Background
Improved medical technology and treatment has led to an increased demand for costly critical care treatment worldwide. Physiotherapists are integral to the interprofessional team that cares for critically ill patients, and plays an increasingly important role in the multidisciplinary team (MDT) approach to cost-effective and efficient patient management and rehabilitation.
Clinicians working in ICU are often dependant on their own experience when making decisions regarding individual patient management, resulting in variation in clinical practice. This may negatively impact patient outcome. Differences exist between novice and cardiorespiratory experts in the organisation of knowledge base and use of cognitive strategies.
Expansion of the conventional ICU physiotherapy role may require additional education and acquisition of specific task-related and diagnostic skills [Citation1]. In a study of minimum standards of clinical practice for physiotherapists working in ICU in Australia and New Zealand [Citation2], a Delphi technique was used to develop a 132-item consensus framework for minimum standards of practice for physiotherapists in ICU. Hanekom et al. [Citation3] reported that comprehensive physiotherapy service, using best available evidence to address pulmonary dysfunction and early mobilisation, decreased reintubations and lessened the burden on nursing care in a South African (SA) setting.
For effective, efficient and safe physiotherapy service delivery in SA ICUs, a competency framework should be established that is endorsed and utilised throughout the country.
Purpose
No formalised guidelines or standards exist for the educational profile or scope of practice requirements for physiotherapy within critical care, which poses a threat to physiotherapy practice and professional credibility. The clinical reasoning process in experienced clinicians has been under-researched in cardiorespiratory physiotherapy. This study aimed to explore the perceptions of SA physiotherapists on minimum clinical standards that physiotherapists working in ICU should adhere to for delivering safe and effective services to critically-ill patients.
Methods
The study followed a mixed methods design. Experienced physiotherapists (clinicians and academics) offering a service to SA ICUs were purposively sampled to participate in focus groups. Eligibility required qualification for five years or longer and (a) three years working experience in ICU, or (b) two years working experience in a senior role in ICU or (c) publication of a minimum of five papers in critical care.
Three focussed group sessions were held in different parts of the country to ensure national participation. The stimulus question posed was: ‘What is the minimum standard of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs’? To inform the formulation of minimum standards three domains were explored: knowledge, skill and attributes.
A nominal group technique (NGT) was used to reach consensus by each focus group. The NGT is a structured brainstorming process which is described as one of the three methods to reach consensus in a health care delivery context. Since all the participants contribute to the discussion this process is thought to overcome issues associated with group decision-making processes. It is efficient in terms of cost and time as a means to obtain substantial amounts of information, and requires little preparation by the participants [Citation4].
Participants took 15 min to reflect in silence on each of the three domains and write keywords on coloured self-adhesive notepads, after which these were up on a wall for discussion. Each keyword was discussed in the group to clarify meaning and identify subcategories. Candidates were finally asked to rank the subcategories and each standard in the subcategory in order of importance, using index cards. Each session was audio-recorded and independently transcribed by an external company.
To better understand the knowledge base to be mobilised, skills and competencies to possess and attributes to be engaged by ICU physiotherapists, the recorded data was explored [Citation5].
An inductive approach to data analysis was used to perform conventional content analysis [Citation6]. Transcripts received were checked for accuracy by three of the researchers (NP, HvA & SH). Coding of the raw data was performed by two researchers (NP & HVA), and specific categories and sub-themes were developed for each domain, using the codes identified. This was reviewed by the remaining two researchers (SP & SH). Themes were developed for each category.
Results
Twenty-five physiotherapists (21 females) consented to participate in one of the three focus group sessions. Mean years of ICU experience was 10.8 years (±7.0; range 3–33). Average duration of the sessions was 5 h, with two of the researchers present at all three sessions. They reported data saturation by the end of the third session.
The NGT analysis considered sixty-six concepts in the three domains. Not all concepts were discussed by all three focus groups. 54% of concepts generated were in the knowledge domain, 35% in the skills domain and only 10% in the attitudes domain. 62% of concepts were considered in more than one domain.
Overall consensus was reached on only six concepts, namely, knowledge of normal integrated anatomy and physiology, knowledge of and skill to conduct a holistic assessment, knowledge and skill of clinical reasoning, and knowledge of physiotherapy techniques. None of the attributes explored during the NGT process reached overall consensus. Handling skills and ethics only emerged within the knowledge domain.
The richness of information obtained through audio-recording inspired the development of three overarching themes: integrated medical knowledge, multidisciplinary teamwork, and physiotherapy practice. These themes were analysed in relation to the superimposed framework of the three domains of basic knowledge, skills and attributes.
The theme of integrated medical knowledge related to knowledge of anatomy and physiology, conditions that patients present with in ICU, ICU environment, pathology and pathophysiology, and medication used in ICU. Participants felt it was important that ICU physiotherapists had skills related to working within the ICU environment and understanding of monitoring equipment, to name a few.
The theme of multidisciplinary teamwork encompassed elements related to communication, continuous professional development (CPD), cultural sensitivity, documentation, ethics, professionalism, safety in ICU and technology. Knowledge of how to communicate, the role of MDT members that work in ICU, safety aspects related to working in ICU, among others were important. Skills under the MDT theme were those related to professional behaviour including maintaining CPD, collaborating with others and teamwork, interacting with team members and patients, cultural sensitivity and working safely in ICU. Attributes related to cultural sensitivity, ethics and ability to work within the MDT.
Components related to the third theme of physiotherapy practice included clinical reasoning, handling skills, interventions and patient care. Knowledge of patient assessment, the clinical reasoning process, handling skills, specific physiotherapy interventions and progression of patient care were important. Skill in performing a holistic assessment of potentially complex patients, clinical reasoning, using specific equipment and patient handling and management were highlighted. Attributes highlighted related to patient care and include being available, dedicated, having a passion for ICU, among others.
This study shares similar findings to those of the Australian Consensus framework and the work of Holdar and colleagues (2013) in terms of integrated medical knowledge [Citation2,Citation7]. It showed similar findings to the Australian Consensus framework, the study by Smith et al (2008) and the Canadian Safety Competencies document in respect of multidisciplinary teamwork [Citation2,Citation8,Citation9]. In this study additional areas emphasised included computer literacy, cultural sensitivity and accurate documentation. The study showed similar findings to the Australian Consensus framework in respect of physiotherapy practice in ICU [Citation2].
Conclusion(s)
This is the first study to explore the perceptions of clinicians on the knowledge, skills, and attributes needed to provide a safe effective physiotherapy service in SA ICUs. The information obtained determined concepts to be included in a list for presentation to a Delphi panel for final consensus to develop minimum standards, which can be presented to the wider national physiotherapy and ICU communities for consensus-building activities.
Implications
This study provides a foundation for obtaining consensus on the minimum standards for ICU physiotherapists in SA. Whether minimum standards will result in standardisation of treatment and improved patient outcome will warrant investigation.
Ethics approval
Ethical approval for the study was obtained from the Health Research Ethics Committee of Stellenbosch University (N13/08/120).
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
References
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