Physiotherapists' perspectives of barriers and facilitators to effective community provision after hip fracture: a qualitative study in England

Abstract

Purpose: to investigate physiotherapists' perspectives of effective community provision following hip fracture.

Methods: qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented.

Results: four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented.

Conclusion: physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Keywords: allied health professional; femoral neck fractures; older people; process mapping; qualitative research; stratified care.

Figure 1

Coding tree. Interview data revealed 65 initial themes which were organised into four main themes summarising physiotherapists’ perspectives on the provision of community physiotherapy after hip fracture: (i) ineffective coordination of care systems, (ii) ineffective physiotherapy stratification, (iii) insufficient staff recruitment and retention approaches and (iv) inhibited physiotherapy progress due to post-fall fear avoidance behaviours. Red indicates barriers, green indicates facilitators and yellow indicates future ideas for potential interventions.

Figure 2

Level one process map of London Borough. Process map depicting four community physiotherapy services (Musculoskeletal Physiotherapy, Bed-Based Intermediate Care, Home-Based Intermediate Care and Community Physiotherapy) available within one London borough. The map depicts where interventions proposed by England-wide interviewees are already in place in a well-resourced system, setting precedent for incorporating them into systems elsewhere (green). The map also depicts where interventions proposed by England-wide interviewees, that are not already in place in a well-resourced system, may be incorporated (red). The labels (blue) relate to process mapping components which depict ‘Health Care Professionals’ and ‘Processes’ [54]. These identify key points along the patient's journey. Sections in red indicate possible ‘Targets’ for intervention/implementation that are not already in place in a well-resourced system [54]. Additional system-wide processes that are part of current, or proposed procedures in the London borough based on interview data, are detailed below: Clinical practice processes: Current procedures-Online notation; linked acute and community rotations for junior physiotherapists; redistribution of resources, staffing and flexibility in the system; rehabilitation ethos, early advice, guidance and support. Proposed procedures-Rehabilitation teams spanning acute to community care. Recruitment/retention processes: Current procedures-Apprenticeship schemes, return to practice schemes, junior to senior development positions; flexible working, family friendly policies, part-time working; links with universities. Proposed procedures-Physiotherapists at board level; research to demonstrate the need for new physiotherapy positions.