Physiotherapy July 2000/vol 86/no 7

377Abstracts

Experience of ‘Problem’ Patientsby Senior Physiotherapists in theContext of their Working Lives

Diane Thomson Physiotherapy Division, Guy’s, King’s and St Thomas’s School ofBiomedical Sciences, London UniversityThe quality and effectiveness of physiotherapy is influenced bythe nature of the relationship between health professionals andtheir patients. This can be seriously disrupted if patients areperceived as ‘problem’ patients by physiotherapists. It is welldocumented that health professionals tend to label andcategorise their patients negatively and positively. Socialevaluations are however complex, varying between individualsand within different relationships, and any labelling processmust be viewed with caution (Finlay, 1997).

Qualitative research methodology using a phenomenologicalapproach was chosen as the most appropriate for assessing howphysiotherapists define and react to ‘problem’ patients in thecontext of their working lives. Ten senior physiotherapistsagreed to take part in two focus groups and seven other seniorphysiotherapists took part in in-depth interviews. The focusgroups were used in an exploratory way to gain insight into a complex problem, and the emerging categories became the conceptual framework for the interviews. Confidentiality was ensured and the full transcript was offered to all theparticipants.

Analysis of the data was carried out following the establishedguidelines of Miles and Huberman (1994). It may not besurprising that the ways in which the participants described

their ‘problem’ patients and how they dealt with them disclosedhow they perceived their professional role. Two main scenarioswere described -- ‘benign’ and ‘non-benign’. The former wasone in which it was construed that patients would eithereventually ‘fit’ into the treatment plan or were incapable ofdoing so. The latter interpreted that patients, although capableof doing so, were resistant.

The first scenario included those who were trapped into adependent state by society, those with exceptional healthcareneeds, and those with psychological problems. The secondgroup were those who resisted the self-care approach and thosewho wanted minimal involvement with the therapist. Otherconfounding variables were those situations in which theparticipants felt unsupported, leading to uncertainty andconfusion and resulting in role ambiguity.

The physiotherapists were all confident of their uniqueknowledge and expertise and employed many coping strategiessuch as ‘honesty’ and a direct telephone link. There is a clearneed for an integration of psychosocial knowledge withanatomical, pathological, biomechanical and neuroscience inencounters with patients and it may be that these patientsshould become ‘special’ cases, thus attracting higher status andspecialist clinicians to deal with them.

References

Finlay, L (1997). ‘Good patients and bad patients: How occupational therapists view their patients/clients’,British Journal of Occupational Therapy, 60, 440-446.

Miles, M B and Huberman, A M (1994). Qualitative DataAnalysis: An expanded sourcebook, Sage, Newbury Park, CA, 2nd edn.

Evaluating the Role of Video-based Advice and Instruction

J Miller, J Hall, K Moore Department of Physiotherapy, Chester and Halton Community NHS Trust

G Rose Department of Physiotherapy, Countess of Chester NHS Hospital Trust

I Stanley Department of Primary Care, University of Liverpool

M Rose Back Pain Rehabilitation Unit, Wirral Hospital NHS Trust

Introduction Growing recognition of the benefits ofphysiotherapy in primary care has led to a potentiallyunmanageable demand. One response is for therapists tominimise the number of treatments required and maintaincontinuity through patient-managed home exercises. Highthroughput of patients, reduced levels of follow-up and greater

reliance on self-treatment place increased demands on thecommunication skills of therapists. However, patients may findthat a clinical environment or poor memory are barriers to theirlearning and subsequent use of new exercise skills. Given thelimited capacity of patients to retain detail and the implicationsfor this on the efficient use of physiotherapists’ time, other waysof passing information to patients, such as videotapes ofexercises, should be examined.

Method The study was based in 20 general practices inCheshire. Practice-based physiotherapists designed theinstructional content and produced videotapes of exercises forshoulder and back pain patients. Patients filled in a functionaldisability questionnaire: the Roland and Morris disabilityquestionnaire (RMDQ) for backs and the shoulder disabilityindex (SDI) for shoulders. These questionnaires give a score ofhow the condition limits the patient – a higher score indicatingmore disability. The SF-36, which is a short generic measure ofsubjective health status comprising of eight dimensions, was alsofilled in. Questionnaires were administered immediately beforetreatment and again six weeks later.

Patients were randomly allocated to three groups whichdetermined how they were to receive their exercise instruction –