Self Management Shared decision making and self-management: How

An important passage from the vision on future care (2022) issued by the Dutch government is: Appropriate care increasingly means hybrid care: a mix of digitally and physically offered care and health support, personalized and tailor-made where possible. Principles here are: self if possible, at home if possible, and digitally if possible. In short, there is a lot of emphasis on self-management and e-health.

The need for self-management or self-management support in various conditions is growing and becoming increasingly important. Beneficial effects of self-management include: gaining greater autonomy, self-confidence, better quality of life, and more optimal participation. Self-management means that patients can choose the extent to which they want to take control of their lives and co-direct how available care is used. Self-management support is the systematic delivery of education and supportive interventions to patients (and possibly their family and social network) so that patients can cope with the consequences of their illness (on physical, mental and social aspects). In doing so, patients develop skills and confidence to maintain health-promoting behavior for the rest of their life.

Physiotherapists’ actions to stimulate proper self-management are designed as much as possible through shared decision-making. Today, shared decision-making (SDM) is, largely, espoused as the preferred model for making decisions in everyday health care. It is a process whereby professionals and patients share knowledge, values and preferences for different options towards treating complaints and diseases. This decision-making process is greatly relevant if one is to achieve informed consent and patient centered care. SDM typically involves the provision of evidence-based information about options, outcomes and uncertainties. This helps patients to consider their options and improves patients’ biomedical and psychosocial health outcomes. It may too increase their knowledge, trust and ownership of their health.

Some healthcare professionals express doubts, saying that patients don’t want to be involved in decisions or don’t want to have so much influence on their own health. Patients might lack the cognitive capacity or ability, might make ‘bad’ decisions. These health care professionals question the ability of patients to take control over their own actions to ‘get better’. THIM is curious what future therapists think on this matter. How should SDM be handled and self-management effectively stimulated? To answer this question, seven first-year physiotherapy students of THIM-NL and five of THIM-CH were interviewed by peers on this topic.

Do you think self-management is important in physiotherapy?

Not surprisingly, all the students perceive selfmanagement as important in physiotherapy. To quote one student: ‘if patients do not have self-management competencies, there is no way they are going forward or improve themselves’.

Students acknowledge that to stimulate selfmanagement, it is important that the physiotherapist has good communication and coaching skills. One student mentions: ‘most clients don't like to be told what to do and think you are talking down to them. By communicating well, we could make it appear that it is their idea. Then they might be more likely to do it’. Another student adds: ‘by narrowing down options and highlighting the option I as a physiotherapist would prefer, I could let them think that they choose by themselves but secretly we choose for them’.

However, although students think self-management is really important, they believe that it is also fundamental that patients can always seek for help of a professional: ‘as a patient, you don’t need to do everything alone’.

How can shared-decision making (SDM) help patients with their therapy?

Students think that SDM might help motivate patients for the therapy: ‘because nowadays patients receive more active therapy and have to do more exercises at home, it is important that the patient agrees with these exercises’.

One student adds that SDM stimulates a sense of responsibility in the patient, about how his/her own therapy can help decrease their complaints. This is backed by some other students, who state that it is important that patients sense a feeling of control over the situation and over their functional improvements. ‘With shared-decisions we can give patients the feeling to be a part of it and be also involved in the process and not obligate them to - do this and that because we know it better than you’.

Although students think SDM is important, some highlight that the physiotherapist is the one who knows best how to help patients and reach their goals: ‘the physiotherapist is better educated for the job than the patient. She/he has the knowledge and must always have control of the therapy’.

Another student concludes: ‘as a therapist you know all the theory and have the experience to help the patient. However, a patient knows his/ her body better than anyone else. So together you make the best decisions’.

Do you think all patients are capable of shared decision making?

Most students agree that not all patients are capable of SDM. Children are often mentioned as a group that is not suitable for SDM. Also, elderly people, and/or patients with an intellectual disability are likely not a good fit for this approach. To quote two students:

- ‘as an adult (18 years and older), you are better in evaluating yourself than children and retirees’.

- ‘some people are mentally unable to find a reasonable or appropriate decision in their situation. Or shortly, certain people are not as smart as other people and are not capable to do this’.

Another student adds: ‘a lot of people can’t separate between what is healthy and what isn’t healthy for them. They don’t want exercises, but a more passive treatment’.

On the contrary, two students believe that everyone is capable of SDM. Some people just find it easier when other people tell them what to do : ‘these patients want you to solve the problem for them and they don’t want anything to do with it’.

One student adds: ‘the therapist just has to install a feeling of confidence allowing the patient to feel free to say everything’. Students however do not name patient education as a means to increase knowledge in their patients. This would be a valid way to increase the patient’s capability to SDM.

Where do you see problems in SDM and selfmanagement?

Several students foresee problems with an increasing SDM and self-management in the physiotherapeutical practice. They fear that it might be difficult to stimulate patient to do their homework exercises where ‘self-management also includes doing things at home without the physiotherapist being there to constantly motivate’. Sometimes patients favor a more passive approach over an active one, as acknowledged by the students:

- ‘some patients might lack a bit of self-discipline’

- ‘some people want you as a physiotherapist to solve their problems’.

- ‘some people are just lazy and not motivated, then it can be very difficult’.

Most students are aware however that good communication is an important element to convince these patients. Education is however barely named. Thereby, according to some students, it might be extra challenging to convince patients when they are ‘stubborn’ or ‘think they have found the solution on Google’.

Another problem that students foresee is that some patients are less capable in SDM and self-management. One student states: ‘some patients select exercises that can be cool for themselves to do but aren’t really effective to solve the problem they came for’. He/she adds: ‘Physiotherapists must retain control of the therapy and have the “last word” if something isn’t effective or doesn’t make sense’.

One student does not see any negative points in shared decision making. In his/her opinion it only brings advantages: ‘of course, the patients can get lazy or busy, but then it is up to you as a physiotherapist to make an exact and motivating plan for them’.

One student sees it a bit differently: ‘The biggest problem I see within SDM and self-management is that the therapist learns for the job and knows what is good for you. It is nice to see that patients think about their body and learn what is good for them. But they are insufficiently equipped for making possible life changing decisions. If they can make a decision on their own, they can also do the work as a therapist. A therapist can also not make a house if you get me. Maybe I’m hard on this, but I pay a lot of money to go to school to be a therapist and it is strange that someone that is not a therapist can say if something is right or not’

What is your personal opinion on hybrid care?

Although most first year physiotherapy students would rather see their future patients face-to-face, they see hybrid care as here to stay. The benefits of faceto-face therapy are quoted as:

- ‘you can better see mimic and gestures of patients’

- ‘the patient can feel safer when a physiotherapist is physically there’

- ‘therapist and patient have a closer contact’

- ‘errors can be corrected right away’

- ‘it might be challenging for older people to cope with modern technology’

- ‘it is more effective’

The last argument is eye-catching, since several scientific articles appeared recently which concluded hybrid care being just as effective, in several patient groups, as non-hybrid care.

Unfortunately, students did not connect hybrid care with self-management. It would’ve been interesting to learn what students think about possibilities for hybrid care to support self-management.

First year, full-time Dutch students of THIM-NL

In the recent adjustment of the Dutch professional competence profile for the physiotherapist (2021), a more important role was set aside for the physical therapist as an innovator. The following part (in italics) was taken from this profile:

It is the physical therapist's responsibility to apply and implement relevant innovations in his action. The physical therapist uses care technology, such as blended care and other ehealth applications when this fits in with the patient's request for help and the patient’s environment. This can happen in addition to treatment, but also as a (partial) substitution of physiotherapeutic treatment with the aim of making the care better and/or more effective. The physical therapist therefore should have an open and critical attitude towards innovations.

The Dutch professional competence profile for the physiotherapist (2021) states the following: The physiotherapist deploys healthcare technology, such as blended care and other e-health applications, when it suits the patient's care needs and living environment.

THIM University is curious about its students’ perceptions on how important they think this innovator role is in their future as a physiotherapist, what they think counts as an innovation, and how they would apply this role of innovator within their future praxis. To answer these questions, 9 THIMNL students and 6 THIM-CH students were interviewed by peers on this topic.

What is meant by ‘innovation’ in physiotherapy?

Most students answer this question in the following manner: ‘Innovation in physiotherapy are new methods, new technologies, new systems, and new products for healthcare’. One student adds: ‘innovation for me means we strive for the highest standard’.

Students reckon that innovating the field of physiotherapy is very important: ‘I think that it’s good to have innovations in physiotherapy. For example, online coaching for the patients. That can be a huge thing because it can save people time and money’.

What kind of innovations would you like to see in the future?

One student mentions the use of artificial intelligence in physiotherapy would be interesting. But also virtual reality and blended physiotherapy, both already used in physiotherapy, would be good according to this student: ‘I also like the idea of the hybrid system which gives the opportunity to partially do treatment from home. It’s for sure more relevant to meet in person but some small treatments or minor adjustments could be doable from home’ Another student adds: ’online treatment and tele-health are becoming more popular in other areas. Hopefully this also becomes a trend in physio as well. Although there needs to be more advancements in e-health to fully allow the physio to do everything they need to be able to do online. Apps will also hopefully play a role in the future, where you can upload exercises and patient videos. There will also hopefully be more technical devices that can be used, but cost will be an issue, as new technology is rarely cheap’.

One Swiss student has an idea for a new innovation: ‘A nice idea would be to introduce robots that can give massages or be able to keep medical records with as much detail as possible’.

Most students however find it challenging to come up with innovations they like to see in the future: ‘I don’t know what technologies I want to see in the future, but I want to see more innovations that already exist to be used by everyone’. Another student adds: ‘and the introduction/usage of these innovations should be subsidized by the government’.

What are the advantages and possible disadvantages of new inventions, in particular regarding the more and more complex devices seen today?

Several advantages are mentioned by students:

- Saves time for the physiotherapist

- Easier and more data collection (for example with wearable devices such as AppleWatch)

- More accessible (distance physiotherapy)

- More fun and/or interesting (gamification)

- Accurate

- Stimulates home exercises (with an app) While on the disadvantages’ side:

- More expensive

- Complicated

- More time to learn about these new inventions

- Less personal contact and human interaction

One student shares a fear regarding future innovations: ‘in the future there could be machines or other technologies that would be better than a Physiotherapist and therefore our future jobs can be at risk’.

Why is it important to continuously strive for innovation in the field of physiotherapy?

Students see a responsibility towards the patient and their own profession: ‘you owe the patient, to help him as best as you can. This means that you should always know the best and newest ways to take care of the patient in the best possible way’. Another student adds: ‘it is important to continue innovating the field of physical therapy because we want to develop our health care to more successful therapy for the patient. When we keep learning, we will find more answers and solutions for problems and difficult questions’.

Do you think that the schools in general have to teach differently due the innovation in the job of physiotherapy?

Students agree that the school is responsible for creating an open attitude towards innovations by teaching about them: ‘we should be getting more lessons about innovations, because it’s our future and it’s in the competence profile’. Another student agrees and adds: ‘So that students will be ready when it comes to working later when they’re done with school’. Some students mention that they haven’t seen much lessons on innovating physiotherapy yet in the first semester. One student mentions: ‘It is important to know things like anatomy and physiology but as you get further in your study, we need to start learning about these innovations to stay up to date to give the best care we can to future patient’. Another student adds: ‘I think that schools don’t change their things that they teach every year. I don’t know how often that changes, but let’s say that every year they change the stuff they teach. They have to do that because otherwise they teach you stuff that isn’t relevant anymore’.

How can a physical therapist personally contribute to the advancement of his/her field?

The students reckon that it is most important that you are open to change: ‘Basically, be curious and be open to try new things. Especially try to grow as a person and never think that you know everything. There is always a new and better way, but if you always stick to the things that you already know, the field will not advance itself’. Other students add that staying active towards attaining more knowledge, also after you finished school, would be a suitable contribution. For example: ‘follow various courses’, ‘read research papers and talk to colleagues’, and ‘attend conferences and seminars’. But the most important personal contribution to the advancement of the field can be summarized by one student: ‘questioning status quo on a daily basis’.

How does the cultural background of the physiotherapist influence therapeutic interventions chosen?