Direct supervision of physiotherapists improves compliance with clinical practice guidelines for patients with hip fracture: a controlled before-and-after study

Exploring Physiotherapists' Perspectives of Group Clinical Supervision Effectiveness for Aquatic Physiotherapy Skill Development: A Qualitative Study

BACKGROUND AND PURPOSE

Participation in regular clinical supervision is recommended for health professionals to ensure quality of care. Effective clinical supervision of physiotherapists typically consists of a one-to-one model using a combination of reflective and direct approaches to supervision. However, this level of support can be difficult to provide in niche clinical specialities such as aquatic physiotherapy, where one expert clinician is tasked with the supervision of many less experienced clinicians. Group supervision is an alternative model which requires fewer resources, but its effectiveness is unknown. This study aimed to explore physiotherapists' perspectives on the effectiveness of a supervisor-led group supervision model in an aquatic physiotherapy service.

METHODS

Sixteen physiotherapists at varied career stages who had experienced aquatic physiotherapy group supervision at an inpatient rehabilitation hospital, participated in an interpretive description study using focus groups.

RESULTS

Four themes were identified: skill development, specialised practice area, group interactivity, and structure and processes. The positioning theory and interactivity theory informed the data analysis.

DISCUSSION

Physiotherapists perceived group clinical supervision to be an effective model for clinical skill development in aquatic physiotherapy. They believed that the model was effective because it afforded them time for reflection in a highly specialised and infrequently practised clinical area. Interactivity between colleagues was viewed as the main strength of group supervision. However, they also felt that skill development would be enhanced if the content of the sessions was structured and group supervision was complemented by direct supervision.

Which performance indicators are used globally for evaluating healthcare in patients with a hip fracture? : a mixed methods systematic review

Aims

Performance indicators are increasingly used to evaluate the quality of healthcare provided to patients with a hip fracture. The aim of this review was to map the variety of performance indicators used around the world and how they are defined.

Methods

We present a mixed methods systematic review of literature on the use of performance indicators in hip fracture care. Evidence was searched through 12 electronic databases and other sources. A Mixed Methods Appraisal Tool was used to assess methodological quality of studies meeting the inclusion criteria. A protocol for a suite of related systematic reviews was registered at PROSPERO (CRD42023417515).

Results

A total 24,634 articles were reviewed, of which 171 met the criteria of the review. Included studies were heterogenous in design and came from varied healthcare systems in 34 different countries. Most studies were conducted in high-income countries in Europe (n = 118), followed by North America (n = 33), Asia (n = 21), Australia (n = 10), and South America (n = 2). The highest number of studies in one country came from the UK (n = 45). Only seven of the 171 studies (< 2,000 participants) were conducted across ten low- and middle-income countries (LMICs). There was variation in the performance indicators reported from different healthcare systems, and indicators were often undefined or ambiguously defined. For example, there were multiple definitions of 'early' in terms of surgery, different or missing definitions of 'mobilization', and variety in what was included in an 'orthogeriatric assessment' in hip fracture care. However, several performance indicators appeared commonly, including time to surgery (n = 142/171; 83%), orthogeriatric review (n = 30; 17%), early mobilization after surgery (n = 58; 34%), and bone health assessment (n = 41; 24%). Qualitative studies (n = 18), mainly from high-income countries and India, provided evidence on the experiences of 192 patients and 138 healthcare professionals with regard to the use of performance indicators in clinical care and rehabilitation pathways. Themes included the importance of education and training in parallel with the introduction of performance indicators, clarity of roles with the clinical team, and the need for restructuring or integration of care pathways.

Conclusion

This review identified a large number of performance indicators related to the delivery of healthcare for patients with a hip fracture. However, their definitions and thresholds varied across studies and countries. Evidence from LMICs is sparse. Both qualitative and quantitative evidence indicates that there remains a pressing need for further research into the use and standardization of performance indicators in hip fracture care and their influence on patient outcomes and economic costs.

Factors influencing participation in clinical supervision: a qualitative study reflecting physiotherapist and manager perspectives

Objective This study aimed to explore physiotherapist and manager perceptions of factors that influence physiotherapist participation in clinical supervision. Methods Individual semi-structured interviews were conducted with physiotherapists (n = 15) and managers (n = 10) from a publicly funded health network. Interviews were audiotaped and transcribed verbatim. Qualitative analysis of transcripts was completed using inductive thematic analysis. Results Three themes explained the factors perceived by participants to influence participation in clinical supervision: the value of clinical supervision; operationalisation of the organisational clinical supervision framework; and the clinical supervision culture. Identified factors influenced participation by either facilitating or discouraging access to supervision and prioritisation of supervision relative to competing professional demands. Conclusions Physiotherapist participation in clinical supervision is crucial for their professional development and to deliver high-quality care. Participation might be enhanced by initiatives that address factors identified in this study. These may include introducing processes that ensure supervisees and supervisors are accountable for their participation in supervision; providing alternative supervisory arrangements during leave, vacancies, or redeployment; allocating on-site supervisors to accommodate preferred supervision formats; and promoting a safe learning environment where physiotherapists can address knowledge or skill gaps without fear of judgement.

Allied health assistant management of people with hip fracture is feasible and may improve patient adherence to hip fracture mobilisation guidelines: a feasibility randomised controlled trial

OBJECTIVES

Determine the feasibility of allied health assistant (AHA) management of people with hip fracture an acute hospital.

DESIGN

Assessor-blind, parallel, feasibility randomised controlled trial with qualitative component.

SETTING

Acute orthopaedic ward.

PARTICIPANTS

People with surgically-managed hip fracture, who walked independently pre-fracture and had no cognitive impairment.

INTERVENTIONS

Rehabilitation from an AHA, under the supervision of a physiotherapist, compared with rehabilitation from a physiotherapist.

MAIN OUTCOME MEASURES

Feasibility was evaluated according to focus areas of demand, acceptability, practicality and implementation. Secondary outcomes included estimates of effect of adherence to hip fracture mobilisation guidelines, discharge destination, 30-day readmission, functional activity, and length of stay.

RESULTS

Fifty people were allocated to receive rehabilitation from an AHA (n = 25) or physiotherapist (n = 25). AHA rehabilitation had high demand with 60% of eligible participants recruited. Satisfaction with AHA rehabilitation was comparable with physiotherapy rehabilitation (acceptability). The AHA group received an average of 11 min (95% CI 4 to 19) more therapy per day than the physiotherapy group (implementation). The AHA group may have had lower cost of acute care (MD -$3 808 95% CI -7 651 to 35) and adverse events were comparable between groups (practicality). The AHA group may have been 22% (HR 1.22, 95% CI 0.92 to 1.61) more likely to walk on any day and may have had a shorter length of stay (MD -0.8 days, 95% CI -2.3 to 0.7).

CONCLUSIONS

AHA management of patients with hip fracture was feasible and may improve adherence to mobilisation guidelines and reduce cost of care and length of stay.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12620000877987. CONTRIBUTION OF THE PAPER.

Boosting inpatient exercise after hip fracture using an alternative workforce: a mixed methods implementation evaluation

BACKGROUND

Hip fracture has a devastating impact on individuals and is an increasing burden for health systems and society. Compared to usual care, increased physiotherapy provision has demonstrated efficacy in improving patient and health service outcomes in this population. However, physiotherapy workforce challenges prevent sustained implementation.

METHODS

Our aim was to evaluate the safety, feasibility, acceptability, effectiveness and implementation cost of thrice daily physiotherapy for patients in the acute care setting after hip fracture at two public hospitals. We added twice-daily exercise implemented by an alternative workforce, to usual care consisting of daily mobility practice by a physiotherapist. Sites identified their preferred alternative workforce, with pre-registration physiotherapy students and allied health assistants chosen. We used a mixed methods approach, using the Consolidated Framework for Implementation Research (CFIR) as a determinant framework to guide implementation planning and data collection. We compared hospital length of stay data to a reference cohort.

RESULTS

We recruited 25 patients during the study period. Acute care hospital length of stay decreased from 11 days in the reference cohort to 8 days in the BOOST cohort (mean difference - 3.3 days, 95%CI -5.4 to -1.2 days, p = 0.003). Intervention fidelity was 72% indicating feasibility, no safety concerns were attributed to the intervention, and uptake was 96% of all eligible patients. The intervention was acceptable to patients, carers and healthcare providers. This intervention was cost-effective from the acute orthopaedic service perspective.

CONCLUSION

Higher daily frequency of physiotherapy can be safely, feasibly and effectively implemented by an alternative workforce for patients in the acute care setting following hip fracture surgery.

What factors affect early mobilisation following hip fracture surgery: a scoping review

OBJECTIVES

Identify and evaluate factors affecting early mobilisation on the day following hip fracture surgery.

DESIGN

Mixed methods, scoping review.

DATA SOURCES

MEDLINE, AMED, CINAHL, APA PsycINFO, APA PsycArticles, ISRCTN, Clinical Trials registry and grey literature accessed in November 2022 with publication dates between 2001 and November 2022.

ELIGIBILITY CRITERIA

English language publications that:1. Include patient populations who sustain a fragility hip fracture managed surgically2. Include patient populations who are mobilised out of bed on the day following their hip fracture surgery3. Report factors which influence the ability to undergo early mobility postsurgery DATA EXTRACTION AND SYNTHESIS: One reviewer screened all titles and abstracts for inclusion. Two reviewers performed data extraction and quality assessments using the relevant Critical Appraisal Skills Programme tools and the Mixed Methods Appraisal Tool.

RESULTS

3337 papers were identified, of which 23 studies were eligible for review, representing 210 811 patients. The heterogeneity in the types of study included, the definition of early mobilisation and the outcome measures used precluded meta-analysis. 13 factors were identified as having an effect on whether people were mobilised on day 1 post-hip fracture surgery, grouped into 5 principal themes: (1) healthcare setting or worker-related factors, (2) patient psychological factors, (3) acute patient health factors, (4) non-acute patient health factors and (5) surgical factors.

CONCLUSIONS

There was a paucity of robust research investigating day 1 mobilisation post-hip fracture surgery.Each of the five factors identified is potentially modifiable through service improvement change and innovation strategies. There is an opportunity to explore how service provision change could be implemented to improve outcomes for all patients following hip fracture surgery demonstrating the clinical and cost benefits of these changes against the cost of delivering the change.

Staying Active with Multimorbidity In Acute hospital settings (StAMInA) trial: protocol for a feasibility randomised controlled trial of allied health assistant mobility rehabilitation for patients with multimorbidity

INTRODUCTION

Key to improving outcomes for patients with multimorbidity is increasing mobility through prescription of a physical activity programme, but this can be difficult to achieve in acute hospital settings. One approach that would assist physiotherapists to increase levels of physical activity is delegation of rehabilitation to allied health assistants. We aim to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient mobility rehabilitation for patients with multimorbidity.

METHODS AND ANALYSIS

Using a parallel group randomised controlled design, participants will be allocated to allied health assistant mobility rehabilitation or physiotherapist mobility rehabilitation. Adult inpatients (n=60) in an acute hospital with a diagnosis of multimorbidity who walked independently preadmission will be included. The experimental group will receive routine mobility rehabilitation, including daily mobilisation, from an allied health assistant under the supervision of a physiotherapist. The comparison group will receive routine rehabilitation from a physiotherapist. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: Acceptability (patient satisfaction); demand (proportion of patients who participate); implementation (time allied health assistant/physiotherapist spends with participant, occasions of service); and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant rehabilitation will be interviewed to explore their perspectives on feasibility. Secondary outcomes include: Physical activity (daily time spent walking); daily mobilisation (Y/N); discharge destination; hospital readmission; falls; functional activity (Modified Iowa Level of Assistance Scale); and length of stay. Descriptive statistics will be used to describe feasibility. Secondary outcomes will be compared between groups using Poisson or negative binomial regression, Cox proportional hazards regression, survival analysis, linear regression or logistic regression.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Peninsula Health (HREC/97 431/PH-2023). Findings will be disseminated in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trial Registry ACTRN12623000584639p.

Interactive clinical supervision training added to self-education leads to small improvements in the effectiveness of clinical supervision of physiotherapists: a randomised trial

QUESTION

Does adding an interactive clinical supervision training program to self-education improve the effectiveness of clinical supervision of physiotherapists, reduce burnout, decrease intention to leave and increase participation in clinical supervision?

DESIGN

Randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Physiotherapists (n = 58) working at a publicly funded health service.

INTERVENTION

Participants in both groups received a self-education clinical supervision training package. In addition, participants in the experimental group received interactive clinical supervision training consisting of three 90-minute workshops.

OUTCOME MEASURES

The primary outcome measure was effectiveness of clinical supervision 4 months after training measured using the Manchester Clinical Supervision Scale (MCSS-26). Secondary outcomes were the Maslach Burnout Inventory, the Intention to Leave Scale, and participation in supervision. Focus groups were also used to gauge impressions of the intervention.

RESULTS

The addition of interactive clinical supervision training slightly improved effectiveness of clinical supervision, with a between-group mean difference of 6.3 units (95% CI 0.3 to 12.3) on the MCSS-26. The estimate of the effect on the proportion of physiotherapists reporting effective clinical supervision (ie, MSCC-26 score ≥ 73) was unclear (OR 1.97, 95% CI 0.50 to 7.81). Physiotherapists in the experimental group reported slightly lower levels of depersonalisation (MD -3.0 units, 95% CI -4.6 to -1.3). There were negligible or uncertain effects on the other burnout domains, intention to leave and participation in clinical supervision. Qualitatively, participants reported that the workshops made them realise that supervisees could take greater ownership of where supervision focused.

CONCLUSION

Adding interactive clinical supervision training to self-education leads to small improvements in the effectiveness of clinical supervision of physiotherapists.

REGISTRATION

osf.io/yz3kx.

Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis

BACKGROUND

Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery.

OBJECTIVE

Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture.

METHODS

Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis.

RESULTS

Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements.

CONCLUSIONS

Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

Feasibility of allied health assistant management of people with acute hip fracture: protocol for a feasibility randomised controlled trial

INTRODUCTION

Guidelines for hip fracture care state that patients with hip fracture should be mobilised on the day after surgery and at least once a day thereafter. However, compliance with these guidelines is poor. One approach that would assist physiotherapists to meet mobility guidelines after hip fracture is to delegate the provision of daily mobilisation to allied health assistants under their supervision. Therefore, we plan to conduct a randomised controlled trial to determine the feasibility of an allied health assistant providing daily inpatient rehabilitation to patients with hip fracture.

METHODS AND ANALYSIS

Using a parallel group randomised controlled design with one-to-one allocation, participants will be randomly allocated to an experimental group (allied health assistant management) or a comparison group (physiotherapist management). Inclusion criteria are: adult with diagnosis of hip fracture; inpatient in acute hospital; walked independently pre-hip fracture and able to communicate in conversational English. The experimental group will receive routine physiotherapy rehabilitation, including daily mobilisation, from an allied health assistant following initial physiotherapist assessment. The comparison group will receive routine rehabilitation from a physiotherapist. The primary outcome will be the feasibility of allied health assistant management of patients with hip fracture. Feasibility will be determined using the following areas of focus in Bowen's feasibility framework: acceptability (patient satisfaction), demand (proportion of patients who participate), implementation (time allied health assistant/physiotherapist spends with participant, occasions of service) and practicality (cost, adverse events). Staff involved in the implementation of allied health assistant care will be interviewed to explore their perspectives on feasibility. Secondary outcomes include compliance with daily mobilisation guidelines, discharge destination, hospital readmission, falls, functional activity and length of stay. We aim to recruit 50 participants. Descriptive statistics will be used to describe feasibility and mobilisation rates will be calculated using Cox proportional hazards regression to compare compliance with mobilisation guidelines.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Peninsula Health human research ethics committee (HREC/63 005/PH-2020). The findings will be disseminated in peer-reviewed journals and conference presentations.

TRAIL REGISTRATION NUMBER

Australian and New Zealand Clinical Trial Registry; ACTRN12620000877987; Pre-results.

Improvement in the Short-Term Effectiveness of the Clinical Supervision of Physiotherapists Who Have Taken Part in a Clinical Supervision Training Programme

Purpose: The purpose of this study was to evaluate change in the effectiveness of clinical supervision of physiotherapists who took part in a clinical supervision training programme. Method: Our pre-post study design used both quantitative and qualitative methods. The programme consisted of three interactive sessions held with physiotherapists from a metropolitan public health network in Melbourne, Victoria, Australia. The effectiveness of clinical supervision of supervisees was measured using the Manchester Clinical Supervision Scale (MCSS-26). The effectiveness of clinical supervision from the supervisors' perspective was measured using a clinical supervisor questionnaire. The physiotherapists' experience of participating in the training programme was then explored in focus groups. Results: A total of 36 physiotherapists participated in the training programme. Twelve weeks later, the physiotherapists (35) reported a moderate improvement in the effectiveness of clinical supervision, with a mean improvement of 5.4 units (95% CI: 2.0, 8.9; p = 0.003) on the MCSS-26 (score range 0-104). After training, a higher proportion of physiotherapists reported receiving effective clinical supervision (97% after vs. 53% before; p = 0.001). In the focus groups, the physiotherapists reported greater flexibility in their approach to clinical supervision and a more effective supervisory relationship. However, difficulty finding time for supervision remained a barrier. Conclusions: Physiotherapists reported an improvement in the effectiveness of clinical supervision after a clinical supervision training programme.

Psychological Distress and Work Environment Perception by Physical Therapists from Southern Italy during COVID-19 Pandemic: The C.A.L.A.B.R.I.A Study

The psychosocial impact of the work environment during the COVID-19 pandemic on health professionals is a growing issue. The present study examined specific psychosocial work environment indicators during the COVID-19 pandemic, through a multiple regression model of a self-administered cross-sectional online survey in a cohort of physical therapists from a region of Southern Italy from March 2020 to May 2021. The questionnaire contained items on work and healthcare issues related to COVID-19. Eighty physical therapists (29 male and 51 female), mean age 32.5 ± 10.1 years, were involved in this survey. The multiple regression analysis showed that "management activity" was significantly correlated to "therapist frustration" during the COVID-19 pandemic (ΔR2 = 0.16; p < 0.03). Findings of this study underline the importance of a healthy psychosocial work environment to enhance job satisfaction of all health professionals and to avoid role conflict and burnout syndrome during the COVID-19 pandemic.

A Systematic Review of Clinical Practice Guidelines for Physical Therapist Management of Patellofemoral Pain

OBJECTIVE

The purpose of this study was to conduct a systematic review to evaluate clinical practice guidelines for the physical therapist management of patellofemoral pain.

METHODS

Five electronic databases (CINAHL, Embase, Medline, Psychinfo, Cochrane Library) were searched from January 2013 to October 2019. Additional search methods included searching websites that publish clinical practice guidelines containing recommendations for physical therapist management of patellofemoral pain. Characteristics of the guidelines were extracted, including recommendations for examination, interventions, and evaluation applicable to physical therapist practice. Quality assessment was conducted using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, applicability of recommendations to physical therapist practice was examined using the AGREE Recommendation Excellence instrument, and convergence of recommendations across guidelines was assessed.

RESULTS

Four clinical practice guidelines were included. One guideline evaluated as higher quality provided the most clinically applicable set of recommendations for examination, interventions, and evaluation processes to assess the effectiveness of interventions. Guideline-recommended interventions were consistent for exercise therapy, foot orthoses, patellar taping, patient education, and combined interventions and did not recommend the use of electrotherapeutic modalities. Two guidelines evaluated as higher quality did not recommend using manual therapy (in isolation), dry needling, and patellar bracing.

CONCLUSION

Recommendations from higher-quality clinical practice guidelines may conflict with routine physical therapist management of patellofemoral pain. This review provides guidance for clinicians to deliver high-value physical therapist management of patellofemoral pain.

IMPACT

This review addresses an important gap between evidence and practice in the physical therapist management of patellofemoral pain.

LAY SUMMARY

If you have kneecap pain, this review offers guidance for your physical therapist to provide examination processes, treatments, and evaluation processes that are recommended by high-quality guidelines.