Abstract
Background: Caring is central to the practice of physiotherapy. However, explicit components of caring required for South African physiotherapy practice within a model of primary healthcare are not detailed.
Method: Employing a narrative enquiry as the selected methodology, data were produced through multiple methods to obtain multiple perspectives and orientation on how caring was facilitated in the physiotherapy curriculum and in practice. Data production, involving student physiotherapists, physiotherapy academics and practising physiotherapists, included in-depth focus group interviews, individual interviews, journal entries and open-ended questionnaires. Initially, the data were analysed separately for each group of research participants, followed by a cross-sectional analysis.
Results: Components of caring were identified from the interactions of student physiotherapists with patients, academics, practising physiotherapists and among the students themselves. Emerging expressions of caring were grouped as collegiality and valuing; listening, and showing empathy and nurturing; being an expert practitioner; having interdisciplinary knowledge and utilising biopsychosocial intervention; having cultural and language competence; and community and human-interconnectedness.
Conclusion: This paper identifies the components of caring that are important for physiotherapy across multiple sectors. The findings are significant for physiotherapy development and may be considered within other health science professions.
Introduction
Caring is proposed as a guiding philosophy and a moral orientation that is central to clinical practice.Citation1 However, very little has been written about the concept of caring in physiotherapy. While caring, helpingCitation2 and benevolenceCitation3 have been cited as the central pillars of physiotherapy, these values remain vague, or are considered to be implicit, or are often classified as inherent traits that are not easily developed though the curricula because of their subjective nature.
Caring may be explained on two levels. The first, “caring for” relates to the task of tending another person, while the second, “caring about”, involves having feelings for another person.Citation4 The act of caring requires displacing one’s own interests with the interests of the person being cared for.Citation5,6 Furthermore, three interrelated components of a caring ethic have been advanced; namely the value placed on individual expressiveness, the appropriateness of emotions and the capacity for empathy.Citation6 These highlight the central focus of empathy and the selfless desire to pay attention to the needs of another person.
RafaelCitation7 developed an overview of Watson’s theory of human caring in the healthcare context. According to Watson, human caring is based on values such as kindness, concern, and love of self and others. Watson asserts that congruency, empathy, negotiation, and sharing and warmth are the foundations of a caring relationship. Balanced sensitivity to oneself is the foundation to empathy. Developing sensitivity to the self involves the clarification of values on personal and cultural beliefs and behaviour, such as racism, classism, sexism, ageism and homophobia, among others, which might pose as a barrier to transpersonal caring. Watson claims that sensitivity to the self includes an awareness of the interconnectedness of all things and beings, and the social, historical and political context which shapes practice. Receptivity, engrossment and reciprocity have been identified as important components to caring in physiotherapy.Citation1,8 However, little has been documented on the explicit components of caring that are considered to be valuable in physiotherapy practice, and particularly within the South African context.
Previously, health service delivery and the education of healthcare practitioners in South Africa were strongly influenced by the curative focus of the biomedical model. This model is framed within scientific objectivity and reductionism.Citation9 According to this model, a patients’ disability and impairment is viewed as a mirror of his or her underlying tissue and pathology.Citation10 The care of the body has dominated in the practice of the health sciences. Emotional care has not been placed in the foreground. Consistent with this model, quality physiotherapy interventions are considered to be those grounded in the scientific knowledge of physiology and pathology. Physical problems are identified by standardised assessment and diagnostic procedures, based on techniques for which the relevant personnel have been specifically trained, with outcomes which can be measured.Citation11 Shifts in South African healthcare policy towards primary health care were based largely on the influence of social forces on health and disease.Citation12 Compared with the biomedical model, a broader, more visible expression of care, particularly at the patient-practitioner interface, is emphasised in primary health care. The aim of this paper was to explore how caring was identified and facilitated in an undergraduate physiotherapy curriculum and in physiotherapy practice, and to define explicit components of caring which are necessary to physiotherapy.
Method
A South African physiotherapy curriculum was examined using a narrative enquiry within a qualitative framework. Qualitative enquiry focuses on achieving an improved understanding of characteristics or properties of phenomena through tools that involve researchers actively “listening” to the narratives of the research participants. The selection of data production tools used in this study focused on voice, plurality and participation. An exploration was carried out on how the community of physiotherapy practitioners experienced caring in the physiotherapy curriculum and in practice. Approaches to data analysis included content and discourse analysis.
This study was significant as it presented the first opportunity for a range of physiotherapy practitioners to present their opinions on the concept of caring and other related issues which they perceived to be valuable to patient-centred practice.
Narrative enquiry explores the lives of individuals and the stories that are generated through interview transcripts, and the keeping of a journal, observation and other writing.Citation13 Used in conjunction with curriculum enquiry, all forms of narrative enquiry share the fundamental interest of making sense of experience, and an interest in constructing and communicating meaning.Citation14
Data were produced through multiple methods, and involved 42 final-year student physiotherapists, seven physiotherapy academics, 23 community service physiotherapists and 19 managers of physiotherapy departments.
Data from student physiotherapists were produced from two focus group interviews and journal entries during the second semester of the final-year programme. Focus group interviews were scheduled, one before and one after the elective clinical block. An elective is a three-week clinical education block in the final year of the programme, during which students practise physiotherapy at a clinical site of their choice. To enable free disclosure, focus group interviews were used simultaneously with journal entries to produce narratives of how student physiotherapists identified and experienced constructs of caring in the university’s undergraduate physiotherapy curriculum from first to fourth year.
Focus group participants were grouped according to their prescribed clinical education block. Pre-elective focus group interviews were conducted at five clinical education sites, and are referred to in the analysis as A1, B1, C1, D1 and E1. Post-elective focus group interviews were conducted at three clinical education sites and are referred to as A2, D2 and E2. Participants were involved in both the pre- and post-elective focus group interviews and participated voluntarily. The number of participants present at each site determined the number of focus group interviews that were conducted at that site. The distribution of participants into smaller groups is indicated in the analysis as focus group 1 (FG1) or focus group 2 (FG2).
Participant allocation to the focus group was pre-determined by the clinical block placement only. All focus group interviews were audio- and videotaped. Verbatim transcripts of the interview data were generated at each stage. Transcripts were anonymised and member checking of the transcripts established by a random selection of participants.
The reflective journals (29) were numbered for identification and were collected from the participants after the final examination.
Data were collected from seven of the nine full-time physiotherapy academics. Interviews were semi-structured, in depth and audio-recorded. Interviews illuminated how physiotherapy academics identified and constructed caring in the undergraduate curriculum. Verbatim transcripts of the interviews were produced.
Community physiotherapists, who were a new cadre of healthcare workers, were legislated from 2003 to complete a year-long period of community service following their exit from the physiotherapy programme. Twenty-three community physiotherapists who participated in this physiotherapy programme were invited to take part in the study at the end of their year of work. An open-ended questionnaire, accompanied by a letter that sought consent for participation, was forwarded to participants. Twenty of the 23 questionnaires were completed and returned. Reflecting on their current practice experience in under-resourced communities, participants reported how they translated their knowledge and skills produced through the undergraduate curriculum into constructs of caring.
Physiotherapy managers, located at hospitals where participating community physiotherapists were employed, or where final-year student physiotherapists attended clinical education blocks, were invited to attend a participatory workshop. Managers reflected on the skills and knowledge that demonstrated caring in the clinical environment. Twelve of the participants were experienced physiotherapists in physiotherapy management positions in urban, well-resourced public hospitals, while seven of them were community physiotherapists and physiotherapy managers at small, rural, under-resourced hospitals. Participants were arranged in six small groups, comprising 3-4 persons. Each group included experienced and novice managers from urban and rural settings.
The participants were given an hour to engage in dialogue within their groups, following which a spokesperson from each group presented its findings to the larger group. The participatory workshop was video- and audio-recorded. A verbatim transcript of the discussion was produced. A scribe or moderator familiar with the research purpose and enquiry was present to ensure that any one person did not dominate the discussion and that the process was participatory.
The primary aim of this paper was to explore how caring was identified and produced through the physiotherapy curriculum. Data analysis was approached inductively.Citation15 The analysis strategy involved the development of an organising system, segmenting the data and making connections.Citation16 The transcripts and diaries were coded without using a predetermined thematic coding structure. Similar and opposing statements relating to a particular conception or issue were grouped together. Noting patterns and themes, identifying plausibility and employing clustering helped to make connections and to generate subcategories and emergent themes. An understanding of the data was achieved by arranging a logical chain of evidence and developing conceptual coherence through a comparison with referent constructs in the literature.Citation17 Coding of the transcripts and diaries, and emerging groupings of data were perused by an expert in curriculum design to ensure the trustworthiness of the process.
Initially, the data were analysed separately for each group of research participants, followed by cross-sectional analysis. It is possible that subconsciously, unarticulated views about caring and interpersonal relationships, which may have been crystallised through readings on the subject and the researcher’s practice, served as a priori categories that guided the analysis. Elements of caring were identified and categorised from the data in relation to the work of Noddings,Citation5 Collins,Citation6 Rafael,Citation7 Higgs and Hunt,Citation18 Broberg et alCitation19 and Mezirow.Citation20
The University of Durban-Westville Research Committee granted permission for this study (Number 03266A).
Results
Components of caring were identified in the interactions of student physiotherapists with patients, academics, practising physiotherapists and among the students themselves. Emerging expressions of caring were grouped as collegiality and valuing; listening, and showing empathy and nurturing; being an expert practitioner; having interdisciplinary knowledge and utilising biopsychosocial intervention; having cultural and language competence; and community and human interconnectedness.
Collegiality and valuing
The notion of caring was made explicit by participants espousing characteristics that were important to interpersonal relationships. The construct of care (academic, group B) was central to the education and training of physiotherapists. Patient advocacy, Batho Pele principles, dignity and patient rights were reported as being important aspects of valuing, and were perceived to be necessary for holistic caring (physiotherapy manager, group C). Collegiality and valuing were regarded as fundamental to caring, particularly the effect that these had on proximity in the patient-therapist interaction: “You have to respect the patient who you are treating” (student focus group interview, D1FG 1).
Participants reported displaying warmth, kindness and sensitivity towards patients in the practice setting. These traits were perceived to enable comfortable interactions and reciprocity of respect (student focus group interview, B1FG1). Some participants also claimed that caring was made visible to the patient by setting aside time at the start of the interaction to understand the patient and his or her circumstances. This was perceived to affect the outcome of the treatment session positively: “You get to know the person for who they are first, before you even touch the patient” (student focus group interview, D1FG1).
Listening, and showing empathy and nurturing
Listening, and showing empathy and nurturing were perceived by participants to be important elements of caring in physiotherapy. Empathy was identified during patient interactions as the act of shifting the focus on one’s own needs to those of the person being cared for: “For every patient who I come into contact with, I ask myself: ‘What if this was me or my brother or sister?’” (student focus group interview, D1FG1) and “When I was on elective, I would actually go home and cry because of the patients I’d seen trapped in broken bodies. I had to pull myself together, and say that we had to make a difference for them” (student focus group interview, A2FG1).
Academic staff reportedly addressed empathy and listening skills during the physiotherapy teaching programme: “I tell students that you can only know what the person’s going through if you’ve walked in their shoes and felt where it pinched” (academic, F) and “I always say to students: ‘Put yourself into the shoes of the patient. Look at the patient as a whole, not just at a particular aspect, and be guided by the wishes of the patient’” (academic, D).
While these components were identified as important by academic staff for patient-therapist interactions, caring was perceived to be absent in the interactions between student and academic physiotherapists. Student physiotherapists claimed that listening and nurturing were neither valued nor displayed by academic physiotherapists towards them: “People (lecturers) don’t stop to listen to you, and you have a whole lot of issues. Lecturers must listen to what students have to say” (student focus group interview, D1FG2) and “It seems like no one cares for us” (student focus group interview, A1FG2). Some academic physiotherapists concurred with the perceptions of student physiotherapists, stating that the focus of the interaction was largely on academic performance, rather than on assisting with the development of the whole person (academic, G): “If you talk care, you must show care. We need to show our students that we care. Students think that we’re so far away from them that we can’t reach them” (academic, F).
Being an expert practitioner
Treating patients with expertise was reported to be an essential element of caring (academic, A). Being competent, having adequate and appropriate knowledge and skill, and displaying expertise were also perceived to be important by student physiotherapists in the patient-therapist interaction: “As first-contact practitioners, we need to be very skilled in what we do, realise when there is a need to refer, and know our limitations” (physiotherapy manager, group C). A participant reported how her competence created an opportunity for her to transfer her knowledge and skill to empower people to take responsibility for their own health: “While attending the clinics, I came across many patients with disabilities that could be corrected by physiotherapy. This urged me to work hard with them and encouraged them to help themselves” (community physiotherapist, D). In contrast, participants claimed that their absence of knowledge and skill during certain clinical encounters left them feeling inadequate and incompetent. The experience was described as “scary, because people’s lives were in our hands, and I felt really lost not knowing what to do” (student diary, 3).
Having interdisciplinary knowledge and utilising a biopsychosocial intervention
Holistic care, interpreted as practice within a biopsychosocial and multidisciplinary framework, was perceived by participants as an important element of caring. Participants claimed that they had insufficient knowledge and skills with regard to implementing a biopsychosocial approach, as the psychological and social aspects of patient care limited the development of holistic care: “We don’t really apply it (the biopsychosocial approach) because it is not stressed to us to do that. Most of our treatments are supposed to be geared towards function. We hardly know about the social and the psychological. We don’t think along those lines” (student focus group interview, B1FG2) and “We’re training people who are not skilled to deal with psychological and social problems. Our curriculum does not address the whole person” (academic, G).
In addition, participants perceived that the multidisciplinary team approach to patient care was not developed in the curriculum. The curriculum did not provide opportunities for student physiotherapists to engage with other health professionals (community physiotherapist, J) and “We should have some background on the other health professions. We are not exposed to the other health science disciplines” (student focus group interview, B1FG1). Participants claimed that this limited the provision of holistic care within the primary healthcare system.
Having cultural and language competence
Participants perceived language and cultural competence to be important factors that influence interpersonal relationships. It was claimed that proficiency in these elements was important when developing a caring disposition: “Being able to break down the language barrier was very important as I was able to gain a better understanding of the patients (the majority of whom are Zulu speaking) and their conditions” (diary, 15). Participants reported that overcoming the language barrier improved the interpersonal relationship between the patient and practitioner, and improved the patient’s level of commitment to, and co-operation with, the planned intervention: “If I could speak someone’s language, I can actually communicate with the person. The person is going to trust me and make the extra effort to do something” (student focus group interview, B1FG2).
Participants claimed that the development of cultural competence was not covered by the physiotherapy curriculum: “You have to know about the different black cultures. You have to know the patient’s culture to maximise your treatment” (community physiotherapist, E) and “It would help if we could have lectures on how to incorporate the different cultures, races and religions” (student focus group interview, E1FG1). Participants claimed that the inclusion of diverse cultural knowledge in the curriculum was necessary to improve interactions in the clinical education environment and in the classroom.
Having community and human inter-connectedness
Participants reported that caring was limited by boundaries arising from issues of race, culture, ethnicity and gender: “We should be taught a bit more on the different cultures because sometimes the patient doesn’t understand me, or they have no confidence in me because I’m young or a female” (student focus group interview, D1FG1) and “To be more effective in what we do, we need to understand their (the patients’) living circumstances, their beliefs. It’s important to have that background to be effective” (student focus group interview, D1FG1).
However, participants reported that these boundaries were blurred, particularly when working in under-resourced communities. They claimed that such experiences provided opportunities for introspection and an examination of their own values and prejudices: “I remember we went to the rural area and saw what people were going home to, their houses, the distances they’d have to walk to get a taxi” (student focus group interview, E1FG1) and “I value life more, and I have learnt to appreciate what I have. It has truly been a humbling experience” (community physiotherapist, T).
Discussion
Caring is a complex and dynamic process that is expressed in many forms.Citation21
The study findings indicated that the focus of caring in the South African physiotherapy curriculum is largely on physical competence, with less emphasis being placed on relational concepts. Scientific reasoning, competency, problem solving, reflective practice and social ecology were previously identified as guiding factors on the interaction between the patient and healthcare practitioner.Citation18 While these are important for a particular aspect of professional development, the explicit relational elements of caring have not been outlined. Participants perceived that displaying respect and sensitivity, while paying attention and listening to the patient, were important characteristics which facilitated and improved the patient-practitioner interaction.
Some participants perceived themselves to be competent in their therapeutic abilities, and were able to transfer and share this expertise with those who required it to alleviate their discomfort. When they encountered patients with treatable conditions, particularly in under-served areas, participants empowered patients by sharing treatment plans with them. Through this, participants examined the self and their concept of the self in relation to others. Caring is a shared vision if the relationship is participatory,Citation22 creating the potential for the unity and the honouring of human interconnections, and creating potential for accountability and responsibility through planned action.
Expert practice is the fusion of the professional and personal self in a genuine expression of care.Citation23 The study findings indicated that participants’ perceptions of their inadequate skills in communication and cultural competence limited the patient-practitioner interaction and influenced the extent of care offered. Participants reported that they were unable to engage fully with patients because of boundaries created by their perceived language and cultural incompetence. Language proficiency and communication are important for effective health delivery.Citation24 Therefore, the need for communication training is supported.Citation25
The study findings also indicated that the participants were unable to provide holistic care because of their perceived under-preparedness with respect to social and psychological aspects of care. The participants reported having no experience within a multidisciplinary team. The initiation of appropriate interventions was hampered. Caring and expertise are intertwined. The fundamental uncertainties of students entering the professional arena should be resolved to strengthen their confidence in their ability to provide care.Citation26 Expansion of the professional knowledge base to physiotherapy is required.
Education and the development of elements of caring, empathy, generosity, solidarity, civic responsibility, humility and self-effacement require an interdisciplinary space in order to thrive.Citation27 In particular, caring in physiotherapy in the South African setting requires the engagement of its practitioners in experiences across a range of contexts in which boundaries are crossed. This is needed in order to motivate an examination of individual and collective prejudices and taken-for-granted assumptions which divide people across groups of race, class and ethnicity, and which therefore exclude caring. Critical discourse has been successfully implemented in international physiotherapy programmes which focus on the creation of interconnections with people and the development of sensitivity to others’ suffering.Citation21,28,29 These may be valuable considerations for inclusion in South African physiotherapy programmes.
Conclusion
The effective and equitable delivery of physiotherapy within a patient-centred framework should be supported by the multiple constructs of caring that have been identified. Knowledge is required to develop interpersonal skills across diverse contexts, while developing cultural pluralism through cultural awareness and sensitivity. This denotes a shift towards the inclusion of practical, emotional and social competences as components of caring. This recommendation is relevant to all health professional programmes.
Conflict of interest
The author declares no conflict of interest that may have inappropriately influenced her when writing this article.
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