Teaching person-centered practice to pre-registration physiotherapy students: a qualitative study

ABSTRACT

Introduction

There has been a call for healthcare to consider more explicitly the needs of the individual patient by adopting a person-centered approach to practice. Consideration needs to be given to how this is taught to pre-registration physiotherapy students.

Purpose

To understand how first-year pre-registration physiotherapy students envision their philosophy of practice and how person-centered aspects of that philosophy might be implemented in a clinical setting.

Methods

Semi-structured interviews were carried out with 10 first-year physiotherapy students. Data were analyzed using thematic analysis.

Results

Five themes were identified: 1) understanding the person and their direction of travel; 2) contextual factors that impact on the delivery of person-centered practice; 3) awareness of personality traits; 4) doing the small things; and 5) the person-centered learning curve.

Conclusion

Understanding the person and knowing what is important to them is central to the participant’s philosophy of practice. They drew on specific personality traits such as listening, being patient, or using small talk to develop rapport to better understand the person they were working with. Despite the challenge of high-pressured, under resourced healthcare contexts, student physiotherapists would strive to do the small things for each person they were working with. Practice-based learning settings presented a steep learning curve and appeared to be important in developing person-centered skills which were introduced in the university setting.

KEYWORDS:

• Physiotherapy
• students
• person-centered practice
• pedagogy
• qualitative

Introduction

There has been a call for healthcare professionals to consider more explicitly the needs of the individual patient by adopting a person-centered philosophy of practice (Groves, 2010). Person-centered practice focuses on ensuring that the individual’s perspective is central to their healthcare (Jesus, Bright, Kayes, and Cott, 2016). Person-centered practice is important because when compared to usual care, it has been found to lead to enhanced self-management and improved physical and psychological health (Coulter et al., 2015). It has also been associated with greater engagement in health promoting behaviors (Hooker, Masters, and Park, 2018).

In the United Kingdom (UK), there is a government move toward a more personalized approach to health (National Health Service, 2021). The premise is that people should be able to have choice and control over their mental and physical health in the same way they do in other parts of their lives. The National Health Service (2019), makes a commitment toward personalized care through six components: shared decision making; personalized care; enabling choice; social prescribing and community-based support; self-management; and personal health budgets (National Health Service, 2019). This personalized approach highlights a shift toward person-centered practice at a government policy level through aspects such as: respect; choice and empowerment; patient involvement in health policy; access and support; and information (Groves, 2010).

Given the importance of person-centered practice internationally, and at a national policy level in the UK NHS, consideration needs to be given to how this is taught to pre-registration physiotherapy students. Pedagogic approaches to teaching person-centered physiotherapy practice in the literature have varied. Some involve service users in single taught sessions or modules (Hale, 2001; Henriksen and Ringsted, 2011; Otterwill et al., 2006; Roskell, White, and Bonner, 2012) others have developed specific module content such as communication skills and narrative reasoning, to promote learning about person-centered practice (Cruz, Caeiro, and Pereira, 2014; Ross and Haidet, 2011) while others have taken a whole curriculum approach, with service users and carers participating across the span of student training (Rapport, Rodriguez, and Bade, 2010; Thomson and Hilton, 2012). Overall, the interventions appear to lead to a greater sensitivity to person-centered practice in physiotherapy students (Killingback, Tomlinson, Stern, and Whitfield, 2021). However, challenges are noted in changing the biomedical perspectives of students developed in the early stages of their education and the perception that person-centered practice is not recognized in clinical contexts (Cruz, Caeiro, and Pereira, 2014). Research highlights a need for an increased focus on person-centered physiotherapy in the curriculum (Solvang and Fougner, 2022).

In September 2020 the University of Hull, in the North-East of England launched a BSc (Hons) Physiotherapy program. This was an opportunity to re-imagine physiotherapy graduates to include person-centered approaches in addition to their current purview as competent and autonomous practitioners with the requisite clinical skills and knowledge to work in a diverse range of settings. As such, person-centered practice was one of the threshold concepts at the heart of the physiotherapy program.

To actualize this, a pedagogic strategy was developed. The strategy was informed through a literature review that explored how person-centered practice was taught in pre-qualifying curricula (Killingback, Tomlinson, Stern, and Whitfield, 2021). The teaching team also drew on the work of Franziska Trede (2006, 2012) and Higgs et al. (2009) who challenged the notion that in addition to the paradigms which shape the broad healthcare environment, each physiotherapist will have their own practice model, informed by their philosophy of practice (i.e. their key values and ways of viewing the world). Broadly speaking philosophy is understood as the pursuit of knowledge and wisdom and deals with fundamental concerns such as the nature of reality, how we conduct life, and how we justify beliefs (Trede and Higgs, 2009). Trede and Higgs (2009) suggested that philosophy and physiotherapy intersect in questions such as: What kind of physiotherapist are you; What type of knowledge is regarded as valuable professional knowledge; What influences the way we reason about a case, come to a diagnosis, make professional judgments, and set goals; and Which beliefs about health, illness, and fitness are adopted? A physiotherapist’s philosophy is developed from professional and personal life experiences, education, practice setting, and learning from reflective practice (Trede and Higgs, 2009).

The physiotherapy program therefore sought to support students in developing their philosophy of practice and understanding of person-centered practice. This is important as it has been suggested that many therapists will not have consciously considered the values and philosophies which underpin their practice (Trede, 2006). Yet, this personal philosophy of practice determines how practice is actualized (Killingback, Clark, and Green, 2021; Trede and Higgs, 2009). For example, therapists whose philosophy of practice is more akin to biomedical paradigms may approach patient encounters through a technical lens in which the therapist is the expert and the practitioners hold the power (Trede and Higgs, 2009). Conversely, those whose philosophy of practice see their relationship with patients as being collaborative and empowering would present as more person-centered in their practice. Therefore, the aim of this study was to understand how first-year pre-registration physiotherapy students develop their philosophy of physiotherapy practice and the extent to which it is person-centered. This is not to disregard the importance of curricular aspects which focus on the requisite clinical skills and knowledge to work in an evidence-informed manner, but to pay attention to the values and philosophy with which educators equip students for practice. This study will address the following research question: how do first-year pre-registration physiotherapy students envision their philosophy of practice and how are person-centered aspects of that philosophy implemented in a clinical setting?

Methods

Study design

A qualitative methodology using semi-structured interviews provided the physiotherapy students with the opportunity to reflect upon their views of their philosophy and how this might be outworked in clinical practice. This qualitative approach was deemed to be the most appropriate to understand the viewpoints of students and explore their perspectives in-depth from an emic perspective (Guba and Lincoln, 1994).

The study was located within a critical realist paradigm. This holds to a complex view of reality and is mindful of the interplay of agency and structural factors within human behavior (Given, 2008; Guba, 1990). Thus, the type of knowledge produced will to some extent be influenced by the questions being asked in relation to the world being studied and unavoidably a reflection of the researcher’s worldview (Danermark, Ekstrom, Jakobsen, and Karlsson, 2005; Maxwell, 2012). It is therefore important to state that all the members of the research team work in higher education with the first author having a background in physiotherapy (CK). As experienced educators, the researchers held views and assumptions about pedagogic approaches which may have influenced the research process. Therefore, the lead researcher (CK) and the author involved in the data collection (AT) documented their pre-conceptions prior to data collection and throughout the data analysis process in a reflexive diary. For example, at the outset of the study, the reflexive diaries documented concerns about the potential power dynamic between students and lecturers and that participants may respond with what they think the researchers as lecturers would wish to hear them say about person-centered practice in physiotherapy. The research team sought to mitigate this by ensuring all interviews were conducted by a researcher (AT) external to the physiotherapy program. The physiotherapy lecturer involved in the study (CK) only had access to the data via anonymized transcripts and students were assured that no data would be used in any assessment processes.

Participant recruitment

A sample of convenience was used to recruit participants (Polit and Beck, 2012). To be eligible for the study, participants had to be members of a first-year student physiotherapy cohort who commenced study in 2020 or 2021 at the University of Hull. The whole cohort was invited to participate in the study through an e-mail invitation by the second author (AT). They were provided with an information sheet about the study and informed written consent was obtained prior to data collection. Ethical approval for the study was obtained from the University of Hull Research Ethics Committee (FHS317).

Study context/pedagogic strategy

The concept of person-centered practice is spiraled throughout the curriculum. Table 1 provides details on the pedagogic approach to teaching person-centered practice in the first-year and the process by which students are encouraged to develop their philosophy of practice.

Table 1. Pedagogic approach to teaching person-centered practice.

Overarching program aims being addressed via this pedagogic strategy:	Competent and autonomous practitioners with the clinical skills and knowledge to assess, evaluate, formulate, and implement treatment programs in a diverse range of settings using a person-centered approach. Compassionate, inclusive, ethical physiotherapists with excellent communication skills who focus on person-centered care.
Theoretical approach:	Social constructivist
First-year	As part of the Foundations of Professional Practice module in Trimester 1 (September – January) of year 1 students spend time learning about person-centered practice. Due to the impact of Covid-19, this module content was delivered online for the 2020 cohort. As the COVID-19 restrictions eased the module content was delivered face-to-face for the 2021 cohort. This involves the following learning activities: Pre-session work: Pre-reading lecturer sourced materials on person-centered practice. Post on a discussion board their thoughts on what they believe to be the most important aspect of person-centered practice and why, and who they believe is the expert in physiotherapy consultations (the patient or the therapist). Face-to-face session: Students hear first-hand from a service user and carer who has experienced physiotherapy at multiple time points. Students work in groups where they read a blog written by a service user. They are asked to discuss what represents good versus poor person-centered practice and then find a picture online which best represents what is happening in the story. Each group then reports back to the whole cohort on their learning using the picture as a focal point of discussion. Students work on their own to write their philosophy of practice, i.e. what kind of physiotherapist they want to be. They aim to develop 5–8 principles and include 1–2 which are reflective of their learning on person-centered practice. Further indicative module content: Reflective practice, communication skills, health coaching, emotional intelligence, self-care, mental health first aid, and self-leadership. Following a one-week introductory physiotherapy placement, students attend a placement de-brief session. A service user is involved in this placement de-brief to offer the patient perspective on their experiences. Part of the debrief session involves them reviewing their personal philosophy of practice. They are asked to reflect on a time on placement where they were faithful to their philosophy (or an aspect of their philosophy) and a time when they found it difficult to be faithful to their philosophy. They will consider reflective questions such as: What made it easy or difficult to be faithful to your philosophy? How did these situations make you feel? What could you have done differently? Were any of your expectations unrealistic given the context? Students consider their philosophy of practice and various person-centered frameworks as part of their module assessment
Module assessment	Early in the module, students are tasked with having a health-coaching conversation with a peer. The conversation is used as a tool for reflection over the course of the module. They are expected to reflect on how person-centered their conversation was (using a person-centered framework and person-centered literature to support their learning), their philosophy of practice, their communication skills, and professionalism (as related to Health and Care Professions and Chartered Society of Physiotherapy standards) to identify strengths, weaknesses, and an action plan to inform future practice. The summative assessment was built using the principles of constructive alignment and is a 15-minute prerecorded voice over PowerPoint where students present the learning achieved on the above areas in a reflective manner.

Vygotsky’s view of social constructivism as a theory of adult learning was selected as the pedagogic approach to teaching person-centered practice in this curriculum. Social constructivism is underpinned by the assumption that learning is about how people make sense and construct meaning from their experiences (Merriam and Bierema, 2014). The role of the teacher within constructivism is to facilitate the learners in negotiating meaning to enable the students to construct their own views of the subject (Bryson and Hand, 2007). This is what the physiotherapy students were asked to do as part of informing their on-going learning around developing their personal philosophy of practice and how this might be implemented.

Data collection

Interviews were conducted online via Microsoft Teams due to the on-going impact of the COVID-19 pandemic. They took place between March and April 2021 for the 2020 cohort and March-April 2022 for the 2021 cohort at a time convenient for participants using a semi-structured interview guide (Table 2). The interview guide was developed through consideration of the literature, the overarching aim of the study, and the research question. Interviews were conducted by AT a female lecturer at the University of Hull trained in qualitative research methods who had no prior relationship with the study participants. Interviews were digitally recorded and no one else was present for the interviews beside the participant and the interviewer. The interviewer was introduced to the participants as a lecturer and researcher.

Table 2. Semi-structured interview guide.

Questions Use prompts such as “tell me more about this” or “how did that make you feel?” as necessary. Would you like to start by telling me about why you decided to become a physiotherapist? [Opener question] What do you understand by the phrase “person-centered practice”? Could you explain it in your own words? Could you explain what you have written as your philosophy of practice from your Foundations of Physiotherapy Practice Module? What was your experience of learning about person-centered practice and developing your philosophy through the Foundations module? [Prompt: tell me more about that]. Were you able to apply any of those principles when you were on placement in November? Did you notice anything in practice which could have been a barrier to working in such a way [based on your philosophy of practice]? You spoke about [link to what they shared in their philosophy] being important in person-centered practice. Did you see that happening in practice on your placement? What are your thoughts on whether person-centered practice is realistic in the National Health Service and what is more about aiming for an ideal? Is there anything about you as a person which will help you practice in a person-centered way? Thinking back to your placement again. Was there anything about the environment that makes person-centered practice easy? Thinking back to your placement again. Was there anything about the environment that makes person-centered practice difficult? Is there anything that you have learned about the collaborative role you will have with patients that will help person-centered practice taking place? Is there anything that you have learned about the collaborative role you will have with patients that will hinder person-centered practice taking place? What do you think might be important about person-centered practice from the perspective of the patient you are working with?

Data analysis

The digitally recorded interviews were transcribed verbatim. Data were analyzed by the first author an experienced post-doctoral qualitative researcher using inductive thematic analysis (Braun and Clarke, 2006). Computer assisted qualitative data analysis software (NVivo 12) was used in the process of data analysis to ensure transparency and provide an audit trail of the data analysis process (Saunders, Lewis, and Thornhill, 2012).

In the first phase of thematic analysis, the data were read and re-read to allow immersion to the extent of being familiar with the depth and breadth of the content. In phase two, the data were inductively coded. Codes were sought to express the data in the forms of concepts by segmenting data. This was followed by phase three where the codes were sorted into potential themes. These themes were refined and defined in phases four and five with final themes reported in phase six (Braun and Clarke, 2006). MT independently cross-checked sections of the qualitative data analysis by comparing the codes and themes to the transcripts. Any discrepancies with the coding or themes were resolved through discussion with the wider research team to reach a consensus. This was a valuable process as it assisted in the refinement and interpretation of themes (Barbour, 2001).

Results

Participant demographics

A total of 10 participants (six females and four males) consented to be involved in the study, five from the 2020, and five from the 2021 cohort. Participants were aged between 18 years and 53 years. Interviews were between 31 and 54 minutes in length. At the time of data collection all participants had completed a one-week introductory placement in a clinical setting. Three had prior clinical experience of working as therapy assistants in the NHS.

Thematic analysis of the interviews led to five themes which were important from the perspectives of participants in envisioning and implementing their philosophy of practice: 1) understanding the person and their direction of travel; 2) contextual factors that impact on the delivery of person-centered practice; 3) awareness of personality traits; 4) doing the small things; and 5) the person-centered learning curve. The age and gender of participants are not reported alongside their direct quotations due to the small cohort size and risk of identification through demographic details.

“More of a taxi driver than a bus driver:” understanding the person and their direction of travel

All participants discussed a sense of understanding the person and knowing what is important to someone in how they presented their philosophy and how those person-centered aspects of their philosophy might be actualized. Participants were mindful of each person having their own history with unique needs, wants, past experiences, and future aspirations. They felt their role as a student physiotherapist was to understand these and incorporate them in working out what was important to the person. To illustrate this one participant used an image of the difference between buses and taxis as to who chooses the destination and direction of travel:

But what I wanted to do was to become more of a taxi driver than a bus driver. So not a normal route, but letting them get in and go “OK, where are we going? What do you want to do?” So that’s my personal philosophy when I’m a physiotherapist. I would much rather be a taxi driver and just lead them to where they want to go, support, facilitate them, enable them, give them the bespoke exercises that gets them from A to B and not that bus driver where they get on and I just drive them then they get off.(Participant 1)

To work out what was important, participants were aware that they needed to get to know the person and so let the person do more of the talking instead of asking reams of questions. For example, one participant learned from listening that the person was a dancer and a dance teacher; their current pain was limiting them from being able to do this and it was affecting her life greatly. This highlighted for this participant the importance of working with people as a collaborative effort. This collaborative working then enabled a sense of teamworking which was seen as important for person-centered physiotherapy to be implemented. To work as a team there was an understanding that they needed to see the patient as a person and as an expert in their own body:

… if you’re understanding that they’re the expert in their own body, you’re basically guiding them to find the answer rather than you telling them. (Participant 10)

In addition, setting goals that were tailored and meaningful to the person was seen as significant; it was important for the person to set the direction of travel:

What is it that makes them tick? Something that’s going to give them that drive. (Participant 9)

However, this had to be held in tension with the sense of responsibility that participants felt in terms of helping the person manage expectations of what might be realistic.

I think in general you’ve just got to try and be realistic. So, for those who maybe need to be told their goals aren’t realistic, you’ve got to be a bit honest. And at the same time, for those who are maybe not optimistic enough, you’ve got to build those up. So, it’s just about finding a balance, I think. (Participant 5)

Participants spoke about the role of supporting self-management as a process where they help patients reach and sustain what was important to them. Some of this was in the form of empowering and reassuring them to be more confident in their outlook of what was possible and to be able to keep moving toward those goals when either the physiotherapist was not there during their period of rehabilitation or when they had been discharged from the service. This was summed up by one participant in “helping patients help themselves” (Participant 5).

“It’s just a classic thing of time:” contextual factors that impact on the delivery of person-centered practice

This theme reflects participant awareness of the healthcare context and the resulting pressures that they perceived had an impact on their clinical practice and their capacity to include person-centered approaches. Time came up frequently among participants in relation to what they perceived to be their ability to practice well using person-centered principles. In many ways this was linked to their understanding of the nature of working within a healthcare context which is resource pressured. They were aware of protocols and targets that must be met, pressure to get people discharged, and this could lead to a loss of person-centeredness as they felt it took time to find out what a person wants rather than what they as student physiotherapists think a person should do. It takes time to build relationships with people, “to warm to you, to be able to open up and say what they want” (Participant 1).

Participants noted a distinction between practice settings of acute hospitals, community teams, or outpatient environments. For example, acute settings meant they might work with upwards of 17 people per day with a different case load twice a week. This led some to feel that person-centered practice was not necessarily realistic in a ward setting. Privacy on acute wards was also seen as a barrier to person-centered practice:

You might be trying to speak to a patient in one bay, but the doctor and the multi-disciplinary team might be in the next bay having a full discussion with the next one. Sometimes it’s not very private. If they want to have a little conversation with you and open up about a problem, it’s sometimes hard to get that privacy element for them … it’s not an easy environment to have patient centered care. (Participant 2)

Participants who had been on community placements tended to perceive that they had more time available. There was a perception that because they were going into someone’s home it was almost compulsory to not rush as much as if they were on an acute ward. One participant, while aware of time pressures but who stated that part of their philosophy was to give an extra minute, felt that time pressures could sometimes be used as an excuse to not be so person-centered in practice:

it’s just a classic thing of time. Well, that’s a great excuse but a minute. What’s a minute? What is a minute?. (Participant 7)

However, participants were aware that some time boundaries were necessary:

I think some people are going to naturally take longer than others. But I think you can have a timescale that’s like don’t go over that because you could sit and have a chat and a cup of tea for an hour! That’s a bit difficult, isn’t it? (Participant 3)

Time was perceived to be a similar pressure in musculoskeletal outpatient departments where there was the viewpoint that you did not have time to talk to people in detail due to the pre-scheduled back-to-back appointments. This led to a need to focus on the physical problem at hand rather than being able to look at the wider picture of the person. However, even in this outpatient context there was a sense that person-centered practice is still possible:

I think it is realistic because, you … realistically it probably doesn’t take as much time as you maybe think to try and understand that person in a well enough way to treat them uniquely. Like you could find out enough about them in 5 minutes or so to tailor what their needs are in the way they want them, I think. (Participant 10)

Thus, this participant raised an important point about the real versus perceived time pressures available to staff. In the healthcare context it was perceived as being hard to give people a lot of time. Instead, participants were seeking to use the little time that was available to be present, to make that person feel important and valued, that they are a person and not just another tick on the register of people to be seen that day. In that moment, the person is the priority, and so even if there was a lack of time, to give the illusion to the person that the time they had with them was theirs to use in the best possible way.

“I wonder what it’s like from their perspective:” awareness of personality traits

This theme encompasses the views of participants regarding the role that they felt their personality traits played in informing their philosophy of practice. It reflects some of the specific characteristics, traits, or values which participants viewed as being important for their practice.

Traits of being caring, compassionate, supportive, being a people person, being creative, friendly, reassuring and encouraging, welcoming, understanding, or jolly were reported by participants. Participants wished to promote dignity and respect with patients, use humor appropriately, be approachable, and be happy in their work, to “be happy as you’re doing it, let the patient know that you are happy doing your job” (Participant 4). There was an awareness that the NHS can be a stressful place to work but part of the philosophy of one participant was that “no matter how busy as a physio I might become, never letting the patient see that stress.” (Participant 2).

Kindness was also viewed as being central to person-centered practice and as such was included explicitly in the philosophy of practice for some participants. Whether they were with a person for 30 seconds or an hour, they had an expectation of themselves that quality of kindness should be evident. A number of participants particularly spoke about the importance of empathy and how they would mentally put themselves in the shoes of someone else to better understand what they might be going through:

I’m thinking, “I wonder what that’s like from their perspective.” I’m continually doing that all throughout my day at university, on placement, at work, really thinking about situations from other people’s perspective. (Participant 9)

Thus, empathy was used as part of their philosophy of practice to consider the patient perspective.

Participants specifically spoke about the importance of being non-judgmental on placement, whether this was about the person’s history, where they lived, or their age. This came to the fore for one participant who worked with a person who had a complex history:

I had a patient and looking through the notes, he was quite a difficult one. The first thing I saw was he had a lifelong alcohol and drug addiction. Then you saw he had hepatitis B, hepatitis C, and HIV. So as a student, you see all this and you think, “oh, my.” And then finally, he was a registered sex offender. So, it was quite a challenge. But you had to just switch off with that and like I said, in terms of respecting individual differences, you’ve just got to say I’ll treat you as a patient and not go too much into the background … that was good in teaching me that just because it says certain things in the notes, you’ve got to put that aside and look at the person and not the notes at times. (Participant 5)

This situation posed some dilemmas for the student. On the one side an understanding of an individual’s psychosocial and medical history is important in personalizing their care; a person’s psychosocial history cannot ethically be ignored for practice to be person-centered. Yet, the student here notes that they have to suspend their judgment on the person’s background while being aware of their history to be able to view them as a person.

Participants spoke about the importance of communication. However, communication was more than verbal and non-verbal skills but also about a personal attitude and traits. For example, the personality trait of being patient was noted as being particularly important when working with people who might have some form of cognitive or auditory impairment. Small talk was used to build rapport and was viewed as a key communication skill as this helped put people at ease. Communication needed to demonstrate an openness toward those they were working with to avoid reductionist approaches:

That relationship, that communication, its professional, but it has that openness, that transparency … I want to care for them, but I want them to know that you’re not just my 9 o’clock appointment on a Monday morning. I want them to know that I’ve got their best interests at heart and that I want to listen and to see and to look, and to understand them. (Participant 1)

“Just the little things can make a big difference:” doing the small things

This theme reflects the views of participants that to enact their philosophy of practice involved a desire to strive for the best for patients. Often, striving for the best was outworked in doing the small things such as finding out what someone prefers to be called, introducing yourself so that they know who you are and what your role is (i.e. not assuming that they know who you are from the uniform you are wearing): “just the little things can make a big difference” (Participant 6). Participants sought to provide the best service possible; they wished to ensure interactions were positive and the person was left with a sense of feeling satisfied, appreciated, safe, and listened to. This was most notably expressed in ensuring that they treated people how they would want their loves ones to be treated as this provided the benchmark of a good service for them.

Simple aspects such as avoiding the use of jargon and putting medical language into layman’s terms, being polite, asking someone how they are and giving them time to reply was seen as important. It was these small things that participants felt made person-centered practice more achievable and could make a difference to someone’s experience of an episode of care. Doing these small things helped them realize that it was possible for them to make a difference to someone’s experience even as a student on placement.

I think sometimes your hands are a bit tied but all you can do is do your bit and then, if outside agencies or outside influences let it down, as long as you’re doing your bit and you can go home and say, “well, I did my best” I think that’s all you can really do.(Participant 5)

Participants talked about valuing the person-physiotherapist relationship and a desire for the person they are working with to know that they want what is best for them, that it is not just about doing a job but about a wish to help that person improve. In some ways it came down to who they were as physiotherapists:

From speaking to people who’ve had better experiences, I’ve noticed that it’s always “oh that nurse was lovely” or “that physio was lovely” … it’s not about the treatment they’ve had, it’s about who’s done it. (Participant 3)

This was not to discount the importance of providing solid evidence-informed physiotherapy, but about being mindful of how they went about their physiotherapy practice.

In a community setting where a physiotherapist may well have a longer-term relationship with some patients, the small things involved remembering details about a person’s life such as wider family members, or the name of their dog. These details were viewed as important in building and maintaining rapport.

Doing the small things was also about being present and making the most of the time they have with each person and that each person gets a sense of them being the priority at that time. Linked to this notion of being present was the principle of resetting between each person they see. There was a desire to not let their tiredness or mood impact on the person and instead be cognizant and conscious in mentally resetting before each contact with a person:

I put each patient, every intervention, every treatment, every day, it’s its own entity … because every day has got to be a reset. (Participant 7)

“It really puts you out of your comfort zone:” the person-centered learning curve

This theme refers to aspects of student learning around their philosophy of practice and how person-centered aspects of that practice might be implemented. Participants discussed the impact that university led learning about person-centeredness had had on their practice:

What I’ve learnt about person-centered care, it’s such a big thing and it’s so, so important, that I think it’s really made me think about what I want to be as a physiotherapist. And I think that’s been the best thing about studying it, learning about it and reflecting on my own practice. So, for me, it’s quite a big thing because I think it makes a huge difference if we can get person-centered practice right, I think our outcomes are far superior. (Participant 1)

Communication skills around health coaching were particularly challenging as it put them out of their comfort zone but were viewed as important in supporting person-centered practice.

For me, that [health coaching] was a massive learning experience and it was quite difficult actually … it really puts you out of your comfort zone and thinking about the importance of the way that you word things and the impact it can have on the other person. Looking back on it now, it was a really good, valuable exercise and obviously it was a large part of our module that we had to do to be examined on it. I remember feeling uncomfortable … I’ve since learned that you do achieve things best when you’re out of your comfort zone. (Participant 9)

Some participants commented on the way in which learning about reflective practice helped support their learning in a clinical setting. Reflective practice was important in that it helped them to step back from what may have happened in the day and gain a different perspective on their response which consolidated learning. The other aspect of university modules that impacted on their learning was hearing first hand from service users and carers.

It really makes you think about the personal needs and wants and how everyone is slightly different … So it’s putting yourself into other people’s shoes but also at the same time realizing that literally everybody will have a different perspective. (Participant 10)

The experience of being on placement and in a clinical environment was new for many participants and a steep learning curve. Part of that learning was about being able to see what good person-centered practice looks like. Participants shared experiences of seeing a range of professionals from carers to therapists who sought to understand the people they were working with and to find out what was important to them. Participants noted the skill with which staff would adapt their practice to the particular person that they were seeing. They could see that the physiotherapists cared about those who they were working with and wanted the best for them. Seeing the positive attributes of the healthcare staff and learning from them reinforced aspects of their philosophy of practice that were important for participants:

I spent a lot of time with the band 4 assistant practitioner. She was really experienced, really knowledgeable, really lovely, all of those things that I said I would want to be basically. (Participant 9)

Participant experiences on placement with person-centered practice were not universally positive. For example, one participant noted times when they observed practice that was not as person-centered as they would have wished and they reflected that they would have approached people differently:

My physio would just be really firm and not explain things … My physio was very much like it was a structured plan with each person, it wasn’t so much tailored as what I personally would have. (Participant 3)

Learning to take account of psychosocial factors that are impacting on a person was part of the learning curve. For one participant this was evident in the experience of working with a person who was fearful of walking again due to her fear of falling. Watching the physiotherapist talk through these fears with the person and helping them overcome the mental barriers taught them about how they need to be cognizant of other factors beyond the physical to support people on their rehabilitation pathway.

Participants discussed their learning around the amount of professional small talk they should be doing with people. They were aware that some people would want to share their whole life story but that this needed to be balanced with the fact that they had a long list of people to be seeing in one day. Therefore, learning the skill of building rapport but also knowing when and how to stop a conversation was one they needed to gain:

“ … you’ve got to know how to stop conversation, but also have enough conversation that you build a rapport with them I think.” (Participant 3)

Discussion

The aim of this study was to understand how first-year pre-registration physiotherapy students envision their philosophy of practice and how person-centered aspects of that philosophy might be implemented in a clinical setting. This knowledge is important because a therapist’s philosophy of practice can influence how their practice is actualized (Trede, 2006; Trede and Higgs, 2009). This study has three contributions to make to the conversation about how to support physiotherapy students in developing person-centered practice.

Firstly, seeking to understand what was important to a person was central to the way in which participants spoke about their philosophy of practice and how those person-centered aspects were realized. This is encouraging since one of the central tenets of person-centered practice is ensuring the individual’s perspective is at the heart of their healthcare (Jesus, Bright, Kayes, and Cott, 2016). This has similarly been described as ensuring physiotherapists see patients as people (Killingback, Clark, and Green, 2021; Killingback et al., 2021). In this study, participants describe how they seek to go beyond the physical ailment or condition which has led to the physiotherapeutic encounter, and instead try to understand what is meaningful to them as people and then work collaboratively to help them achieve those aims. Participants drew on their personality traits to help them get to know what was important to a person. This included their ability to communicate. However, communication was more than just verbal and non-verbal skills, rather it was about using those skills alongside their personality traits to better understand the person. For example, attributes such as being patient, listening, using their small talk skills to develop a rapport, wanting to communicate that they care and for the person to understand that they had their best interests at heart.

This sense of understanding what was important to someone, and the traits needed to reach that understanding highlight the importance of the values of participants. This is significant because there has been criticism of the NHS regarding the poor quality of care in places (Berwick, 2013). A national review highlighted the poor culture of the NHS in some places which focussed on processes instead of people (Francis, 2013). One of the recommendations from the Francis (2013) report was around the importance of assessing candidates’ values, behaviors, and attitudes prior to employment or on healthcare training programs. In response, values-based recruitment has been introduced with the aim of selecting candidates whose personal values align with the NHS values of working together for patients; respect and dignity; commitment to quality of care; compassion; improving lives; and everyone counts (Department of Health, 2015). In support of this, Health Education England published their Value Based Recruitment Framework (Health Education England, 2016). UK physiotherapy education providers follow this values-based selection process in screening applications and interviews which may explain the positive values associated with these participants. What is difficult to ascertain is whether the values-based recruitment approach has worked, and these students are arriving at university with strong core values, or whether it is part of the training around person-centered approaches which have helped develop their values. The ideal situation is that it would be both however, further research would be required to better understand this. Continuing with a values-based approach would appear to have merit based on the values reported by these first-year physiotherapy student participants.

The second contribution this study makes to how physiotherapy students developed person-centered practice was the way in which participants reported striving to do their best for each person they were working with by doing the small things which were within their scope to influence. They were mindful of the high pressured, under resourced NHS context in which they were working, with real- and perceived-time pressures, and so within this setting they sought to do the small things which they perceived would make a difference to people and their experience of physiotherapeutic care. They sought to be present and value the person-physiotherapist relationship. This is important because the therapeutic relationship is a central component of person-centered practice and is associated with better clinical outcomes in physiotherapy (Miciak et al., 2018). Four conditions are noted to enable a therapeutic relationship to be established and maintained: being present, receptive, genuine, and committed; they represent the intentions and attitude of the physiotherapist (Miciak et al., 2018). It was therefore pleasing that these participants, in the early stages of their physiotherapy training were able to articulate some of these foundational aspects of the therapeutic relationship.

It was interesting to note that participants perceived the environment or context of practice-based learning, be that an acute, community, or outpatient setting to influence their ability to practice in a person-centered manner. This has similarly been reported in other pedagogic studies of how students develop person-centered skills. For example, in a study of final year physiotherapy students in Norway, practice contexts such as outpatient clinics on the university campus were found to strongly promote person-centered practice, whereas acute hospital settings with their time constraints and hierarchical organization tightly restricted it (Solvang and Fougner, 2022). The context of environment is one of the constructs at the heart of person-centered practice frameworks (Killingback, Green, and Naylor, 2022; McCormack et al., 2021). This is because the environment can have a major impact on the operationalization of person-centered practice by enhancing or limiting person-centered processes (McCormack and McCance, 2006; McCormack et al., 2021). What is noteworthy in this current study is that participants were aware of the challenges presented by the different environments yet sought to do the small things within their power of influence to be more person-centered in their practice. Thus, while the practice-based context or environment can influence the role of person-centered practice it does not appear to inhibit students from enacting some aspects of person-centered practice. When physiotherapy educators are designing a curriculum with person-centered practice at the heart then emphasizing the importance of doing the small things in practice-based settings would have merit.

The third contribution this study makes is around the pedagogy of teaching person-centered practice to physiotherapy students. As far as the authors are aware this is the first study to outline the pedagogic approach of having students develop their own philosophy of practice on the kind of physiotherapist they wish to be. Participants were able to articulate their philosophy of practice and share how they sought to implement this in clinical practice. Throughout the rest of their undergraduate training, they will be encouraged to refine their philosophy of practice based on reflective practice, practice-based learning, and university teaching.

This study focused on the early stages of student learning (i.e. the first trimester). It would appear that teaching and learning approaches in these early stages are already prompting deep learning on aspects of practice beyond the biomedical. Physiotherapy educators need to ensure students are supported in developing their relational ways of practicing as a balance to the more technical aspects of physiotherapy training (Kleiner et al., 2022).

The practice-based learning setting was a steep learning curve and can be an important place for developing person-centered skills (Solvang and Fougner, 2022). Indeed, it has been said that the arena of practice-based learning is where students work to find the balance with professional and personal skills in building alliance (Solvang and Fougner, 2022). In this current study, participants learned to implement relational skills of professional small talk and consider psychosocial factors and the role they play in rehabilitation. They also got to see good examples of what person-centered practice looked like, and this reinforced aspects of what was important to them from their philosophy.

The authors are mindful that embedding person-centered approaches into pre-registration education is an expectation of national physiotherapy governing bodies (Australian Physiotherapy Council, 2015; Chartered Society of Physiotherapy, 2020; Commission on Accreditation in Physical Therapy Education, 2020). The full range of approaches employed by education providers will not necessarily be recorded in the academic literature. However, more studies which explicitly present their approaches to teaching these complex concepts are important if educators are to embed person-centered philosophies in curricula.

Strengths and limitations

At the time of data collection participants had only spent one-week in a practice-based learning setting. Capturing their views and experiences at this early time point (i.e. their first year of training before they have completed their 1000-hours of learning in practice-based settings) was a strength of this study to permit understanding of the views of students before they had potentially become entrenched in biomedical philosophies which are suggested to be developed early in physiotherapy training (Cruz, Caeiro, and Pereira, 2014).

Recruitment was a challenge for this study. Only 10 participants consented to be involved from the 25 students in the 2020 cohort and the 34 students in the 2021 cohort. This may have been due to the high academic workload at the time of recruitment; however, it was important to try and capture student views in their first year at university. There is the limitation of the self-selecting nature and the risk that this sample was made up of students who already see value in person-centered practice. Participants may have responded with what they thought the researchers (as lecturers) would wish them to say about person-centered practice so this may have been a further limitation. All members of the research team work in higher education thus there is a risk that this is a limited lens through which to approach the study as the applied clinician perspective related to current practice may have been absent.

Conclusion

This study sought to understand the views of first-year pre-registration physiotherapy students on how they envision their philosophy of practice and how person-centered aspects of that philosophy might be implemented in clinical practice. Findings suggest that understanding the person and what is important to them is central to the student’s philosophy of practice. Participants drew on specific personality traits such as listening, being patient, or using small talk to develop rapport to better understand the person they were working with. There was an awareness of high-pressured, under resourced healthcare contexts and the challenge of limited time in some instances. However, despite these pressures student physiotherapists would strive to do their best for each person they were working with. This may often have been the small things such as introducing themselves, finding out what someone prefers to be called, and avoiding medical jargon which were perceived to make a difference for people. Practice-based learning settings presented a steep learning curve and appeared to be important in developing person-centered skills which were introduced in the university setting.

For physiotherapy educators involved in designing a curriculum to qualify students to practice in a person-centered manner then this study would suggest that having students develop their own philosophy of practice on the kind of physiotherapist they wish to be has merit. Facilitating learning explicitly around the importance of doing the small things within the sphere of influence for student physiotherapists in practice-based learning should not be underestimated and explicitly emphasized in university content. This study also raised the positive impact of values-based recruitment when selecting candidates for physiotherapy programs.

To better understand the impact of including support for students to develop their philosophy of practice in the pre-registration curriculum, further research is needed of a longitudinal nature. This would enable added understanding of how their views and practice changes over time and into the post-qualification period. Mixed-methods approaches would be helpful to draw on both quantitative methods to capture a broader sample of respondents and qualitative to provide depth of understanding.

Acknowledgments

The authors wish to thank the participants for giving up their valuable time to be involved in this study.

Disclosure statement

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

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.