Physiotherapy private practitioners’ opinions regarding interprofessional collaborative practice: A qualitative study

ABSTRACT

Physiotherapy private practitioners comprise a growing proportion of Australia’s primary care workforce, yet their views and experiences of interprofessional collaborative practice (IPCP) are poorly documented. The aim of this study was to explore Australian physiotherapy private practitioners’ opinions regarding IPCP. Twenty-eight semi-structured interviews were conducted with physiotherapists in 10 private practice sites in Queensland, Australia. Interviews were analyzed using reflexive thematic analysis. Data analysis produced five themes that characterized physiotherapists’ perceptions of IPCP: (a) quality of care considerations; (b) not a one-size-fits-all approach; (c) the need for effective interprofessional communication; (d) fostering a positive work culture; and (e) fear of losing clientele. The findings from this study suggest that physiotherapy private practitioners value IPCP because it can deliver superior client outcomes, can strengthen interprofessional relationships, and has the potential to enhance the professional reputation of the organizations within which they work. Physiotherapists also claimed that IPCP can contribute to poor client outcomes when performed inappropriately, while some reported approaching interprofessional referrals with caution following instances of lost clientele. The mixed views toward IPCP in this study highlight the need to explore the facilitators and barriers to IPCP in the Australian physiotherapy private practice setting.

KEYWORDS:

• Collaboration
• interprofessional
• physiotherapy
• primary care
• qualitative

Introduction

There are calls for changes to models of care internationally to reduce fragmented health care systems (World Health Organization, 2010). Such systems are characterized by structural flaws in funding and governance and contribute to inefficiencies and inequities in health care provision (operation and Development, 2015). Implementing collaborative care models is widely recognized as a key strategy in moving health care systems from fragmentation to positions of strength (World Health Organization, 2010). Interprofessional collaborative practice (IPCP) has been defined as “a situation when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings” (World Health Organization, 2010, p. 13). Physiotherapists have been recognized as crucial members of collaborative practice models in primary care due to their potential to address issues associated with an increased chronic disease burden, an aging population, rapidly rising health care costs, and human resource shortages (Adams et al., 2014; Maharaj et al., 2018; Sangaleti et al., 2017). Despite making up a growing proportion of Australia’s primary care workforce (Anderson et al., 2005; Department of Health and Aged Care, 2021), there is limited published information pertaining to physiotherapy private practitioners’ opinions of IPCP.

Background

When IPCP is employed, the full scope of knowledge, skills and abilities of available health practitioners can be utilized, and the provision of patient care is more likely to be safe, timely, efficient, effective, and equitable (Interprofessional Education Collaborative, 2016). Effective IPCP creates positive interaction, engenders mutual trust and support, encourages communication between professions, and limits demand on a single profession (Reeves et al., 2017). Organisational improvements are facilitated by enhancing care coordination and continuity, promoting equality of status between professionals, increasing job satisfaction and engagement, and creating a healthy workplace (Gilles et al., 2020). However, interventions carried out by a team that is not functioning well can be less effective than those by professionals working independently and in some practice contexts the implementation of IPCP could be unnecessary (Körner et al., 2016; Perreault et al., 2014).

In the Australian physiotherapy private practice context, the small-scale, monoprofessional clinic is the dominant service delivery model (Department of Health and Aged Care, 2021; J. A. Seaton et al., 2020). These single specialty clinics refer to a sole practitioner model of care or a facility only employing one professional group. Opportunities for unplanned informal contact and spontaneous interaction with health practitioners from different professions may be scarce for physiotherapists working within these practice models (Bennett-Emslie & McIntosh, 1995). Physiotherapy private practitioners’ perceptions regarding what constitutes IPCP may therefore not align with models of best practice that, for example, promote regular multiprofessional team meetings to discuss specific patient cases (D’Amour et al., 2008; Interprofessional Education Collaborative, 2016; Reeves et al., 2010).

Concerns have been highlighted regarding the feasibility of engaging in IPCP when health practitioners work in isolation from one another, or in clinical settings that do not conform to formal team-based processes (Oandasan et al., 2009; Perreault et al., 2014; Szafran et al., 2019). Most research documenting IPCP in primary care, however, has focused on collaboration between medical and nursing practitioners (McInnes et al., 2015; Schadewaldt et al., 2013). Subsequently, published models of IPCP in the physiotherapy private practice setting are ill-defined (J. Seaton et al., 2021). Furthermore, failure to acknowledge the complexity and specificity of the primary care context, such as differences in the public and private health sectors, may lead to poor practices and misunderstandings regarding IPCP (Barrow et al., 2015). To inform the development of practical fit-for-purpose strategies which can support sustainable models of collaborative practice in the physiotherapy private sector, it is essential to understand physiotherapy private practitioners’ perceptions of IPCP. Therefore, the aim of this study was to explore physiotherapy private practitioners’ opinions regarding IPCP in one Australian state (Queensland).

Methods

Study design

This study was part of a larger sequential explanatory mixed methods project (Creswell & Plano Clark, 2017) that sought to lay the theoretical foundation for education, practice, research and policy regarding IPCP in the physiotherapy private sector. A qualitative research design oriented toward interpretive description (ID) was employed to enable physiotherapists to share their views and experiences regarding IPCP in the private practice setting (Thorne et al., 1997). As an inductive analytical approach explicitly built on constructivist epistemological assumptions, ID asserts that knowledge is not absolute, but is “socially constructed through the subjective person who experiences it” (Thorne, 2008, p. 49). ID draws on experiences and evidence from the clinical setting leading to findings with clear implications for practice, rather than research that aims to theorize (Thorne et al., 2016). Ethics approval was obtained from the James Cook University Human Research Ethics Committee (H7951). This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) guidelines (see Online Supplementary Files; Tong et al., 2007).

Study setting

Participants were physiotherapists from private practice facilities in the region covered by the Northern Queensland Primary Health Network (NQPHN; Figure 1). Spanning an area of 510,000 square kilometers, this tropical environment is home to an estimated 730,000 people. Most of the population are located within the major regional centers of Cairns, Mackay, and Townsville, while approximately 8% of inhabitants live in remote and very remote areas (Northern Queensland Primary Health Network, 2022). Sites eligible for recruitment were in Modified Monash (MM) categories 2–7 and employed physiotherapists registered with the Australian Health Practitioner Regulation Agency (AHPRA). The MM Model classification system categorizes different geographical areas in Australia based on population size and relative remoteness. It consists of seven categories, with MM category 1 representing metropolitan areas, and MM category 7 representing very remote communities.

Figure 1. Northern Queensland primary health network region – study locations.

Adapted from Northern Queensland Primary Health Network (2022).

Site selection and participant recruitment

Site selection was informed by the findings of an online survey conducted in the first phase of the larger mixed methods project (J. A. Seaton et al., 2020). Eligible sites (n = 105) were identified from the publicly accessible “Find a Physio” search tool, an index of physiotherapy private practice facilities in Australia maintained by the Australian Physiotherapy Association (https://choose.physio/findaphysio, accessed 15 May 2019), as well as online business directories (for example, Yellow Pages®).

Recruitment was conducted using a combination of e-mail with telephone follow-ups. All physiotherapy private practitioners (n = 31) who expressed interest in further participation by providing contact information on their submitted survey were emailed. The initial e-mail invitation included a participant information sheet, containing detail of the study purpose, the role and experience of the first author and interviewer as a male physiotherapist and current doctoral candidate. Recruitment was predominately convenience based, in that participants were selected on a first-come-first-served basis. This approach was used to efficiently recruit participants who were readily available and willing to participate in the study. A semi-purposive stratified element was also used to ensure physiotherapists worked at a range of private practice sites, varying with respect to organizational model, service provision, team composition and geographic location. Physiotherapy private practitioners who agreed to participate in the study (n = 10) were then asked to identify physiotherapists employed at their facility to take part in an interview through a process of snowball sampling. Invitations to participate in an interview were sent to all additionally identified individuals (n = 18). To be included in the study, participants were required to be: (a) registered physiotherapists with AHPRA; (b) employed in a physiotherapy private practice facility within the NQPHN region for no less than one month; (c) over the age of 18 years and willing to consent to the study; and (d) proficient in spoken and written English. No study participants had a working relationship with the research team. Figure 2 illustrates the recruitment process for the study.

Figure 2. Flow chart illustrating the recruitment process for the study.

Data collection

Semi-structured face-to-face interviews were carried out by the first author at physiotherapy private practice sites within the NQPHN region between March 2020 and February 2021. Semi-structured interviews ensure that the data from each interview align with the research aim yet allows open exploration of each participant’s unique experiences and views of IPCP. An interview guide was developed by the interprofessional research team and informed by the findings from the online survey (J. A. Seaton et al., 2020), which were used to frame the questions and serve as stimulus material for the interviews. The interview guide was piloted with two physiotherapists who had greater than 10 years clinical experience in private practice to ensure that questions and exploratory probes elicited responses with the intended focus on participants’ opinions regarding IPCP in the physiotherapy private sector. The final interview guide is available in the Online Supplementary Files.

As interviews commenced, demographic information was collected in the form of a brief paper-based questionnaire to provide context for participants’ experiences. Interviews were conducted individually in private consultation rooms at each facility and duration ranged from 16 to 117 minutes (mean = 39 minutes). Interviews continued until each participant indicated that they did not have anything else to share. Memos were immediately recorded after each interview to ensure that a reflexive stance was maintained in relation to the research and participants (Birks et al., 2008). All participants provided written informed consent and agreed to the interview being audio-recorded and transcribed. Audio-recorded interviews were transcribed verbatim with the assistance of secure online transcription software (www.otter.ai). Each participant was provided with a copy of the interview transcription and an opportunity to correct or remove any data before the analysis (Patton, 2015).

Data analysis

Reflexive thematic analysis (RTA) was used to facilitate the identification of patterns or themes in the data (Braun & Clarke, 2019). This inductive, iterative approach allowed for flexibility in the interpretation of the data and investigation of both surface meanings and underlying assumptions. RTA aligns well with ID because both prioritize reflexivity and aim to understand the contextual meanings that individuals attach to their lived experiences (Braun & Clarke, 2019; Thorne, 2008).

The first step in the data analysis process was familiarization with the data through careful and repeated reading of transcripts and memos, noting casual observations of initial trends. Open coding was subsequently performed which involved a line-by-line examination of the data to identify preliminary codes. For the first five transcripts, coding was completed independently by two authors (JS and AJ) to sense-check ideas and explore multiple assumptions of the data in a reflexive manner. Crucial to this process was the authors’ shared understanding of terminology and concepts relevant to IPCP (Braun & Clarke, 2019). After this step, codes were gradually consolidated and grouped into themes relating to participants’ opinions regarding IPCP. Themes were then refined and named collectively by the research team. Endorsed themes were worked into a comprehensive description and populated with quotes to ensure grounding in the data and representation across participants to provide an integrated account of participants’ views and experiences of IPCP. Data were managed using NVivo 12 software (QSR International; https://www.qsrinternational.com).

Results

Participants

Physiotherapists from a total of ten different private practice sites within the NQPHN region agreed to participate in the study. The characteristics of the participating sites are presented in Table 1. Six of the ten clinics were co-located with at least one other health service. Co-location refers to health services that are situated in the same physical space (for example, an office, building or campus), although they are not necessarily fully integrated with one another.

Table 1. Characteristics of participating physiotherapy private practice sites.

Site number	Organisational model	Primary physiotherapy clinical area	Physiotherapy services provided*		Health professions employed	Co-located health services	Classification of facility location (MMM)
1	Multiprofessional	Neurological	DVAMedicare CDMMotor accident compensationNDISTelehealthWork injury compensation		Exercise physiology (n = 2) Nursing (n = 1) Nutrition and dietetics (n = 4) Occupational therapy (n = 8) Physiotherapy (n = 6) Psychology (n = 4) Social work (n = 1) Therapy assistant (n = 5)	Nil	MMM 2
2	Monoprofessional	Paediatrics	NDISTelehealth		Physiotherapy (n = 1)	Nil	MMM 2
3	Monoprofessional	Musculoskeletal	DVAMedicare CDMMotor accident compensationTelehealthWork injury compensation		Physiotherapy (n = 3)	Dental clinic GP clinic Pathology Pharmacy Podiatry	MMM 2
4	Multiprofessional	Musculoskeletal	DVAMedicare CDMNDISWork injury compensation		Exercise physiology (n = 1) Physiotherapy (n = 4)	Occupational therapy Speech pathology	MMM 4
5	Monoprofessional	Musculoskeletal	DVAMedicare CDMWork injury compensation		Physiotherapy (n = 1)	Massage therapy Podiatry	MMM 5
6	Multiprofessional	Pain	DVAMedicare CDMMotor accident compensationTelehealthWork injury compensation		Exercise physiology (n = 1) Medicine (n = 1) Occupational therapy (n = 1) Physiotherapy (n = 2) Psychology (n = 1)	Ear, nose and throat surgery clinic Obstetrics and gynecology clinic Ophthalmology clinic Optometry Private hospital Psychology Speech pathology	MMM 2
7	Monoprofessional	Musculoskeletal	DVAMedicare CDMMotor accident compensationNDISTelehealthWork injury compensation		Physiotherapy (n = 9)	Exercise physiology GP clinic Massage therapy Orthopaedic surgery clinic Pathology Pharmacy Podiatry Psychology	MMM 2
8	Multiprofessional	Musculoskeletal	DVAMedicare CDMMotor accident compensationWork injury compensation		Nursing (n = 3) Medicine (n = 9) Physiotherapy (n = 1) Psychology (n = 1) Social work (n = 1)	Nil	MMM 5
9	Multiprofessional	Musculoskeletal	DVAMedicare CDMMotor accident compensationNDISTelehealthWork injury compensation		Exercise physiology (n = 3) Occupational therapy (n = 1) Physiotherapy (n = 6)	Audiology Cardiology clinic GP clinic Paediatric clinic Pharmacy Private hospital Psychology	MMM 2
10	Multiprofessional	Musculoskeletal	DVAMedicare CDMMotor accident compensationNDISTelehealthWork injury compensation		Massage therapy (n = 1) Physiotherapy (n = 6)	Nil	MMM 2

*As denoted on Australian Physiotherapy Association “Find a Physio” search tool.

CDM, Chronic Disease Management; DVA, Department of Veterans’ Affairs; GP, general practice; MMM, Modified Monash Model; NDIS, National Disability Insurance Scheme.

Individual interviews were conducted with 28 physiotherapists (Table 2). The mean age of interview participants was 33 years (range 21–61 years), and they had approximately nine years of clinical experience (range 1–38 years).

Table 2. Demographic and workplace information of participants.

Participant number	Gender	Highest tertiary qualification	Location of entry-level training	Physiotherapy experience (years)	Classification of workplace location (MMM)	Principal physiotherapist	Organisational model	Co-located
1	Female	Bachelor degree	Australia	1	MMM 2	No	Multiprofessional	No
2	Female	Bachelor degree	New Zealand	3	MMM 2	No	Multiprofessional	No
3	Male	Bachelor degree	Australia	9	MMM 2	No	Multiprofessional	No
4	Female	Bachelor degree	Australia	2	MMM 2	No	Monoprofessional	Yes
5	Female	Masters degree	Australia	10	MMM 2	No	Multiprofessional	No
6	Female	Bachelor degree	Argentina	3	MMM 2	No	Multiprofessional	No
7	Male	Bachelor degree	Australia	5	MMM 2	No	Monoprofessional	Yes
8	Male	Bachelor degree	Australia	7	MMM 2	No	Multiprofessional	No
9	Female	Bachelor degree	Australia	11	MMM 2	Yes	Monoprofessional	No
10	Female	Masters degree	Australia	13	MMM 2	Yes	Monoprofessional	Yes
11	Male	Bachelor degree	Australia	5	MMM 2	No	Monoprofessional	Yes
12	Male	Bachelor degree	Australia	1	MMM 2	No	Multiprofessional	Yes
13	Female	Bachelor degree	Australia	25	MMM 2	No	Monoprofessional	Yes
14	Male	Bachelor degree	Australia	2	MMM 4	No	Multiprofessional	Yes
15	Male	Graduate certificate	Australia	10	MMM 4	No	Multiprofessional	Yes
16	Male	Masters degree	Australia	12	MMM 2	Yes	Monoprofessional	Yes
17	Male	Bachelor degree	Australia	6	MMM 2	No	Multiprofessional	Yes
18	Male	Bachelor degree	Australia	5	MMM 2	No	Multiprofessional	Yes
19	Female	Masters degree	Estonia	5	MMM 2	No	Multiprofessional	No
20	Female	Bachelor degree	New Zealand	19	MMM 2	No	Multiprofessional	No
21	Male	Bachelor degree	Australia	5	MMM 2	No	Monoprofessional	Yes
22	Male	Graduate diploma	Australia	38	MMM 5	No	Multiprofessional	No
23	Male	Masters degree	Australia	15	MMM 4	Yes	Multiprofessional	Yes
24	Male	Masters degree	Australia	21	MMM 5	Yes	Monoprofessional	Yes
25	Female	Masters degree	Ireland	14	MMM 2	Yes	Multiprofessional	No
26	Female	Bachelor degree	Australia	1	MMM 2	No	Monoprofessional	Yes
27	Male	Masters degree	Australia	1	MMM 2	No	Monoprofessional	Yes
28	Male	Masters degree	Australia	15	MMM 2	Yes	Multiprofessional	Yes

MMM, Modified Monash Model.

Reflexive thematic analysis of the data produced five overarching themes: (a) quality of care considerations; (b) not a one-size-fits-all approach; (c) the need for effective interprofessional communication; (d) fostering a positive work culture; and (e) fear of losing clientele.

Quality of care considerations

This theme describes the perceived effects of IPCP on quality of care. Nearly all participants explained that IPCP has the potential to significantly enhance the quality of client care: “I think it’s extremely important to have interprofessional collaboration in place for the client to address their needs comprehensively.” (P1) Participants associated IPCP with the notion of the right care in the right place at the right time with the right practitioner: “ … there’s lots of benefits of interprofessional collaboration. In terms of positives for the patient, they probably get the best care from the best provider for that particular problem or area.” (P15) Interprofessional collaborative practice was likened to providing optimal care from the most appropriate practitioner for a given complaint:

It might be someone starts with intervention from a physio for something that’s quite specific, and then through that it’s recognised that actually we need to address some of your chronic health issues to maybe reduce your risk of future problems and … the best person for you now is the exercise physiologist.

(P28)

Most participants stressed that given the increasing complexity of client care underpinned by a growing burden of chronic conditions and an aging population, IPCP should play a larger role in their clinical practice than it was currently doing: “Now that we’re talking about [IPCP], I definitely think I could be doing more to collaborate with other professions … especially given that working in the community means treating people with complex conditions.” (P6) Among the population groups that were identified by participants to benefit most from an interprofessional approach to care were people with persitent pain and those living with disability: “ … for people who are suffering from chronic pain, it would then be beneficial to have an interdisciplinary team in place to deal with all aspects of their condition.” (P1) Australia’s National Disability Insurance Scheme (NDIS) provides access to, and planning and funding of, supports for people with disability: “I think it’s an amazing thing to have all these people weigh in on, especially complex management. So, say for [National Disability Insurance Scheme] participants, I think it’s imperative because they’ve got a lot going on” (P4)

Several participants stated that explaining the reasons behind why IPCP is needed for certain clients was highly important in gaining their respect and trust. Although this was occasionally met with resistance from clients, participants shared the view that it was their responsibility to advocate for and clearly articulate why an interprofessional approach was indicated:

If you’re not getting the outcome you want, or you feel that there is extra information that you are lacking that could be facilitated by another health professional, you better be referring. Sometimes you get resistance from your patient on referring, but we need to communicate why that’s a good thing

(P5)

Not a one-size-fits-all approach

This theme describes how IPCP, if not performed effectively and efficiently, can unnecessarily complicate care and potentially result in adverse clinical outcomes. Participants argued that some clientele groups, by nature of their presenting condition, often do not require resource-intensive interprofessional teamwork. In the management of most acute musculoskeletal conditions, participants believed that IPCP was not necessarily needed: “I think a lot of people do just get better from one approach if their injury is one-dimensional. Say, for example, an ankle sprain.” (P1)

Involving the services of multiple professions shortly after a client commences physiotherapy was also viewed in a negative light. Participants maintained that some clients can be overwhelmed if confronted by a team of health practitioners during the early intervention stage. The participants clarified that this was particularly the case for clients who presented with more acute complaints that were generally considered to respond well to physiotherapy treatment alone: “I think by involving too many people too early on, it might be a bad thing … I think that having too many people weigh in on a situation that’s not exactly complex … I just don’t think it’s necessary sometimes.” (P4) The principal physiotherapist of a multiprofessional clinic claimed that interprofessional referral can sometimes send the wrong message to clients, who may become despondent because they believe their needs have been neglected. In the Australian physiotherapy private practice setting, a principal physiotherapist is typically owner or director of the clinic. Principal physiotherapists are responsible for the overall management and administration of their practice, which includes overseeing the financial aspects of the business, as well as hiring and managing other physiotherapists and support staff:

… we’re identifying people … but instead of managing themselves, we’re over-referring. So, we’re sending people off where they feel pathologised. I think with experience, you get better at not referring too quickly. I think where that backfires, tends to be when people feel like they’ve been fobbed off. So, it depends on how you frame things

(P25)

The principal of another multiprofessional practice added that IPCP can be perceived as doing the “right thing,” which may contribute to unnecessary over-referral: “I think we like the idea of interdisciplinary care because it’s a nice idea, but sometimes … only one person is needed to provide all the care for a patient.” (P28) Such statements raise questions in relation to when IPCP is indicated in the clinical setting.

The need for effective interprofessional communication

This theme describes the importance of effective interprofessional communication to facilitate optimal client outcomes. Participants considered that good interprofessional communication had positive effects on physiotherapists’ clinical practice, which in turn, resulted in better outcomes for their clients: “If there’s better communication between all the clinicians involved in a patient’s care, I tend to find I can be better at what I do and I can probably provide better education, or better treatment to patients” (P15) Participants described effective interprofessional communication as ensuring that the client journey is more streamlined and efficient:

… if you’ve got the communication between different health professionals, it’s going to make a patient’s health treatment … a lot easier for them. They’re going to have a lot better intertwined treatment between professions if and it just makes the whole process a lot smoother for them as well.

(P26)

Several participants however asserted that when clinical discussion is low, this can produce negative effects:

I think that sometimes there can be confusion if there’s not enough discussion, or the quality of discussion between professionals isn’t appropriate, or as much as it needs to be. So, then there can be a profession … doing a certain intervention for the patient that might not line up exactly with what another professional is doing. If that creates confusion for the patient, that can be detrimental.

(P17)

One physiotherapist held the opinion that when there are multiple practitioners involved in a client’s care, this will inherently lead to communication issues: “The more providers involved, of course the more difficult the communication problems are.” (P28) Although there might be the chance that more problems could arise, this largely depends on the skills of the individual practitioners and their ability to include clients in decision-making processes. One participant, for example, reported that physiotherapists are well positioned to clarify messages for clients that have had difficulty interpreting from other health practitioners, namely medical specialists: “I’ve had people that have been seeing specialists for several years, and they’ll come in and you’ll explain to them what is going on and then it will be like, ‘Really? That’s what’s wrong with me?’” (P22)

Fostering a positive work culture

This theme explains how effective IPCP builds camaraderie between practitioners from multiple professions that can lead to the development of an interprofessional network with reciprocal benefits. For sole practitioners or participants employed in single specialty clinics, engaging in IPCP meaningfully resulted in stronger rapport and relationships with health professionals from various external organizations within the region. Participants working in multiple specialty clinics likened IPCP to feeling valued as a team member, whereby conflict was largely non-existent. Although participants acknowledged that there are situations when the role of one practitioner is more dominant, they also described instances where all clinicians involved were given equal opportunity to contribute and provide input to a client’s care. Such occasions were associated with high levels of practitioner satisfaction:

Often with patients there’s a particular profession that isn’t as necessary as it might otherwise be. But I can recall for this particular patient, everyone was essentially playing a significant part, which made the collaborative process truly collaborative, in that when we would have a team meeting, everyone had an equal amount to say. It was quite enjoyable professionally to bounce things off everyone else

(P17)

Physiotherapy private practitioners who did not adopt an interprofessional approach to care were perceived by interview participants to be potentially missing out on opportunities to learn and develop as practitioners. Several physiotherapists held the belief that working in an interprofessional manner was much more professionally rewarding and personally satisfying when compared to practising in isolation from other professions: “ … it’s definitely more rewarding. It’s eye opening. You find out about your other clinicians and other professions in a more intimate way, and it’s actually quite rewarding in that aspect too. It’s definitely more interesting.” (P3)

Several participants believed that interprofessional team environments could alleviate professional isolation. One physiotherapist, who had several years’ experience working as sole practitioner in a rural town, believed that some private practice facilities promote a stronger sense of collegial team culture than others – a factor which could be highly desirable for prospective employees:

I worked for myself … and it was a very successful clinic. I was booked solid for months and months. However, I began to feel it would be nice to have more professional collaboration with people. So, it was one of the reasons that I moved. When I came to [this town], I didn’t look for a job on offer, I targeted this place, and came in and saw [the practice principal] for that exact reason. So, talking to me about interprofessional collaboration, you’re pretty well singing to the choir.

(P5)

Most study participants identified as being a member of an interprofessional team and were appreciative to work as part of one. A physiotherapist with a strong sense of interprofessional identity issued a call to action inviting all health practitioners working in their respective silos to become more collaborative:

I love working in an interdisciplinary practice. I feel very lucky, and I love that I’ve got access to lots of brains in lots of different areas … and if you have never worked in an interdisciplinary team, you don’t know what you’re missing out on.

(P20)

Fear of losing clientele

This theme described physiotherapy private practitioners’ opinions regarding whether interprofessional referral practices resulted in a loss of clientele. This issue was perceived to be largely specific to private practice and may not be observed in other settings. Many participants believed that by referring a client to a health practitioner at another organization who happened to work in close proximity with other physiotherapists, the client would recognize this act of good faith and repay them with their ongoing loyalty:

… they will not lose the patient by referring them to someone else for something else. They’ll gain their trust because that person knows that you have their best interests at heart. You send the person to somebody else, they’ll come back to you because they know you want the best for them.

(P5)

Principal physiotherapists asserted that engaging in IPCP meaningfully enabled the establishment of a stable referral base, as one explained: “We rely on and utilize our relationships with local GPs [general practitioners] and specialists to generate a large portion of our referral base.” (P28) Another practice principal argued that participating in IPCP resulted in more appropriate referrals from a greater number of practitioners:

I just think it’s a really important part of what we do. Even if you don’t want to justify it from a patient continuity of care perspective, I think the biggest thing is it’s really good for your business model. In private practice, you get more referrals, you get better referrals … you get more timely referrals, and you get more appropriate referrals.

(P23)

Some participants, however, recalled the negative effects of IPCP in physiotherapy private practice, whereby referrals to health practitioners at different private sector organizations had resulted in the client being redirected away from them for that episode of care:

We’ve had people redirected from us. So, that’s a bit disappointing. So, we’ve recommended a surgeon to somebody, they’ve had surgery and they’ve got a physio in their rooms. And that surgeon has recommended that physio because they have a mateship or an agreement. So, that’s just a disappointing part of the job that exists.

(P16)

Even participants who had not experienced occasions whereby clientele had been diverted away from their care following a well-intentioned interprofessional referral regarded the act as a possible unintended consequence of IPCP that would leave them relatively confused and frustrated:

If by me sending them to the doctor they were then referred away from me, I’d be pretty p … ed off. That’s a bit of bad faith and I don’t operate like that. So, if it did happen to me, it would very much leave a sour taste.

(P18)

One participant stressed that physiotherapy private practitioners should not take it personally when clients do not return after accessing the services of another health profession, assuming client goals are being met:

I’d be concerned if they didn’t come back to see me, but as long as they’re reaching their goals with … other [health professions] like exercise physiologists and OTs [occupational therapists] … and they’re still being treated and going in the right direction. I think that’s the most important thing.

(P27)

Many participants strongly believed that the client-related benefits of IPCP should be the primary motivating factor to engaging in collaborative processes and fearing loss of income should not underpin such decisions: “If that’s their view, then they’re in private practice for the wrong reasons.” (P1). “It should always be what’s best for the patient. So, if we’ve acknowledged that [interprofessional] collaboration is best for the patient, we can’t possibly say it’s not going to do us any favors.” (P9)

Discussion

The aim of this study was to explore Australian physiotherapy private practitioners’ opinions regarding IPCP. This study builds on, and explores, preliminary findings from an online survey (J. A. Seaton et al., 2020), with a sample of physiotherapists employed in private practice sites within the NQPHN region. Five main themes characterized physiotherapy private practitioners’ views and experiences regarding IPCP: (a) quality of care considerations; (b) not a one-size-fits-all approach; (c) the need for effective interprofessional communication; (d) fostering a positive work culture; and (e) fear of losing clientele.

Interprofessional collaborative practice was considered to be an approach to clinical care that better meets the needs of people with chronic and complex health conditions given that no single health profession has all of the skills and expertise required to intervene adequately and holistically (Andermann, 2016). Increasingly, people are experiencing multiple chronic conditions and frequently present to primary care practitioners, including physiotherapists (Australian Bureau of Statistics, 2022; Australian Institute of Health and Welfare, 2022). The sharp rise in multimorbidity within the community is contributing to increased complexity of care, which, in turn, is often associated with an increase in the number of health practitioners involved in a person’s care (Jansen et al., 2015). These patients may express concerns about multiple appointments, a loss of continuity of care, inadequate and conflicting information, and communication issues with and among treating clinicians (Adeniji et al., 2015; Boeckxstaens et al., 2020). Although the results of this study provide evidence in support of IPCP models of care as best practice for people with multiple comorbidities, the value of receiving care from a single health practitioner who has an established rapport with clients was considered an appropriate service delivery model for less complex conditions. At present, research suggests that care recipients lack opportunities to provide direct feedback concerning their service needs and preferences in primary care (Soklaridis et al., 2017). Further research to gain an in-depth understanding of the client perspective is required to improve the overall quality of IPCP in primary care.

According to study participants, individuals with acute presentations requiring rapid intervention are less likely to benefit from intensive IPCP compared to people with chronic and complex conditions. Most physiotherapists stressed that acute musculoskeletal problems can be appropriately managed by physiotherapy alone, without compromising quality of care. Experienced clinicians argued that IPCP does not necessarily eliminate the need for single specialty care, nor should it be discouraged. There is strong evidence demonstrating that excellent clinical outcomes for musculoskeletal conditions, such as knee osteoarthritis, can be achieved by one profession (Barton et al., 2021).

The critical role of effective communication to facilitate successful IPCP in primary care was highlighted in this study. However, physiotherapy private practitioners also had concerns that involving too many practitioners from various professions in a client’s care can lead to communication issues. Although this may be a misguided assumption based on anecdotal evidence, it is important to acknowledge that health practitioners, including physiotherapists, may not always possess the requisite communication skills for IPCP in primary care (Szafran et al., 2018). Health practitioners remain primarily educated in silos with an emphasis on uniprofessionalism despite most of clinical practice requiring collaboration (Health Professions Accreditors Collaborative, 2019).

Interprofessional collaborative practice was perceived to break down traditional silos and reduce the burden on individual practitioners. Participants reported that effective IPCP resulted in believing they were valued as a part of a primary care team, where significant autonomy was given to them, and conflict was largely non-existent. It is possible that physiotherapy private practitioners’ service delivery model may have influenced their attitudes toward IPCP. More than half of study participants worked in multiprofessional clinics, which were regarded as supportive team environments where shared decision-making could be achieved. Among participants working in single specialty clinics, most were co-located with other health services. Co-location has been found to intensify interprofessional interactions and consequently informal and formal communication and knowledge exchange (Bonciani et al., 2018). Physiotherapy private practitioners working in isolation from other health professions may therefore not report the same effects of IPCP as those who work in close physical proximity to clinicians from different professional backgrounds. Future research should investigate the facilitators and barriers to IPCP across a diverse range of physiotherapy private practice contexts. Such research will allow the identification and development of practical strategies to improve, where needed, IPCP for private sector physiotherapists.

Physiotherapy private practitioners, especially those who had a financial stake in their respective clinics, acknowledged that participation in IPCP helped build a referral network to generate client referrals, and can enhance professional reputation. However, for some physiotherapy private practitioners prioritizing the benefits of IPCP for clients came at a financial cost. The act of referring clients to medical specialists, namely orthopedic surgeons working at other private sector facilities, occasionally resulted in a loss of clientele. Participants attributed this observation to the growing trend of specialists employing a physiotherapist in their clinic. Similarly, referring clients to health practitioners at another private practice facility where physiotherapy services were also offered was viewed as a potential threat to business. Previous research suggests that it is perhaps in the financial interests of principal physiotherapists to employ practitioners from the professions that are frequently referred to within their facility, rather than continuing to seek the services of these health professionals at external organizations (Myburgh et al., 2014; Perreault et al., 2014).

Limitations

There are limitations of the present study. One limitation is a potential volunteer bias. Although physiotherapy private practice sites were carefully selected to ensure that recruited participants were “information-rich” (Patton, 2015), those eligible for study inclusion were chosen from a list of survey respondents who expressed interest in further research (J. A. Seaton et al., 2020). Physiotherapy private practitioners may have therefore agreed to participate in the current study because they were either interested in engaging in, or held strong opinions toward, IPCP. This study, however, deepens our understanding of IPCP from the perspective of an understudied population, physiotherapists working in private practice in regional and rural Australia. Additionally, no health practitioners from other professions were included in the study. Although this might be viewed as a limitation because it may not capture a holistic definition of IPCP, it was considered a strength of this study. In line with social constructivism, the objective was to bias and privilege the accounts of physiotherapy private practitioners, whose voice is largely omitted from the published literature despite comprising a growing proportion of the Australian primary care workforce (Department of Health and Aged Care, 2021).

Conclusion

This study provides new and relevant information pertaining to physiotherapy private practitioners’ opinions regarding IPCP. The findings from this study suggest that physiotherapy private practitioners value IPCP because it can deliver superior client outcomes, strengthen relationships with practitioners from other professions by nurturing a positive work environment, and create a competitive advantage for practice owners through enhancing their professional reputation. Participants also claimed that when performed inappropriately, IPCP can contribute to potentially over-complicated management, which may contribute to poor client outcomes and some reported approaching interprofessional referrals to practitioners at other private sector facilities with caution due to past experiences that resulted in a loss of clientele. The mixed views toward IPCP in this study highlight the need to explore the facilitators and barriers to IPCP in the Australian physiotherapy private practice setting. Future researchers should consider employing direct observational methods to compare whether physiotherapy private practitioners’ self-reported accounts align with their actual interactions. Such research may inform the development of flexible and practical strategies that will support sustainable models of IPCP in physiotherapy private practice.

Authors’ contributions

JS was responsible for collecting and interpreting the participant data. JS and AJ were both responsible for data analysis. JS conducted the primary manuscript draft. JS, AJ, CJ and KF completed subsequent manuscript revisions. All authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

No financial or material support of any kind was received for the work described in this article.

Notes on contributors

Jack Seaton

Jack Seaton, BPhysio (Hons), is a Lecturer in Public Health and Tropical Medicine and PhD Candidate at James Cook University.

Anne Jones

Anne Jones, PhD, is an Associate Professor and the Academic Head of Physiotherapy at James Cook University.

Catherine Johnston

Catherine Johnston, PhD, is a Senior Lecturer and Clinical Education Manager for the Physiotherapy program at the University of Newcastle.

Karen Francis

Karen Francis, RN, PhD, is a Professor of Nursing and the Associate Head Research and Graduate Studies at Charles Sturt University.