We conducted interviews with five physiotherapists and six physiotherapy assistants; these lasted between 60-90 minutes and were audio recorded and transcribed verbatim. Post qualification experience for physiotherapists ranged from 1-32 years, and assistants had between 1 and 30 years experience.
We developed seven themes that help to understand the benefits and challenges of delivering treatment interventions in a person’s home: (1) seeing the person in their own world; (2) developing people skills; (3) thinking outside the cubicle; (4) enjoying the above and beyond; (5) treading a fine line between patient and friend; (6) feeling outside my comfort zone; (7) needing a support network. Each theme has been illustrated by a verbatim quotation.
Seeing the person in their own world
This theme describes the value of seeing the person in the context, and complexity, of their own world.
I think that holistic approach is really important: Yes we’re there to get their knee bending . . . but in the bigger picture, I want them to be able to go outside and use their knee . . . to go and see friends, or do dancing . . . I saw quite a nervous chap . . . most of the time, we didn’t spend doing exercises . . . his knee was functionally really good . . . getting back to work was his main worry. So, we spent a lot of time talking about how to get back to work . . . the kind of holistic approach for him was very important (Physiotherapist)
Participants compared the encounter in a medical setting, and its focus on the body part, with a more relational encounter at home.
[being at home] sort of takes it out of that context where the mindset of you’re just there just to fix you . . . you’re with that chance to be able to talk with people, they’re able to see you as being human. (Assistant)
Entering a person’s home was described as a privilege, where the balance of power can shift from clinician to patient: the patient becomes person.
You’re in there and it’s a privilege to be in someone’s home. They’ve let you in. You’re not just seeing them; you’re seeing everything really . . . you probably will go to their bedroom to do some exercises on the bed, into their kitchen . . . So it’s quite invasive into their world, but it also gives you a lot more in terms of the whole picture. (Physiotherapist 52)
Participants felt that in their future clinical practice, they would focus more on striving to ‘see the person’.
Thinking about the patient as a whole - I think is what I’ll take forward . . . That’s been one of the key things that I’ve taken away. (Physiotherapist)
I would say that I’d strive now to see the person as an individual . . . . . to try and just understand where that person’s coming from, because even with something that you think is as simple as a knee replacement . . . the impact on that one person’s life . . . You don’t just know that stuff instinctively, you’ve gotta know the person. (Physiotherapist)
Developing people skills
This theme describes the benefits of ‘people skills’ which allow you to enter a person’s world and provide individualised, and therefore effective, care.
To be truthful they need to have good people skills to be able to talk to people and not talk down to them . . . don’t make ‘em feel like they’re on detention . . . personal skills count a lot . . . You’ve sort of got to win their confidence and once you do that it’s amazing what you can get out of them . . . get that then you’re rockin’ and rollin’. (Assistant)
Good people skills meant getting to know the person in their context and having the flexibility to respond to individual needs.
The reality is that things change quickly, you have to be pragmatic . . . real life is wonderfully, beautifully messy. . . You can’t know a thing that’s gonna come up. (Physiotherapist)
It’s just making that patient feel really comfortable . . . letting them know that it’s okay and everyone doesn’t follow the same rehab path . . . I think you have to realise you have to be very flexible around the patient. (Assistant)
Thinking outside the cubicle
This theme describes how seeing the person in a real world in situ can enhance creative thinking.
in a sort of sterile clinic or environment where the floor’s totally flat, there’s no obstacles . . . it doesn’t bear that much resemblance to somebody’s house . . . I think seeing people in their own home, it’s just different . . . you can see it, it’s not just theoretical. (Physiotherapist)
Participants enjoyed the freedom to be less prescriptive, to use their imagination, and to be creative ‘outside the cubicle’
I enjoyed being able to give the people the realisation that you don’t need any fancy equipment . . . utilising the equipment that they’ve got, their chairs, their stairs . . . a bit of rope that the husband has got in the shed . . . It was taking it away from just ‘here’s a sheet with some exercises on it’ . . . the skills of being able to adapt to the situation. (Assistant)
This creative and less prescriptive approach was contrasted to the clinical space
[in the clinical space] you probably can’t build up as much of a picture, and you can’t see the home environment that you’re working with . . . we’re able to kind of walk through a day in the life, rather than just talk through it . . . thinking about the bigger picture . . . doing a bit of detective work. . . . I think [we] probably get a bit trapped in the cubicle thinking . . . fix the problem, next patient, fix the problem, next patient . . . (Physiotherapist)
The above and beyond
This describes the personal gain from having a real impact on people’s lives.
I gained . . . personally . . . building relationships; being able to gain more of an insight into human beings . . . this has been really important to me. To be able to spend the time talking to people and understanding what makes them tick . . . I want to take on the stories . . . I think if I wasn’t doing that . . . I’d be less satisfied and more likely to burn out . . . that’s the bit that I enjoy the, the above and beyond. (Physiotherapist)
There was a sense that the gains of this were mutual, benefitting patient and therapist.
It was so lovely walking around that big park, seeing her in her community and she had a lump in her throat, ‘I never would have been able to do that three months ago, you have no idea what that surgery's done for my life’. And you know she squeezed my hand and said ‘that's great thank you’. And she didn't have much honestly . . . she had nothing. It was great. So thank you. (Physiotherapist)
Treading a fine line between patient and friend
This describes the challenge of managing the boundary between yourself and your patient.
You always have to realise that the patient . . . is a patient and not a friend . . . there is that fine line . . . [be] clear to them that you’re here to rehab them . . . some patients want to have a laugh and a joke with you but I wouldn’t say that is unprofessional . . . it’s polite to have that five minute conversation . . . and then once that’s out the way, get on with the treatment. (Assistant)
There was a tension between developing a good rapport and the need to maintain a professional boundary
Building rapport is really important to get the patient engaged, but it’s managing the professional relationship is the difficult bit. . . You do get to you know their family, you meet their kids, you know their dogs’ names . . . and you obviously share your own life stories . . . I found it kind of difficult to negotiate that barriers sometimes . . . because they feel like you’re now friends . . . so it’s difficult to steer back from a close to a professional relationship. (Physiotherapist)
There was a sense that you could cross the line and share too much.
Doing a bit of a share . . . appropriately . . . it breaks down barriers very quickly, doesn’t it . . . It is knowing where to stop . . . not sharing too much . . . I think it’s very blurred . . . sometimes you might cross that line (Physiotherapist)
Participants describe a ‘middle area of closeness’ where you enter a person’s world far enough, but not so far that you become ineffective.
I think there is kind of a middle area of closeness . . . it’s not the more you get into their lives, the more help you can offer . . . there’s a threshold that helps, and then maybe as you get too far, you’re not objective . . . I think you can get a lot from [talking] but if you go to the extreme . . . you hardly have any impact in terms of your knowledge. (Physiotherapist)
Participants described situtations where it might be more challenging to walk this fine line. For example, if you felt more of a connection.
Some people you do sort of click with . . . I got to the point where I liked him, he was a nice bloke . . . I can understand where you’re coming from, you used to be fit and healthy . . . now you can hardly walk . . . . It’s sort of seeing somebody sort of knocked back quite severely . . . . I felt that I want to be able to help him as much as I could (Assistant)
Feeling outside my comfort zone
This describes a feeling of vulnerability when working at a geographical distance from a medical setting.
They were sort of under the impression that I was a physio . . . ‘What do you mean, you’re not a physio?’ . . . and it just sort of made me feel a little bit, uncomfortable . . . there was a husband firing a lot of questions at me . . . it made me get my back up a little bit . . . . I don’t really like it when he’s sort of interrogating me (Assistant)
There was a sense that it was very important to have access to support from colleagues. For example: severe pain, swelling, lack of expected progress, or if things just ‘didn’t look right’.
It was just mainly with the people who weren’t progressing as much . . . the lady who wasn’t getting beyond 30 degrees of movement . . . . I felt I’d sort of done everything that I could. So, of course, I’d go back and touch base with [the physio] . . . even [the physio] was a bit baffled. (Assistant)
Physiotherapsists recognised that this could be extremely challenging for assistants, and emphasised the need for communication and support
I think the important thing would be just to emphasise openness and communication . . . . ‘Don’t sit on something: if you’re worried about something, tell me . . . I might be worried about it as well, and I’ll tell someone else’ (laughter) . . . report it . . . discuss it . . . have a conversation. . . reason it through . . . give your point of view . . . I guess it’s wanting to have trust. (Physiotherapist)
Balancing support and autonomy
This theme describes the challenge of providing the right level of support whilst also encouraging creative and independent decision making.
It’s quite nice . . . to feel like you’re making an impact independently . . . But at the same time, it’s nice to have that support . . . I didn’t feel at all like I was kind of abandoned or deserted . . . I think if the physio was coming in every single time they’d be pressure . . . are they kind of judging [me]? (Assistant)
There was a sense that a collaborative and supportive partnership between physiotherapist and assistant provided a safe place to learn.
I took on a lot of skills and I learnt a lot about myself, I learnt a lot more about how to present myself to a patient because I was independent and I was learning from the [physios] . . . so I was pitching the best skills from everybody and putting them into what I want to become. (Assistant)
Summary of findings
Our findings, summarised in Figure 1, illustrate how home-based therapy was underpinned by a relational and holistic approach (seeing the person in their own world). This approach relied on individualised care (developing people skills) and creativity (thinking outside the box), and could lead to both professional and personal gains (enjoying the above and beyond). Participants could find it challenging to manage the professional boundary (treading a fine line between patient and friend), and geographical distance from the medical setting could make them feel vulnerable (feeling outside my comfort zone). At these times, the right level of support from colleagues, which made them feel supported yet still autonomous, was important (balancing support and autonomy).