The final coding system (Table 3) was developed from 155 topic-relevant interview passages and included the four competency categories (a) professional expertise, (b) didactic-methodological competence, (c) personal competence, and (d) social-communicative competence. Each competency category was further divided into subcategories showing different characteristics where applicable.
Table 3
Coding system with competency categories, subcategories and respective characteristics
Competency categories | Subcategories | Characteristics |
Professional expertise | Theoretical knowledge | Anatomy, physiology & pathology |
Pathology-specific exercise therapy |
Practical skills | Exercise demonstration |
Didactic-methodological competence | Topic selection | Patient participation |
Coherent structure and sequence of topics |
Topic variety |
Exercise selection | |
Teaching method | Exercise instruction |
Dealing with language barriers |
Volitional strategies | Illustrated exercise handouts |
Affordable and readily available training equipment |
Personal competence | Empathy | |
Friendliness | |
Humor | |
Affinity for sports and exercise | |
Authenticity | |
Social-communicative competence | Motivation | Verbal encouragement |
Monitoring and highlighting progress using objective performance tests |
Group cohesion |
Patient-centered care | Addressing fears and uncertainties |
Taking care of every patient |
Addressing patients by their family name |
Group facilitation | |
Feedback | Giving feedback |
Asking for feedback |
Professional boundaries | |
Professional expertise
The main category professional expertise comprised exercise therapy skills and knowledge acquired as part of vocational education and expanded through continuing education and work experience. Two subcategories were identified: theoretical knowledge and practical skills. Theoretical knowledge was defined as knowledge that can be found in textbooks or scientific literature. Patients and therapists considered knowledge about anatomy, physiology and pathology as essential components of professional expertise. In addition, both stakeholder groups stressed the importance of pathology-specific exercise therapy.
“I like to have information about how I can improve my condition and which specific exercises I need to do.” (Patient 3)
“The program should be well structured. It should have an adequate selection of exercises. The therapist should reflect on how to dose the exercise. How many repetitions? What are the patient’s goals? What effect do I want to achieve?“ (Exercise therapist 5)
The practical skills subcategory was defined as abilities that can best be learned by practical experience. The therapist’s capacity to provide the patient with a clear exercise demonstration was important to both stakeholder groups.
“I expect the therapist to be able to demonstrate the exercises. That she not only gives a theoretical explanation, but also participates in the exercises shown.” (Patient 5)
“When the patient is more of a visual learner, the therapist should demonstrate the exercise” (Exercise therapist 1)
Didactic-methodological competence
The main category didactic-methodological competence referred to the selection of course topics and methods of instruction. Four subcategories were identified: topic selection, exercise selection, teaching method and volitional strategies. The subcategory topic selection described aspects of selecting and structuring the GEP content. Therapists reported that they tried to consider the patients' wishes, expectations and needs when selecting course topics. A coherent structure and sequencing of session topics was identified as a core component from the therapist’s perspective.
“Structure and planning are important insofar as they ensure professionalism. A therapist who changes his mind about what he would like to do five times during the course of the GEP session, and then runs out of the room to fetch different training equipment five times because of that, does not seem very competent to me.” (Exercise therapist 1)
Topic variety was mentioned by both stakeholder groups as a way of creating a pleasant learning environment and providing patients with different therapeutic approaches.
“I think it is brilliant that we covered so many different topics. Sometimes we performed the exercises standing up, then sitting down, lying down or with different training equipment.” (Patient 3)
“Exercises should not be focused just on strength training. I always like to incorporate topics like mobilization, stretching and myofascial release.” (Exercise therapist 4)
The subcategory exercise selection was defined as the therapist’s choice of basic and alternative exercises. Patients and therapists referred to the ability to modify an exercise for different situations as important. In particular, patients appreciated the therapist not urging GEP participants into performing an exercise in exactly one way (all or nothing), but that the heterogeneous nature of the group was taken into account. Therapists stated three pre-defined difficulty levels per exercise as being sufficient when trying to account for the disparity in participant performance.
“He always gave me something to do. Moreover, I could even do the exercise at the highest difficulty level. That was great!“ (Patient 1)
“It is important to be able to provide different exercise variations. I personally like to show exercises in three difficulty levels. First, I show the basic exercise. Then, when the patient cannot handle that, I show him the easier variant. If it is too easy, I show him the difficult variant. That way, you can cover most group participants.” (Exercise therapist 4)
The subcategory teaching-method was defined as the therapist’s ability to explain exercises and apply patient-specific methods of instruction. In this regard, therapists reported that language barriers and comprehension difficulties could be overcome through exercise demonstration, by breaking down tasks into separate steps or by using tactile cues. Volitional strategies for the implementation of unsupervised training and physical activity into the daily life home setting were mentioned by both stakeholders. Whereas patients referred to individualized exercise handouts as being helpful and a source of motivation, therapists emphasized the importance of teaching exercises using affordable and readily available training equipment.
“She was able to motivate me by giving me exercise handouts. Something to read up on in case I do not remember the exercise.” (Patient 5)
“I like show exercises that the patients can easily do at home. For example, I use resistance bands or balance pads." (Exercise therapist 5)
Personal competence
The main category personal competence included statements relating to the therapist’s personal characteristics. The five subcategories deduced were empathy, friendliness, humor, affinity for sports and exercise, and authenticity. Empathy was important to both stakeholder groups and included sympathy for the patient’s life situation as well as receptiveness to fears and worries expressed by group participants. Whereas friendliness was exclusively referred to by patients, both stakeholders regarded humor as essential.
“I expect the therapist to be relaxed and to have a sense of humor.” (Patient 3)
“I think it is important that there is a certain relaxing atmosphere. That you can laugh together. Because experience has shown me that it is more pleasant this way in group-based exercise therapy.” (Exercise therapist 4)
The subcategory affinity for sports and exercise was defined as the therapist’s ability to express a positive attitude towards physical activity. Therapists stressed the importance of leading by example by making their exercise demonstrations mirror their verbal instructions. To this end, a certain level of physical fitness and personal experience with the exercises taught were mentioned as necessary. In contrast, both stakeholder groups also emphasized the value of authenticity, which was defined as showing vulnerability, putting pretenses aside and being oneself. In this regard, authenticity was seen as a way of connecting with patients and sharing feelings.
“The therapist should be able to admit when she herself is suffering from back pain. It is important to me, that she is genuine and authentic.” (Patient 1)
“Yes, I am getting older now, too. I can no longer do every exercise that we teach the patients. So sometimes, I simply tell them: ‘Listen, I too have knee and shoulder problems, which is why I cannot do the difficult exercises. However, you can also benefit from the easier exercises if you do them regularly.’” (Exercise therapist 2)
Social-communicative competence
The main category social-communicative competence comprised therapist-patient communication and interaction. Five subcategories were identified: motivation, patient-centered care, group facilitation, feedback, and maintaining professional boundaries. Besides verbal encouragement, a motivational strategy stated by both stakeholder groups was the implementation of objective performance tests to monitor and highlight patient progress.
“Today, for example, we repeated a performance test that we had already done last week. We had to write down how many seconds we were able to do these exercises. Then we were asked by the therapist to practice the exercises in our spare time. Today we checked again to see if we had improved. I think that if you set these small goals with your patients, you actually motivate them.” (Patient 3)
“The performance test takes place twice over the course of the program. Besides asking individual patients for their result, I also chart everyone’s result on a whiteboard. That way I can easily visualize potential increases in performance and patients are motivated by their individual progress.“ (Exercise therapist 5)
Another motivating factor stated by therapists was the promotion of group cohesion by creating a pleasant learning environment conductive to the formation of bonds between group members.
“It is important that the therapist manages to create a state of group identity.” (Patient 1)
“It is incredibly motivating when patients exchange information with each other. The more they communicate, the more they spend time together and are motivated during GEP. This is particularly true for the inpatient rehabilitation setting. The patients have lunch together. Some of them arrange to meet in the evenings. That can create very nice dynamics.” (Exercise therapist 1)
The subcategory patient-centered care was defined as the therapist’s ability to respond to the needs of individual participants. To this end, a key aspect mentioned by patients and therapists was the consideration of fears and uncertainties expressed by group participants. Commonly stemming from insufficient knowledge about their respective pathology, patients welcomed the therapist’s professional opinion and reassurance.
“It is not that I cannot do the exercises. I simply fear to get hurt again. However, when I have confidence in the therapist and she assures me: ‘You can do this!’ Then I dare to try the exercises.” (Patient 1)
“Some doctors still advise their patients to rest their back. In that case, I first have to educate and reassure the patient. For example, I have to tell him that in order to stay healthy, intervertebral discs rely on physical activity.” (Exercise therapist 4)
To avoid the risk of overlooking quiet and inconspicuous patients, therapists highlighted the importance of dividing their attention as equally as possible between group participants. In addition, memorizing and addressing patients by their family name was described by patients as going the extra mile.
“She also addressed people by name, even though we were a group. She really made the effort.” (Patient 5)
The subcategory group facilitation was defined as the therapist’s ability to lead group discussions and interactions while remaining impartial. Therapists stressed the long-term value of active, group-based learning instead of front-of-class teaching.
“Patients should exchange ideas with each other. That way, they have the opportunity of finding solutions on their own. I like to let them work on everyday problems in the group, because I do not always want to tell them the solution beforehand. Thus, the things they work out do not just go in one ear and out the other.” (Exercise therapist 2)
The subcategory feedback was defined as the therapist’s ability to provide patients with information about their performance as well as asking for their opinion regarding course topics, exercise selection and therapist behavior. Although therapist feedback varied in timing and occasion, both stakeholder groups highlighted the importance of giving instructions on movement correction and commending patients for their performance.
“She should check if I'm doing the exercises the right way.” (Patient 2)
“Yes, you should always try to commend patients on their performance. For example, I think it is very important to say: ‘Great Job! You've done this very well!’” (Exercise therapist 2)
Patients and therapists further mentioned the value of collecting and incorporating patient feedback in the planning and structuring of topics and exercises.
“It is important to check whether the group is satisfied and what they would like to cover in the next course unit.” (Patient 3)
“The therapist should frequently ask patients for their feedback. For example: ‘Are you guys missing something? Have you thought of anything that we need to add?’ (Exercise therapist 1)
The subcategory professional boundaries was defined as the therapist’s ability to strike a balance between becoming a trusted confidant to patients and maintaining a sense of professionalism. Both stakeholder groups stated boundaries as beneficial for patient-therapist interaction and maintaining therapist authority.
“She did it very well. She was approachable. However, in a professional way, she also clearly emphasized her role as therapist.” (Patient 1)
“I think it is important for patients to have fun, and I tend to let them have their fun with me, too. However, they also have to know when it is enough. I believe that this is important, especially in closed groups. They have to know who is in charge.” (Exercise therapist 3)