Patient values in physiotherapy practice, a qualitative study

Abstract Objectives Physiotherapy is, like all healthcare professions, relational and value‐laden. Patient‐centred care, evidence‐based practice and value‐based practices are concepts in which patient values lie at the heart of high‐quality healthcare practices. Nevertheless, physiotherapists have limited awareness of what patient values are in the physiotherapy encounter. The purpose of this study is to explore these patient values. Methods A qualitative study design using content analysis was used involving 17 adult participants with chronic or recurrent musculoskeletal pain. Data were collected during July 2015–July 2016 in three primary care physiotherapy facilities in Rotterdam, The Netherlands. Two researchers analysed the interviews and derived relevant codes from the data. After an iterative process of comparing, analysing, conceptualizing, and discussing the data, a pre‐existing analytic framework was refined in which distinct values were delineated. Results Emerging patient values were encompassed in three themes, each consisting of two to four elements: (1) values about oneself (uniqueness and autonomy), (2) values regarding actions of the professional (technically skilled professional, conscientious professional, compassionate professional, responsive professional) and (3) values regarding interactions between patients and the professionals (partnership and empowerment). Conclusion This study emphasizes the need for discussing patient values in the clinical encounter and helps physiotherapists to understand what deems to be important for patients with musculoskeletal pain in physiotherapy practice. The results of this study contribute to the existing body of knowledge of this important aspect of the quality of physiotherapy practice and may inspire clinicians and educators to actively implement patient values in clinical practice and the physiotherapy education.


| INTRODUCTION
Physiotherapy is, like all healthcare professions, deeply relational and value-laden. It can be characterized by the nature of complex interactions between physiotherapists and their patients. This complexity results from the often multifactorial nature of health problems, the limited evidence base of physiotherapeutic interventions and the unique and personal contextual aspects of the personal health problem. The clinical encounter is the place where the separate worlds of patient and healthcare professional meet and ideally merge. This merging of professional and layman knowledge, professional and patient experiences and professional and patient values is, however, not straightforward. Physiotherapists experience tensions between the choice of treatment they feel is best for their patients and the beliefs and attitudes of patients themselves (Jeffrey & Foster, 2012). In their turn, patients in physiotherapy practice often experience a lack of feeling believed or being understood by their physiotherapists (Harding, Parsons, Rahman, & Underwood, 2005;Potter, Gordon, & Hamer, 2003;Toye & Barker, 2012;Trede, 2012). This lack of understanding can be the consequence of limited attention of healthcare professionals for the personal needs and values of their patients (Kennedy et al., 2017). One reason for this may the fact that the meaning of the concept of patient values is currently incomplete, too abstract and/or undertheorized (Charles, Gafni, & Freeman, 2011;Kelly, Heath, Howick, & Greenhalgh, 2015;Rosenbaum, 2013).

Values are basic principles that individuals, groups or societies
have about what is deemed to be good, bad or desirable (Moyo, Goodyear-Smith, Weller, Robb, & Shulruf, 2016). They are formed from an early stage in life and are further shaped by life events, social contacts and education (Schwartz, 2012). Rokeach defines values as enduring beliefs that influence a specific mode of conduct or end state of existence that provide us with our moral framework (Rokeach, 1973). Patient values are parts of the concepts 'evidencebased practice' (EBP), 'value-based practice' (VBP) 'patient-centred care' (PCC) and are also embodied in the declaration of Helsinki (Fulford, Peile, & Carroll, 2012;IOM, 2001;Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996;WMA, 2001). In these concepts, patient values are considered to lie at the heart of high-quality healthcare practices and underscore the importance to consider aspects that people value in healthcare practices such as being taken seriously, being treated by a competent professional, feeling safe and being involved in decision-making (Bernhardsson, Larsson, Johansson, & Öberg, 2017;Entwistle, Firnigl, Ryan, Francis, & Kinghorn, 2012;Schoot, Proot, Meulen, & Witte, 2005;Skea, MacLennan, Entwistle, & N'dow, 2014). This latter meaning of patient values refers to people's preferences and expectations regarding medical interventions or procedures.
Results of our earlier systematic review of qualitative studies regarding the content and meaning of the concept of patient values, shows that patient values in healthcare can be divided into three categories: (1) values concerning the life and philosophy of the patient, such as the wish for autonomy and the desire to be considered a unique person; (2) values related to the characteristics and behaviour of the professional, such as being responsive, compassionate and professional and (3) values regarding the relationship between the patient and the professional, such as the wish for partnership and empowerment (Bastemeijer, Voogt, van Ewijk, & Hazelzet, 2017). Until now, it remains unknown how these values and expectations merge (or not) with professional interpretations of complex health problems and shape clinical encounters in physiotherapy.
The aim of this study is to describe the aspects of physiotherapy practice that people with musculoskeletal pain value in high-quality care. These findings will be used to further develop our earlier found taxonomy of patients values in healthcare.

| Design
This study is designed as an explorative qualitative study using content analysis (Krippendorff, 2018). The 32-item consolidated criteria for reporting qualitative research checklist is used to design and report the study (Tong, Sainsbury, & Craig, 2007).

| Participants and setting
Seventeen participants were recruited from three primary care physiotherapy practices in Rotterdam, The Netherlands. These sites were assumed to be high-quality care practices judged by independent auditors. The participants were asked to enrol into this study by their physiotherapist, who was instructed regarding inclusion criteria by the principal investigator (CB). Participants were eligible if they sought consultation for chronic or recurrent musculoskeletal low back, neck and shoulder pain. Those are among the most prevalent pain problems in primary care, known for their complex biopsychosocial character and therefore appropriate health problems suited for the aim of this study (Jordan et al., 2010). Purposive sampling was used to achieve variation in terms of gender, age and level of education given the fact that values have been formed during life, by personal life events, social contacts and education (Schwartz, 2012). From each location, five to seven participants were recruited of which nine were female and eight were male, aged between 33 and 79 years (57 years on average). Eleven of the participants suffered from chronic or recurrent low back or neck pain and six of them from shoulder pain. Nine participants had at least tertiary education (Table 1; Characteristics of participants). Participants were informed about the aim of the study and received written information about participating in medical scientific research prior to the start of the study. After 5 days, eligible participants were contacted by the principal researcher (CB) by telephone for definitive enrolment into the study. An interview was scheduled at a location of their choice.  (Bastemeijer et al., 2017). These topics and other (non-)related topics were discussed in depth and participants were encouraged to illustrate their thoughts with lived experiences. Data collection was ended when saturation was obtained (where the last three interviews contribute little or no new understandings) (Gentles, Charles, Ploeg, & McKibbon, 2015).

| Data collection
The interviews lasted 35-64 min (53 min on average), were audiotaped and transcribed verbatim by an independent administrative assistant. All participants verified the verbatim of their own interview as part of a member checking process. The findings and quotes were completely anonymized by the interviewer.

| Data analysis
Content analysis as described by the procedures and criteria of Krippendorf was used to explore the acquired data (Krippendorff, 2018). The unit of analysis was the transcriptions of interviews. To familiarize the researchers to the transcripts and audio files, two researchers (CB and LV) separately read and re-read the interviews to code meaningful words, sentences or paragraphs. Both manifest (analytical) content and latent (interpretative) content was analysed.
Subsequently, both researchers discussed their mutual interpretations and together formed a shared understanding of the data. Then they investigated whether analytical and interpretative (sub-)elements that arose by discussing and organizing the initial codes could be organized in the themes and elements as found in our earlier review (Bastemeijer et al., 2017). Data points that were ambiguous or non-placeable were discussed by the two primary investigators to determine appropriate organization within the (sub-) elements which helped to sort the experiences of patients with physiotherapy practice. All aforementioned steps of the analysis were discussed with the whole research team in order to prevent (unconscious) bias, to verify the analysis and provide analyst triangulation. Atlas.ti was used for data management and further organization and interpretation of the themes, elements and sub-elements (Friese, 2013).
Trustworthiness of the study was addressed by enhancing credibility, dependability, conformability and transferability (Trochim &

| RESULTS
A previously designed scheme (Bastemeijer et al., 2017) was used to organize the data into three themes: (1)

| Theme 1: Values of oneself
This theme includes values that reflect the broad ideas of participants about health and healthcare and comprises two elements: (1) uniqueness and (2) autonomy.

| Uniqueness
The majority of the participants indicate that personal recognition and the wish to be seen as a unique individual is important.

| Autonomy
This emerging element was discussed in the interviews as the patient's right to decide. The participants want to be well-informed by the professional in order to make a good decision by themselves or to understand why a certain decision by the professional is the correct one.  (4) responsive professional.

| Technically skilled professional
All participants value a physiotherapist who is competent,

| Conscientious professional
Conscientious behaviour refers to the critical attitude of the practitioner and his moral consciousness in which the patients' interests must prevail. At first, participants value a professional who acts morally in clinical decision-making. The physiotherapist must

BASTEMEIJER ET AL.
establish an ongoing commitment to the patient and remain honest, even though the problem or situation is complex. He must not lapse into a routine action and respect his own professional boundaries and honour existing commitments.

| Responsive professional
Data analyses revealed the importance of a committed and responsible execution of treatment and care by a physiotherapist who adapt to the patients' needs and circumstances. For example; providing information is important, but the professional must adjust the depth of information to the extent of the patient's needs.
P07 Understandably, they don't need to tell me exactly which muscle is which, or be too specific medically.
That's not necessary, I would rather it was kept simple.
The physiotherapist should also consider continuity of care. Participants mentioned that the outer appearance of facilities with regard to hygiene and soundness contributes to a sense of feeling safe. The practice should be clean, hygienic and in order.
P12 Most important is the quality of care, but the treatment should be carried out in a clean and hygienic environment, not in some scruffy clinic. That gives the right impression and makes you feel more comfortable and safe.

| Partnership
Participants value that interaction with the professionals is based on equality and involves mutual respect in an open and understanding ongoing dialogue. They should be able to talk easily and deliberately. Participants would like to have a certain influence on their treatment, but they expect the professional to take the lead in this collaboration due to the professional's superior knowledge.
P06 The discussion is equal, however, I am seeing a professional for their expertise otherwise I wouldn't be seeing them.
P08 Sometimes it is difficult as a patient to understand the problem, medically the professional should be able to do this. You can't do this as a patient.

| Empowerment
The majority of the participants' value empowerment by the physiotherapist. It enables them to keep control of their own situations and support or educate them in how to deal with the problem.
Empowerment also includes professionals who help patients towards self-management and prevention. (1) uniqueness, (2) autonomy, (3) technically skilled professional, (4) conscientious professional, (5) compassionate professional, (6) responsive professional, (7) partnership and (8)  Toye & Barker, 2012). Important aspects of dissatisfaction are the feeling of not being heard, understood or even not being taken seriously (Potter et al., 2003;Trede, 2012 participants room to describe the aspects they explicitly value in physiotherapy practice. The pre-defined taxonomy served as a guide for these interviews but was not used as a compelling tool. Themes of this taxonomy were openly discussed and adjustments could be made. Thematic analyses were carried out by two experienced researchers in the field of physiotherapy and were further discussed with a team to protect the conclusion drawn from implicit bias.
Theoretical saturation was used as criterium to end further data collection. Weaknesses of this study involve the choice of including participants with spinal or shoulder pain, which are common health problems in physiotherapy practice, but maybe give an incomplete representation of results.

| CONCLUSIONS AND PRACTICE IMPLICATIONS
The findings of this study help physiotherapists to understand what patients with musculoskeletal pain value in physiotherapy practice.
Three themes were defined and categorized in a (pre-existing) tax-