapists in the workplace.     

Differences in Nurse and Surgeon Perceptions of Teamwork: Implications for Use of a Briefing Checklist in the OR

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organization's Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved.     

冠状动脉支架术后患者家属居家康复知识需求的调查

目的了解冠状动脉（冠脉）支架术后患者家属对居家康复相关知识的需求。方法采用自行设计的冠脉支架相关知识调查问卷，对329例患者家属进行调查和分析。结果家属对疾病知识、介入治疗、术后药物服用及生活方式等相关知识有不同程度的缺乏。结论护士应重视患者家属的需求，制定个性化的健康教育方案，提供不同层次患者家属的健康教育与咨询服务，有效地提高家属的康复知识，从而预防并发症，促进早日康复，提高生活质量和减轻患者家属压力的目的。     

小组治疗模式在地震截肢伤员康复中的作用

目的探讨小组治疗模式在地震截肢伤员康复过程中的影响。方法对5·12汶川地震后收治我科的85例截肢伤员，采用以骨科医生、骨科护士、物理治疗师、职业治疗师、心理咨询师、志愿者、社会工作者、伤员及家属等共同参与的小组治疗模式对地震截肢伤员实施综合康复措施，评价其康复效果。结果接受综合治疗干预后，85例地震截肢伤员在生理、心理、社会功能等各方面均有显著改善（P〈0．05）。结论针对地震截肢伤员的问题以小组治疗模式进行干预可明显提高伤员的整体康复效果及生存质量。     

Accuracy of physiotherapists' predictions for mobility outcomes at 1-year post spinal cord injury

The primary objective of this study was to determine the accuracy of physiotherapists' predictions of mobility for people with spinal cord injury (SCI). Five physiotherapists and 47 patients from two SCI units were recruited. Two sets of predictions about mobility at 1 year were made for each patient shortly after they commenced rehabilitation. The predictions were made using standardized outcome measures. One set of predictions was made by the physiotherapists from the patients' SCI unit who had face-to-face contact with the patients and the other set of predictions was made by the physiotherapists from the other SCI unit who had no face-to-face contact with the patients and instead relied on chart records, and vice versa for patients from the second SCI unit. Correlations between mobility at 1 year and the predictions made by the physiotherapists who had face-to-face contact with the patients ranged between 0.54 and 0.85. The corresponding correlations for the physiotherapists who did not have face-to-face contact ranged between 0.40 and 0.71. Contact and non-contact physiotherapists' predictions were within one point of outcomes between 55% and 83% of the time. Physiotherapists were reasonably accurate at predicting future mobility. Face-to-face contact with patients slightly improved the accuracy of predictions.     

Comparison of perceptions and barriers to mobilization in critical care: A comparison of nursing staff and physiotherapists—A single-site service evaluation

Background

Mobilization is a key component in the recovery of those admitted to critical care. However, previous research has demonstrated challenges in the implementation of mobilization within critical care, including staff knowledge, attitudes, and behaviours.

Aim

The aim of the current study was to explore the perceived barriers and limitations to mobilization from the perspective of nursing staff, and to compare these with physiotherapists.

Study Design

Single-site service evaluation utilizing the patient mobilizations attitudes and beliefs survey for ICU and locally developed barriers to rehabilitation questionnaire.

Results

About 135 participants (126 nurses and 9 physiotherapists) were invited to anonymously complete the questionnaires (either paper or electronic), with a response rate of 73.0% (n = 92) for nursing staff and 100% for physiotherapists. Nursing staff reported significantly higher perceived barriers to rehabilitation on both questionnaires when compared with physiotherapy staff, which was not associated with years of experience within critical care. Behavioural barriers were most frequent in both professions which included items such as time availability and presence of perceived contra-indications to mobilization.

Conclusion

Nursing staff reported greater perceived barriers to rehabilitation when compared with physiotherapists. Further quality improvement projects are now required to reduce these barriers and assist the implementation of mobilization as part of the rehabilitation process.

Relevance to Clinical Practice

Rehabilitation is an essential element of practice within critical care. Understanding the system, local and personal barriers will allow for improvement projects to enhance the delivery of care and improve clinical outcomes.     

An investigation of interprofessional collaboration in stroke rehabilitation team conferences

The aim of this paper is to report a study examining the team processes occurring in team conferences in a stroke unit. Team conferences provide an opportunity for all members of the rehabilitation team to report patients' progress and establish patients' rehabilitation goals. The findings suggest that little discussion or consideration of alternative intervention plans are undertaken and that team conferences serve to disseminate decisions rather than establish patients' rehabilitation goals. Core members of the rehabilitation team have developed specific roles. The physiotherapist 'proposes' decisions which are 'seconded' by the occupational therapist. The doctor acts to sanction decisions and the nurses action them. Team conferences are effective for dissemination of decisions and for giving rise to a sense of team collaboration.     

The effect of ward design on the well-being of post-operative patients

Changes in the design of hospital wards have usually been determined by architects and members of the nursing and medical professions, the views and preferences of patients have seldom been sought directly The Hospital Anxiety and Depression scale and the Disturbance Due to Hospital Noise questionnaire were administered to 64 female patients on bay and Nightingale wards together with a questionnaire designed for this study Perceptions of social and physical factors of ward design were examined, and their relationship to psychological well-being and sleep patterns The results show that the bay ward seemed to offer a more favourable environment for patients but some of the disadvantages of bay wards are balanced by better staffing levels and better and more modern facilities Visibility to nurses was lower on the bay ward The Nightingale ward was perceived as significantly noisier than the bay ward and noise levels were significantly correlated to anxiety scores Paradoxically the increase in noise levels appeared to improve the perceived level of privacy on the Nightingale ward Seventy-five per cent of patients were found to prefer the bay ward design, and since neither design appears to have major disadvantages their continued introduction should be encouraged However, recommendations are made concerning the optimizing of patients' well-being within the bay ward setting