Rehabilitation of COVID-19 patients in hospital settings during the pandemic: a phenomenological study of Finnish physiotherapists’ perspective

Abstract

Introduction

The subjective experiences of healthcare professionals during the COVID-19 pandemic have been extensively studied; however, little research has focused on the experiences and perspectives of physiotherapists’, especially in the Nordic countries. The aim of this study was to explore the lived experiences and perceptions of physiotherapists regarding the rehabilitation of COVID-19 patients in hospital settings during the COVID-19-pandemic in Finland.

Methods

Hermeneutic phenomenology was employed as a methodology. Ten physiotherapists were recruited using purposive and snowball sampling. The data were collected through semi-structured interviews and analysed using thematic analysis.

Results

Four themes were identified: (1) pragmatic development of sensitive rehabilitation practices in a new and confusing working environment; (2) becoming a member of a cohesive team; (3) mixed feelings and reactions when facing the brutality of an unknown disease; and (4) being supported by colleagues but lacking support from the healthcare organisation.

Conclusion

The results may benefit healthcare organisations in improving organisational processes for ensuring the wellbeing of physiotherapists during future crises. Concrete actions to support employees could be developed by arranging resources for professional counselling and reflection during and after such crises, and by developing appropriate systems for recognising professional conduct in spite of difficult circumstances.

Keywords:

• Covid-19
• pandemic
• rehabilitation
• experiences
• perceptions
• phenomenology
• thematic analysis

Introduction

Coronavirus (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Although most people recover from COVID-19 without hospitalisation, the disease can lead to critical illness, with complications such as respiratory failure, acute respiratory distress syndrome (ARDS), sepsis and septic shock, thromboembolism, and multi-organ failure. These conditions require medical attention in an intensive care unit (ICU) or medical ward in a hospital [1].

The rehabilitation of critically ill COVID-19 patients with severe risk of functional limitation is encouraged to prevent complications [1–4]. The International Classification of Functioning, Disability and Health (ICF)-based rehabilitation interventions that are commonly used on COVID-19 patients include pulmonary-function rehabilitation, expectoration coaching, position adjustment, breathing training, exercise therapy, deep breathing exercises, psychological interventions, and health-promotion activities [4].

The subjective experiences of healthcare workers (HCWs) during the pandemic have been widely studied [5–9], and the impact of the COVID-19 pandemic on the mental-health outcomes of hospital-based HCWs has been reviewed [10]. However, these studies have mainly focused on the perspectives of medical doctors and nurses. A lack of research that investigates the experiences of HCWs other than medical doctors and nurses from the pandemic is identified [5]. Studies investigating the perspectives of physiotherapists working in hospitals during the pandemic, have been conducted in a few geographical contexts: in The Netherlands [11], Spain [12], Nigeria [13] and, in the US [14].

COVID-19 is the first pandemic caused by SARS-CoV-2 [15], and there is a need for research that evaluates both the specific and general far-reaching impacts of the pandemic in the field of physiotherapy and rehabilitation [5,16]. No previous study has explored physiotherapists’ situation regarding working with rehabilitation during the pandemic in the Nordic countries. Therefore, the aim of this study was to explore the lived experiences and perceptions of physiotherapists regarding the rehabilitation of COVID-19 patients in hospital settings during the COVID-19-pandemic in Finland.

Methods

This study was a qualitative exploratory study, which aimed to describe the lived experiences and perceptions of Finnish physiotherapists of the early pandemic. Instead of employing plain phenomenology, wherein the structures and dynamics of human experience are described, this study employed the philosophical framework of hermeneutic phenomenology to analyse and describe this phenomenon from the perspective of those who experienced it, and furthermore, to understand and interpret these experiences and phenomena by examining their underlying essence [17,18].

Study context

This study was carried out between November 2022 and January 2023 at one university hospital in Finland. The majority of the data was collected during December 2022.

Participants

Ten individuals participated in this study. All were registered physiotherapists with a background in working in an ICU, and/or on medical wards at the hospital subjected to study. They had been working as physiotherapists for a varying number of years.

The participants were recruited using purposive [19] and snowball [20] sampling strategies. The aim was to reach physiotherapists who worked with COVID-19 patients during the first wave of the pandemic. The inclusion and exclusion criteria are presented in Table 1. Twelve potential participants were identified and approached via e-mail or a private message on Facebook Messenger. Ten individuals gave their signed consent to participate after receiving full oral and written information about the study. Furthermore, they were informed that the data was to be anonymised. Information power and data saturation were considered to be reached [21].

Table 1. Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Employed in a hospital as a physiotherapist during the Pandemic	Only experience of treating patients who had tested positive for COVID-19 was when such patients became infected during hospitalisation due to another health condition
Participated in the rehabilitation of COVID-19 patients in an ICU or on a medical ward between Q1 2020 and Q3 2022
Participated in the rehabilitation of COVID-19 patients as a full-time or part-time task, alongside working with other patient groups.

Data collection

The semi-structured interviews followed an interview guide (Appendix 1) [20]. The topics in the interview guide were selected with reference to comparable studies [11–14], and was further refined based on a pilot interview carried out beforehand. Additional field notes were taken both during and after each interview, to capture reflections regarding the context and setting, as well as to document other aspects such as the interaction between the interviewer and interviewees [20]. The interviews were audio recorded with an external voice recorder (Sony PX370).

Each interview began by asking participants to describe their experiences in participating in rehabilitation COVID-19 patients during the pandemic. Open-ended questions around the pre-determined topics were asked in a flexible and spontaneous order. Five interviews were conducted face-to face at the participants’ workplace, and five were conducted via video call on Teams, based on the preferences of the participants. The interviews ranged between 25 and 65 min (46 min on average). The interviews were conducted in Finnish and transcribed verbatim by one of the authors (ST).

The interviewing author (ST) has background in postoperative physiotherapy. Other authors have backgrounds in physiotherapy, with clinical experience in internal medicine (TT) and pulmonary rehabilitation (KW), and one author (AWE) has a background in education. None of the authors has been working with COVID-19 patients in hospital during the first COVID-19 wave, but one author (KW) was involved in developing the first national guidelines for COVID-19 rehabilitation in Sweden. Moreover, one of the authors (ST) had been working as a physiotherapist with COVID-19 patients in hospital settings in the later phases of the pandemic, from 2021.

Data analysis

The analytical techniques of phenomenology are considered to be abstract, as they are not described in detail in the literature [18]. Therefore, thematic analysis (TA) [21] was employed in combination with the philosophical framework of hermeneutic phenomenology, in order to systematically analyse the qualitative data in the different steps of the analysis. The aim of TA was to identify latent themes that captured the most important and relevant elements of the data on the interpretative level [21]. The six steps of the analytical process of TA were followed in data analysis.

Two Finnish speaking authors with full professional proficiency in English (ST, TT) individually identified codes based on interesting, meaningful, and/or relevant segments in the data. Latent codes were identified in the coding phase, which means that the codes also captured underlying meanings on the interpretative level [21]. OpenCode version 4.03. was used to sort the codes in the transcripts. The codes with similarities were compiled into clusters, which formed potential themes. These clusters and potential themes were translated into English in collaboration between two Finnish speaking authors (ST, TT) and one author with Finnish as second language (AWE), to reach mutual agreement about translations. After that, the clusters and potential themes compared and discussed among all members of the research group (ST, TT, AWE, KW) to reach consensus. During this process, the final themes were analysed both on a latent level [21], and in relation to each other (Table 2).

Table 2. An example of the data-analysis procedure.

Original data	You don’t have the tools… the infection, the disease itself, is so kind of challenging that your tools… they just run out. You can do your best, but your best probably isn’t enough. So there was a feeling of inadequacy at times. (Participant 1)	My own first thought was ‘how interesting is this, where there’s no prior knowledge’, so I thought at first that I would like to be involved in such a way that I can see what it’s all about. I thought to myself that I have a front-row seat, I get to do something that hasn’t been done before. (Participant 4)
Code	Feeling of inadequacy	Interest in the new disease
Subtheme	Fear and frustration when facing a brutal disease	Curiosity of the unknown
Theme	Mixed feelings and reactions when facing the brutality of an unknown disease

Results

The four themes and their subsequent sub-themes are presented in Table 3.

Table 3. Thematic analysis presented as themes, sub-themes, and codes.

Theme	Subtheme	Code
1. Pragmatic development of sensitive rehabilitation practices in a new and confusing working environment	Gradually experimenting with rehabilitation practices by utilising prior knowledge	Comparing COVID-19 patients to influenza/other lung-disease patients
		Getting confirmation for rehabilitation practices from new publications
		Hands-on experimentation
		Repetition of treatment practices
	Striving to encourage movement-sensitive patients	Acknowledging sensitivity
		Supporting the patience of patients
		Facilitating trust during mobilisation
		Innovating with regard to communication
	Lack of clarity in available guidelines	Lack of concreteness in rehabilitation recommendations
		Lack of clarity in organisational guidelines
2. Becoming a member of a cohesive team	From an outsider to a central part of a multi-professional team	Lack of clarity in customary professional roles
		Perceiving role as meaningful and clear
	A sense of cohesion within multi-professional teams	Working towards common goals
		Sensing a good atmosphere
		Sensing cohesion
3. Mixed feelings and reactions when facing the brutality of the unknown disease	Fear and frustration when facing a brutal disease	Being scared
		Being stressed by the idea of missing important things
		Fear of contagion
		Feeling of inadequacy
		Feeling of isolation
	Curiosity of the unknown	Interest in the new disease
		Enthusiasm regarding a new field of physiotherapy
	Embodying distress and neglecting one’s own needs	Experiencing delayed stress reactions and physical stress symptoms
4. Being supported by colleagues but lacking support from the healthcare organisation	Feeling invisible within the healthcare organisation while experiencing high demands	Lack of recognition
		Lack of reflection
		Lack of coping support
		Lack of access to professional counselling
	Sensing solid support from colleagues	Being supported by colleagues with professional reflection
		Being supported by colleagues with professional development

Theme 1: Pragmatic development of sensitive rehabilitation practices in a new and confusing working environment

This theme captures the essence of the experiences and perceptions of the physiotherapists as practitioners of a new field of physiotherapy, wherein new rehabilitation practices were developed during a confusing and unprecedented time. Three sub-themes were identified within this theme.

Gradually experimenting with rehabilitation practices by utilising prior knowledge

The participants described contrasting COVID-19 patients with other patient groups, such as those with other lung diseases and influenza or who contracted diseases during earlier pandemics, in terms of the rehabilitation practices. The efficacy of practices in COVID-19 rehabilitation was confirmed by those physiotherapists who had been working during other global epidemics, such as the swine flu pandemic.

It was a bit like just having to work by experimenting, just having to go for it, when there was no such ‘ready-made’ information yet. (Participant 10)

Striving to encourage movement-sensitive patients

The sensitive nature of COVID-19 rehabilitation was acknowledged by the participants, especially with regard to a patient’s level of physical capacity and ability to tolerate movement. The participants described striving to support patients in defining their own level of capacity, while maintaining oxygen saturation at a tolerable level during movement or coughing.

In the ICU, we observed that: ‘well, now the patient is perhaps extubated, will he be able to cope, can we help him to sit?’. And then already on the way up we could see that: ‘well, he’s not there yet’. Like, ‘this is still too much for him’ and then, we backed off a bit. (Participant 10)

Lack of clarity in available guidelines

There were insecurities about which rehabilitation practices were appropriate, as the recommendations and guidelines produced in response to the pandemic lacked concreteness, which resulted in challenges in terms of practical implementation. Lack of clarity in organisational guidelines regarding use of personal protective equipment and the policy of limiting patient contact was also described to be challenging in the process of developing COVID-19 rehabilitation practices.

It was still decided that it [PEP training] was to be put into practice, despite this going against a broad international recommendation. (Participant 3)

Theme 2: Becoming a member of a cohesive team

This theme relates to physiotherapists collaborating with other professionals, and the positive ‘team spirit’ that was crucial for managing the challenges of COVID-19.

From an outsider to a central part of a multi-professional team

The profession of physiotherapist did not have a core position in the care of COVID-19 patients in the early phase of the pandemic. However, as the pandemic progressed, the participants felt that their role within the multi-professional teams was becoming more significant, e.g. by having comprehensive responsibility for evaluating how well patients coped during mobilisation:

Maybe at first, it was thought that the physiotherapist wouldn’t be needed there, but at the point when people started to leave the ICU, we thought: ‘wait a minute, you have been lying in bed for four weeks’; these people just can’t… they can’t even sit or even get out of bed. So they were just like the basic rehabilitation patients. (Participant 6)

A sense of cohesion within multi-professional teams

Working towards a common goal created a cohesive atmosphere in the multi-professional teams, which was experienced as both professionally interesting and a cooperation that worked exceptionally well. Additionally, participants expressed a wish for continued teamwork also in non-COVID-19-related situations.

There was such a team spirit, a sense of ‘now we are about to find out together what this is all about and how such patients could be treated’. (Participant 4)

Theme 3: Mixed feelings and reactions when facing the brutality of an unknown disease

This theme encapsulates the emotional experiences of the physiotherapists, and how they responded while encountering the unprecedented and contagious virus.

Fear and frustration when facing a brutal disease

The participants experienced a multitude of emotions during their first encounters with COVID-19 patients, as the fierceness of the disease became a reality. Feelings of inadequacy and frustration from the lack of knowledge of effective rehabilitation practices, which led to an inability to help patients. Additionally, many of the participants experienced fear of contagion when working with COVID-19 patients, as well as feelings of isolation from colleagues, family, and friends.

You don’t have the tools… the infection, the disease itself, is so kind of challenging that your tools… they just run out. You can do your best, but your best probably isn’t enough. So there was a feeling of inadequacy at times. (Participant 1)

Curiosity of the unknown

Along with the negative emotions, the participants also experienced an interest in being part of developing new procedures for rehabilitating and treating COVID-19 patients. There was curiosity regarding the new disease, and enthusiasm in terms of being the first physiotherapists to treat COVID-19 patients, as well as testing out the most effective rehabilitation strategies.

My own first thought was ‘how interesting is this, where there’s no prior knowledge’, so I thought at first that I would like to be involved in such a way that I can see what it’s all about. I thought to myself that I have a front-row seat, I get to do something that hasn’t been done before. (Participant 4)

Embodying distress and neglecting one’s own needs

Some of the participants described being surprisingly calm while participating in the rehabilitation of COVID-19 patients during the early pandemic, even though they acknowledged that it was a physically and mentally stressful time. These participants described experiencing intense physical and mental stress reactions later, however, after the primary reaction of calmness had subsided:

I was surprisingly cool in that situation, but I didn’t realise until afterwards how burdensome it was. It was like the [stress] symptoms didn’t come on until afterwards. (Participant 1)

Theme 4: Being supported by colleagues but lacking support from the healthcare organisation

This theme captures how the physiotherapists felt solidly supported by their fellow colleagues. However, this was contrasted by how they felt abandoned by the healthcare organisation during this demanding situation.

Feeling invisible within the healthcare organisation while experiencing high demands

The participants described feeling invisible within the healthcare organisation during the challenging times of the early pandemic, although, a high degree of flexibility of individual employees was required. The participants did not feel prioritised by their employers and there was a lack of recognition of their efforts, both individually, and as physiotherapists on a group level. Furthermore, participants felt disregarded by their employer as requests for professional counselling was denied.

At that point, I tried to get into professional counselling and everything for the stress and burden of the pandemic … But I didn’t get any help, and I was like ‘okay, they don’t really care about me at all in this organisation’. (Participant 1)

There was a lack of reflection on the work done within COVID-19 teams both during and after the early phases of the pandemic. The participants felt left alone by the organisation, as they perceived that there was no assistance in processing the experiences, which in fact were quite traumatic.

No one has ever said ‘let’s sit down and talk’, ‘let’s go through it and talk about how it was for you and what you feel and what did it leave you feeling’. This is actually the first time I have got to talk about this. (Participant 2)

Sensing solid support from colleagues

The support from other physiotherapists with prior experiences of pandemics was generally felt to be essential to coping. The participants described being supported by their colleagues with regard to both professional development and the ability to reflect on the situation. Experienced colleagues who had worked during previous pandemics were particularly important in supporting professional development.

When you pondered about those things and read those studies together, you got a better idea of it compared to if you had been thinking about it yourself, alone inside your own head. (Participant 6)

Discussion

The study provides valuable information about Finnish physiotherapists’ experiences of rehabilitation of COVID-19 patients in hospital settings during the early phases of the pandemic. To our knowledge, this is the first study in Nordic countries to explore the lived experiences and perceptions of physiotherapists during this unprecedented time. The themes identified related to how the physiotherapists experienced the pragmatic development of sensitive rehabilitation practices in a new and confusing working environment: they became members of a cohesive multi-professional team; they experienced mixed emotions while facing the ferocity of the unknown disease; and they felt supported by colleagues but lacked support from the healthcare organisation.

Similar to studies conducted in the Netherlands and Nigeria, this study reveals that practices of rehabilitation of COVID-19 patients were developed in a new and confusing working environment, by gradually experimenting with rehabilitation practices and utilising prior knowledge from previous crises such as the swine flu pandemic [11,13]. In the USA, new clinical paradigms were also created in practice, and physiotherapists had to learn ‘on the fly’ as no information about the disease was available [14]. Although the uncertainty inherent in COVID-19-related work has decreased as a result of the growing expertise regarding the disease and practices [22], the Finnish physiotherapists in this study experienced challenges in applying rehabilitation recommendations given in the early phases of the pandemic. This was also described by physiotherapists in the Netherlands, where a lack of sufficient knowledge led to uncertainty [11].

Along with the feeling of having solid support from fellow colleagues during the early pandemic in Finland, multi-professional teams were felt to play an important role in coping with work during otherwise chaotic times. Similarly, a high degree of cohesion among multi-professional COVID-19 teams was identified in Ireland [23], Spain [24], and the UK [25]. These teams had a strong connection among team members, which was based on solidarity, support, an attitude of consensus, and acceptance of new ideas and initiatives that served common goals. These factors form the foundation of what is conceptualised as psychological safety within teams, which affects learning behaviour and, in turn, team performance [26]. The results of this study support the notion of psychological safety in team work. Edmondson argues that a rapidly changing working environment requires individuals and teams to be able to adapt to these new environments, along with new working policies [26]. Therefore, the results of this study indicate that cohesion and a sense of psychological safety among the multi-professional teams were preconditions of physiotherapists’ ability to cope during the chaotic early period of the pandemic.

The physiotherapists described experiencing a wide spectrum of emotions and reactions to the pandemic, and the need to maintain determination to cope with the exceptional working conditions. Varying emotional responses to the pandemic were experienced in other contexts, and one of the most frequently reported responses is fear [11–14]. Physiotherapists in Spain, however, experienced the pandemic quite differently, describing positive or constructive feelings in addition to the chaos and drama [12]. As in this current study, feelings of chaos and confusion were experienced in other contexts [11,14]. The impact of gender has not been discussed in prior qualitative studies investigating the perspectives of physiotherapists working in hospitals during the pandemic [11–14]. In this study, the theme ‘gender’ was included in the interview guide. However, in spite of this, gender and its possible impact during the circumstances under scrutiny, did not seem to be an issue of importance.

The Finnish physiotherapists described feeling invisible within the healthcare organisation, stating that they lacked organisational support to cope with the pandemic. This same experience was shared globally, with physiotherapists and HCWs not being supported by healthcare systems while working on the front line during the early COVID-19 pandemic [13,27,28]. The discussion about support, and lack thereof, is nothing new – the importance of provision of adequate support for healthcare professionals was emphasised much earlier, after learning about the psychological and occupational impacts of the SARS outbreak in 2003 [29]. Contrasting with this, the Finnish physiotherapists described experiencing a strong support from their colleagues, which was perceived as being essential to coping with the unstable working conditions of the pandemic. The crucial role of colleagues has been emphasised also in other studies [11–13].

Strengths and limitations

One of the strengths of this study is the variety of backgrounds and pre-understanding of the four authors. According to the ideology of hermeneutic phenomenology, the author’s pre-understanding of the research subject is valuable, and can guide in interpretation of the research data while authors openly acknowledging their own preconceptions and reflecting on their subjectivity in the research process [17]. Therefore, all authors maintained reflexivity, i.e. being self-aware and critical about their own role in the research process, and preconceived assumptions and values brought into this study were integrated in each phase of the process in order to ensure the quality and transparency of this qualitative study [30].

One limitation is the professional relationship between one author (ST) and some of the participants. One author (ST) and some of the participants were working in the same hospital during data collection. This may have affected the confirmability of the results. Moreover, the relationship between the author and the participants could have impacted the recruitment process, as it may have caused them to feel pressure to participate. However, voluntary participation was emphasised, and each participant was given a reasonable time to consider their participation during the recruitment process.

Another limitation is the lack of extensive descriptive information regarding the study participants. This was an intentional decision, made to minimise the risk of participants being identified based on their quotations by other professionals in the healthcare organisation. This may, however, have affected the dependability of the study, as precise knowledge about the gender distribution and professional experience of the participants would have contributed to the findings and provided context for the reader.

The third limitation is the representativeness of the sample. The recruitment process in this study was performed only in one hospital in Finland, which may have affected the generalisability of the findings. In this study, the phenomenon of interest was aimed to be described from the perspective of those who experienced it, and furthermore, to be understood and interpreted by examining their underlying essence. Aiming to produce generalisable descriptions about the phenomena and experiences was not the aim in the current study, and therefore, the philosophic framework of hermeneutic phenomenology was applied.

Conclusion

The participants in this study felt that well-functioning collaboration within cohesive multi-professional teams was crucial for managing the challenges of COVID-19. Support from colleagues was argued to be the key to the physiotherapists coping with the great demands of their work during the pandemic. The fact that they did not feel supported by the healthcare organisation should be taken seriously. The results of this study show that healthcare organisations can improve with regard to supporting also the wellbeing of physiotherapists during situations when working conditions and structures change rapidly, as in the case of an unexpected epidemic or world event. Healthcare organisations need to develop concrete strategies to support all employees, by providing professional counselling and opportunities for reflection during and after such crises. There is also a need for developing appropriate systems for rewarding and recognising professional conduct on all levels of the organisation. Longitudinal research is needed to investigate the long-term effects of participation in the rehabilitation of COVID-19 patients during the pandemic, with regard to both mental health and the professional status of the physiotherapists whose professional duties were affected by this global crisis.

The authors of this manuscript would like to thank all participants who consented and took their time to participate in the study. No funding was received for this study.

Ethical approval

This study followed the principles of the Declaration of Helsinki [31] and complied with the guidelines of the Finnish National Board on Research Integrity TENK [32]. The study was designed in agreement with the guidelines of The Human Sciences Ethics Committee of the Helsinki Region Universities of Applied Sciences in Finland.

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.

Appendix A.

The interview guide