Background: Shared Decision Making (SDM) is primarily intended to enhance patient autonomy. To date, the relationship between patients’ perceived levels of involvement and autonomy support has never been investigated in the field of physical therapy. Based on the recently reported extremely low level of observed SDM in physical therapy, similarly poor patient perceptions are expected. Objective: The main objectives of this study were to examine patients’ perceptions of SDM and autonomy support in physical therapy and to explore the relationship between both. Design: Patient survey after real consultations in physical therapy. Methods: Patients completed the Dyadic Observing Patient Involvement (Dyadic OPTION) instrument and the Health Care Climate Questionnaire (HCCQ) to examine patients’ perceived levels of SDM and autonomy support, respectively. Multilevel analyses were applied to determine the relationship between both perceptions. Results: Two hundred and twenty-nine patients, who were recruited by 13 physical therapists, agreed to participate. The median Dyadic OPTION score was 72.9 out of a total possible score of 100. The median HCCQ score was 94.3 out of a total possible score of 100. Patients’ experienced level of SDM (b = 0.14; p < 0.001) and patients’ age (b = 0.12; p = 0.001) contributed to patients’ perceived autonomy support. None of the physical therapist characteristics were related to patients’ perceived autonomy support. Limitations: Only 13 out of 125 therapists who were personally contacted agreed to participate. Conclusion: Using patients’ perceptions, we found that a relationship between SDM and autonomy support existed. In contrast to observational studies, our study also demonstrated that the participating physical therapists individually tailored patient support by adapting their implementation of SDM to each patient.
Due to growing evidence supporting that active treatment offers greater benefits to patients than passive treatment, exercise therapy in physical therapy has drawn more attention [
Since the late 1960s, patient autonomy has gained increased attention in healthcare. It contains, at a minimum, “self-rule that is both free from controlling interference by others and from certain limitations such as inadequate understanding that prevents meaningful choice”. Consequently, therapist support of patients’ autonomy requires health care providers to allow and encourage fully competent patients to make decisions about their lives and medical treatment without attempting to control those decisions. This way, an autonomous patient acts freely, in accordance with a self-chosen plan [
determination is respected because it is simply good to be autonomous [
The growing interest in patient autonomy has resulted in identifying new approaches to decision making in medical treatment. Until recently, treatment decisions were predominantly controlled by the therapist. However, according to the theoretical developments in decision making, patient involvement is recommended but in such a way that the medical expertise of the therapist is not ignored. This approach is called Shared Decision Making (SDM), and it presupposes that the therapist and patient are equals in the decision making-process [
To support patient autonomy, SDM was developed as a patient-therapist communication tool to increase patient involvement in decision making [
Compared to the medical research field, studies on the concept of patient involvement are still scarce in physical therapy literature. The opportunities to use SDM in healthcare have been previously described in ethics- based studies [
The relationship between patients’ perceived levels of involvement and autonomy support has not yet been investigated in physical therapy. Based on recently reported extremely low level of SDM in physical therapy, similarly poor patient perceptions of their own decisional involvement as well as their autonomy support may be expected. On the other hand, patients’ subjective perceptions do not always agree with objective measures of SDM [
Therefore, the main objectives of this study were to examine patients’ perceptions of their own decisional involvement and autonomy support in physical therapy and to explore the relationship between the perceived levels of SDM and autonomy support.
Patients’ perceptions of SDM and autonomy support were measured within a larger study that also assessed observed levels of SDM via audio recordings and therapist self-report data. This paper focuses on patients’ perceptions.
From March 2010 until March 2011 two hundred and sixty-eight patients of 13 self-employed physical therapists were invited to participate in this study. Patients were recruited in the waiting room before a therapy session. Each patient was informed of the study procedures by the researcher and voluntarily gave written consent. Patients were native Dutch speakers and at least 18 years of age.
Using information provided by therapists, patients with a history of psychiatric disease or central nervous system disorder were excluded. The following information was recorded: age, gender, education level, employment status, participation in sports, prior history of physical therapy and consultation type (first consultation, neither first nor last session, last session).
The following therapist-related information was recorded: age, gender, additional training, years of work experience, working as a soloist or in a group, and status as a member of an interdisciplinary team.
Immediately after the physical therapy consultation, patients completed 2 questionnaires while sitting in the waiting room: the Dyadic Observing Patient Involvement (Dyadic OPTION) instrument to measure perceived level of SDM, and the Health Care Climate Questionnaire (HCCQ) to measure perceived level of autonomy support.
The Dyadic OPTION instrument was developed to measure the perceived level of SDM and is derived from the OPTION instrument originally developed by Elwyn [
The HCCQ measures the perceived level of autonomy support and was developed based on the Self-Determina- tion Theory proposed by Deci and Ryan [
Item | Behavior | Median score (min - max) | 0 | 1 | 2 | 3 | 4 |
---|---|---|---|---|---|---|---|
1 | The therapist drew attention to an identified problem as one that requires a decision making process. | 3.0 (0 - 4) | 7.0 | 0.0 | 8.7 | 35.4 | 48.9 |
2 | The therapist stated that there is more than one way to deal with the identified problem. | 3.0 (0 - 4) | 9.6 | 10.9 | 24.0 | 30.1 | 25.3 |
3 | The therapist assessed my preferred approach to receive information to assist decision making. | 2.0 (0 - 4) | 11.4 | 19.7 | 33.2 | 22.3 | 13.5 |
4 | The therapist listed “options”, which can include the choice of “no action.” | 3.0 (0 - 4) | 9.6 | 14.4 | 24.0 | 27.1 | 24.9 |
5 | The therapist explained the pros and cons of options to me (taking “no action” is an option). | 3.0 (0 - 4) | 8.3 | 5.2 | 20.5 | 37.1 | 28.8 |
6 | The therapist explored my expectations (or ideas) about how the problem(s) are to be managed. | 3.0 (0 - 4) | 4.4 | 2.2 | 7.0 | 43.7 | 42.8 |
7 | The therapist explored my concerns (fears) about how problem(s) are to be managed. | 3.0 (0 - 4) | 3.5 | 3.1 | 12.2 | 43.7 | 37.6 |
8 | The therapist checked that I have understood the information | 3.0 (0 - 4) | 2.2 | 1.7 | 4.8 | 41.5 | 49.8 |
9 | The therapist offered me explicit opportunities to ask questions during the decision making process. | 4.0 (0 - 4) | 0.9 | 0.4 | 4.8 | 31.0 | 62.9 |
10 | The therapist elicited my preferred level of involvement in decision making. | 3.0 (0 - 4) | 2.6 | 1.7 | 14.8 | 41.0 | 39.7 |
11 | The therapist indicated the need for a decision making stage. | 3.0 (0 - 4) | 5.2 | 7.0 | 27.1 | 32.3 | 28.4 |
12 | The therapist indicated the need to review the decision. | 3.0 (0 - 4) | 5.7 | 8.3 | 33.6 | 26.2 | 26.2 |
Each behavior (1-12), as rated by the patient, is presented. The corresponding median, minimum (min) and maximum (max) scores are displayed. The score distribution for each item of the Dyadic OPTION instrument is presented as a percentage. 0: no attempt to indicate the behavior; 1: perfunctory or unclear attempt to indicate the behavior; 2: baseline skill level of the behavior; 3: the behavior is performed; 4: the behavior is achieved to a high standard.
loss (Williams GC, Grow VM, Freedman Z, Ryan RM, Deci EL. Motivational predictors of weight loss and weight-loss maintenance. J PersSoc Psychol. 1996: 70; 115-126) and smoking cessation (Williams GC, Deci EL. The National cancer institute guidelines for smoking cessation: do they motivate quitting? J Gen Intern Med: 1996: 11; ?-?), and is still used to measure the perceived level of autonomy support in studies of breast cancer (Shumway D, Griffith KA, Jagsi R, Gabram SG, Williams GC, Resnicow K. Psychometric properties of a brief measure of autonomy support in breast cancer patients. 2015: Jul 9; 15:51) and chronic low back pain (Murray A, Hall AM, Williams GC, McDonough SM, Ntoumanis N, Taylor IM, Jackson B, Matthews J, Hurley DA, Lonsdale C. Effect of a self-determination theory-based communication skills training program on physiotherapists’ psychological support for their patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2015 May; 96(5): 809-16). The HCCQ contains 15 items, as shown in
The HCCQ was used as an outcome measurement in the present study.
The Statistical Package for the Social Sciences (SPSS) version 21.0 was used for all data analyses.
To compare the total Dyadic OPTION and HCCQ scores, both scores were standardized to a scale ranging
Item | Behavior | Median score (min - max) | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
---|---|---|---|---|---|---|---|---|---|
1 | I feel that my therapist has provided me choices and options. | 7.0 (1 - 7) | 4.8 | 1.3 | 1.7 | 11.8 | 13.1 | 16.6 | 50.7 |
2 | I feel understood by my therapist. | 7.0 (1 - 7) | 0.4 | 0.0 | 0.0 | 0.9 | 2.2 | 16.2 | 80.3 |
3 | I am able to be open with my therapist at our meetings. | 7.0 (4 - 7) | 0.0 | 0.0 | 0.0 | 0.9 | 0.9 | 13.1 | 85.2 |
4 | My therapist conveys confidence in my ability to make changes. | 7.0 (1 - 7) | 0.4 | 0.0 | 0.0 | 6.6 | 4.8 | 24.5 | 63.8 |
5 | I feel that my therapist accepts me. | 7.0 (4 - 7) | 0.0 | 0.0 | 0.0 | 1.7 | 1.3 | 16.2 | 80.8 |
6 | My therapist has made sure I really understand my condition and what I need to do. | 7.0 (4 - 7) | 0.0 | 0.0 | 0.0 | 3.9 | 3.5 | 18.8 | 73.8 |
7 | My therapist encourages me to ask questions. | 6.0 (2 - 7) | 0.0 | 0.4 | 0.4 | 19.7 | 13.5 | 23.1 | 42.8 |
8 | I feel a lot of trust in my therapist. | 7.0 (1 - 7) | 0.4 | 0.0 | 0.0 | 2.2 | 0.9 | 18.8 | 77.7 |
9 | My therapist answers my questions fully and carefully. | 7.0 (2 - 7) | 0.0 | 0.4 | 0.0 | 3.5 | 0.9 | 19.7 | 75.5 |
10 | My therapist listens to how I would like to do things. | 7.0 (1 - 7) | 0.4 | 0.0 | 0.0 | 9.6 | 7.0 | 21.8 | 61.1 |
11 | My therapist handles people’s emotions very well. | 7.0 (4 - 7) | 0.0 | 0.0 | 0.0 | 11.4 | 5.2 | 22.3 | 61.1 |
12 | I feel that my therapist cares about me as a person. | 7.0 (3 - 7) | 0.0 | 0.0 | 0.4 | 7.0 | 6.1 | 20.1 | 66.4 |
13 | I don’t feel very good about the way my therapist talks to me. | 7.0 (1 - 7) | 2.6 | 2.2 | 0.4 | 1.7 | 0.4 | 10.9 | 81.7 |
14 | My therapist tries to understand how I see things before suggesting a new way to do things. | 6.0 (1 - 7) | 0.4 | 0.0 | 0.0 | 18.3 | 8.3 | 25.3 | 47.6 |
15 | I feel able to share my feelings with my therapist. | 7.0 (1 - 7) | 0.4 | 0.4 | 0.9 | 17.5 | 8.7 | 20.1 | 52.0 |
Each behavior (1-15), as rated by the patient, is presented. The corresponding median, minimum (min) and maximum (max) scores are displayed. The score distribution for each item of the HCCQ is presented as a percentage. 1: strongly disagree; 2: moderately disagree; 3: disagree; 4: neutral; 5: agree; 6: moderately agree; 7: strongly agree.
from “0” to “100”. Because the answers on both questionnaires were non-parametrically distributed, the transformed scores are reported as medians. Patient descriptive statistics are reported as means.
Because data were nested per physical therapist, multilevel analyses were applied using linear mixed models. First, the physical therapist was entered as the “subject” and a series of univariate analyses were performed with the HCCQ (perceived autonomy support) entered as a dependent variable (
Two hundred sixty-eight patients were invited to participate in the present study, of which 242 (90.3%) accepted. In seven cases, the assessment was prematurely discontinued due to recording failure during the consultation. Data from another six patients could not be analyzed because one or more HCCQ or Dyadic OPTION items were not answered. Consequently, 229 cases are reported in this paper (with an average of 17.6 cases (range 15 - 20 cases) per physical therapist). The patients’ mean age was 46.3 years (range 19 - 89 years; SD 15.4 years) and 127 patients (55.5%) were female. The distributions of the remaining demographic data are presented in
Independent variables | Model A | Model B | Model C | ||||||
---|---|---|---|---|---|---|---|---|---|
Adjusted mean difference | 95% CI | p-value | Adjusted mean difference | 95% CI | p-value | Adjusted mean difference | 95% CI | p-value | |
Therapist characteristics | |||||||||
Sex Male Female | 0.20 | −2.89; 3.30 | 0.89 | ||||||
Age | 0.30 | −0.08; 0.14 | 0.58 | ||||||
Experience | 0.02 | −0.11; 0.15 | 0.71 | ||||||
Additional training Yes No | −5.26 | −10.09; −0.42 | 0.04† | / | / | / | |||
Working in group Yes No | 1.74 | −1.27; 4.76 | 0.23 | ||||||
Working in interdisciplinary team Yes No | 0.69 | −3.44: 4.81 | 0.72 | ||||||
Patient characteristics | |||||||||
Sex Male Female | −1.21 | −3.40; 0.97 | 0.28 | ||||||
Age | 0.13 | 0.06; 0.20 | <0.001† | 0.12 | 0.04; 0.19 | 0.002†† | 0.12 | 0.05; 0.18 | 0.001††† |
Education Level Primary school Secondary school Higher education/university | 2.77 1.08 | −1.56; 7.10 −1.22; 3.38 | 0.21 0.36 | ||||||
Employment Yes No | −0.11 | −2.38; 2.67 | 0.93 | ||||||
Practicing sports Yes No | 1.58 | −0.69; 3.84 | 0.17† | −0.05 | −2.34; 2.23 | 0.96 | |||
Prior history of consulting the therapist for another disease Yes No | −0.97 | −3.30; 1.36 | 0.41 | ||||||
Consultation type First Neither the first nor the final Final | 2.94 3.87 | −4.22; 10.11 −2.53; 10.27 | 0.42 0.23 | ||||||
Dyadic OPTION score | 0.15 | 0.09; 0.21 | <0.001† | 0.13 | 0.07; 0.19 | <0.001†† | 0.14 | 0.08; 0.20 | <0.001††† |
Model A: p-values indicate the results from the linear mixed model analysis per independent variable. †Represents significance at the 0.20 α-level. Additional training was not entered into the model because there was only a single physical therapist who did not have any additional training. Model B: p-values indicate the results from the linear mixed model analysis per independent variable. ††Represents significance at the 0.05 α-level. Model C (final model): p-values indicate the results from the linear mixed model analysis per independent variable. †††Represents significance at the 0.05 α-level.
Variables | Patients (N = 229) |
---|---|
Age | 46.4 (15.4) |
Gender | |
Female | 128 (55.7%) |
Male | 101 (44.3%) |
Education level | |
Primary school | 17 (7.6%) |
Secondary school | 112 (48.9%) |
Higher education/university | 100 (43.6%) |
Employment status | |
Employed | 143 (62.5%) |
Unemployed | 86 (37.5%) |
Practicing sports | |
Yes | 135 (58.8%) |
No | 94 (41.2%) |
Prior history of consulting the therapist for another disease | |
Yes | 150 (65.5%) |
No | 79 (34.5%) |
Consultation type | |
First | 24 (10.6%) |
Neither the first nor the last | 198 (86.3%) |
Final | 7 (3.1%) |
Demographic data of all patients are displayed. Age is presented in years and as the mean followed by the standard deviation (SD); the other variables are presented as actual numbers followed by the percentages.
Physical therapist | Gender | Age | Experience | Additional training | Working in group | Working in interdisciplinary team | Number of consultations | Median dyadic option score (min - max) | Median hccq score (min - max) |
---|---|---|---|---|---|---|---|---|---|
1 | Female | 41 | 17 | Yes 1, 2 | Yes | No | 20 | 74.0 (25 - 96) | 94.3 (72 - 100) |
2 | Male | 55 | 21 | Yes 6 | Yes | No | 19 | 75.0 (50 - 94) | 93.3 (70 - 100) |
3 | Female | 29 | 4 | Yes 1 | No | No | 20 | 71.9 (23 - 100) | 97.1 (82 - 100) |
4 | Male | 40 | 17 | Yes 1, 4 | Yes | No | 17 | 73.0 (52 - 90) | 89.5 (77 - 100) |
5 | Female | 27 | 4 | Yes 1 | Yes | No | 17 | 70.8 (35 - 100) | 89.5 (75 - 100) |
6 | Male | 52 | 25 | Yes 1, 3, 4 | Yes | No | 19 | 75.0 (46 - 100) | 95.2 (67 - 100) |
7 | Male | 63 | 36 | Yes 5 | No | Yes | 17 | 75.0 (40 - 100) | 94.3 (72 - 100) |
8 | Female | 25 | 1 | Yes 1 | Yes | No | 15 | 77.1 (50 - 100) | 94.3 (73 - 100) |
9 | Male | 54 | 30 | Yes 1, 2, 4 | Yes | No | 18 | 72.9 (33 - 100) | 90.5 (76 - 100) |
10 | Male | 40 | 15 | Yes 2, 3 | No | No | 18 | 68.8 (15 - 100) | 91.4 (57 - 100) |
11 | Male | 55 | 28 | Yes 1 | Yes | No | 16 | 76.0 (13 - 100) | 96.2 (78 - 100) |
12 | Male | 61 | 30 | Yes 1 | No | No | 18 | 76.0 (29 - 100) | 96.7 (81 - 100) |
13 | Female | 27 | 2 | No | Yes | No | 15 | 70.8 (13 - 90) | 89.5 (68 - 97) |
The demographic data for each physical therapist are displayed. Age is presented in years. Experience refers to the number of years spent working as a physical therapist. Additional training refers to the subject of the training (1 manual therapy, 2 sports physical therapy, 3 movement consultant, 4 myofascial therapy, 5 cardiotraining, 6 physical education). Working in interdisciplinary team refers to the therapists’ discipline (a speech therapist). For each physical therapist, the number of rated consultations is reported. The median, minimum (min) and maximum (max) Dyadic OPTION and HCCQ scores are presented; the total possible Dyadic OPTION score was 0 - 48 and the total possible HCCQ score was 0-105. Both the Dyadic Option and HCCQ scores were standardized and reported on a scale ranging from 0 - 100.
Patients’ perceived involvement in decision making resulted in a non-parametric distribution of the Dyadic OPTION scores as presented in
The distribution of patients’ perceptions of autonomy support is presented in
The HCCQ score in relation to individual patients’ characteristics and the Dyadic OPTION score.
Patients’ age (p = 0.001) and Dyadic OPTION score (p < 0.001) were positively correlated with the HCCQ score. As the patient’s age increased by one year or the Dyadic OPTION score increased by one point, the adjusted mean differences of the HCCQ was 0.12 and 0.14, respectively (
Although the p-value of additional training was less than 0.20 in model A, this variable was not entered into model B or C because there was only a single physical therapist who had no additional training. The remaining variables were not significantly correlated with the HCCQ score (
This paper presents the two principle findings of our study.
The first main finding confirms, based on the perception of the participating patients, the relationship between SDM and autonomy. The second major finding is that the participating physical therapists adapt their implementation of SDM to each individual patient, thereby custom tailoring the autonomy support of the patient.
Although SDM is strongly recommended based on the intrinsic value of patient autonomy in current healthcare [
Considering that, in the current study, SDM is related to patients’ perceptions of autonomy support and that autonomy support is related to various clinical benefits in conventional medicine such as increased or improved patient satisfaction, health outcomes and patient compliance [
Taking these clinical benefits and the intrinsic value of patient autonomy together, SDM is likely to be instrumentally important in physical therapy.
This appears especially true considering the increasing use of exercise therapy in treatment [
Assuming that the relationship between autonomy support and its clinical benefits applies directly to physical therapy must be approached cautiously. The evidence supporting autonomy support-related clinical benefits is based on research in conventional medicine; no research has been conducted on these factors in physical therapy to date. Consequently, whether SDM, and thus autonomy support, contributes to clinical benefits in physical therapy remains unclear. Further research is therefore urgently needed.
A second and unexpected finding is that, in the perception of the patients and based on the 0.3% explained variance, physical therapists’ adapt their SDM practice to each individual patient to custom tailor their autonomy support. This result was beyond our expectations because most prior research has reported that healthcare workers develop their “own style” and apply this style to most of their patients [
In addition to these major findings, we observed that patient age influenced perceived levels of autonomy support. In cases of similar levels of perceived autonomy support, the relationship between SDM and autonomy support was found to be stronger for older patients. This finding was quite remarkable because observational studies typically reveal higher levels of SDM in consultations with younger patients than in those with older patients.
A possible explanation for this relationship may be that there are discrepancies in preferred levels of involvement between these groups. Older patients may prefer to take more passive roles, whereas younger patients are more likely to be actively involved in the decision making process [
The present study demonstrated a strong relationship between the perceived levels of SDM and the perceived levels of autonomy support; however, we would like to include a critical note to this paper regarding patient scores on both the Dyadic OPTION instrument and the HCCQ.
All of the participating patients in this study indicated very high ratings on both questionnaires. This result is not consistent with the findings of our observational study, which reported very low levels of SDM in physical therapy [
One possible explanation for high patient scores may be that patients are hesitant or not likely to be critical of their therapist [
Second, despite using a meticulous explanation of SDM, it is possible that patients consider SDM as “being heard” or “feeling free to tell their story”, as mentioned in a study by Saba [
One limitation of the present study is the small number of participating physical therapists. This reduces the generalizability of our results. It is therefore recommended to recruit a greater number of physical therapists in future research.
Additionally, as noted in the method section, the Dutch version of the Dyadic OPTION instrument was based on the Dutch version of the OPTION instrument. The translation from the original English OPTION instrument to the Dutch OPTION instrument was performed by the research group of Elwyn almost 8 years ago [
The lack of reliability or validity studies on both Dutch questionnaires in physical therapy literature is a limitation as well. Although data on reliability and validity are absolutely necessary to confirm our results, the similarity between the current high patient ratings and the outcome of various patient perception studies is undeniable.
Given that the current study provides more questions than answers, it is difficult to make clear recommendations. However, based on the current findings regarding patients’ perceptions, there is at least one important practical guideline suggested.
Physical therapists must be strongly encouraged to implement SDM in practice because it is strongly related to the patients’ feelings of being respected as an autonomous person in treatment decision making. Whether SDM implies a better perceived autonomy support or vice versa, cannot be demonstrated by this study and requires a randomized control study. In the meantime, we recommend physical therapists to listen to the preferences of their patients, encourage the patients to ask questions, provide information, offer choices, support the patients’ initiatives and avoids paternalistic approaches in treatment. After all, the patient knows the most about his or her own capabilities and must be considered as the expert of his or her own life (style) [
Given the small number of participating therapists and the focus on autonomous physical therapy settings in the Flemish part of Belgium, this study must be considered as a pilot study. In future research, we recommend expanding the number of participating therapists and including also physical therapists working in different settings, such as hospitals or rehabilitation centers.
Given the high ratings indicated on both the Dyadic OPTION and the HCCQ, we advise investigating patients’ perceptions of SDM and autonomy support using analog patients. Prior research has shown that analog patients give ratings that are similar to those given by real patients; however, the use of analog patients reduces ceiling effects [
Using information regarding the perception of the participating patients in current physical therapy study, the relationship between SDM and autonomy support is confirmed. Our study also demonstrated that the participating therapists tailored their support of the patient by adapting their implementation of SDM to each individual patient. Finally, our results indicated that, in this study, patient age influenced the perceived levels of autonomy support.
The authors express their gratitude to the physical therapists and patients for their participation in this study.
Ignaas Devisch,Katreine Dierckx,Dominique Vandevelde,Patricia De Vriendt,1 1,Myriam Deveugele, (2015) Patient’s Perception of Autonomy Support and Shared Decision Making in Physical Therapy. Open Journal of Preventive Medicine,05,387-399. doi: 10.4236/ojpm.2015.59043