Physiotherapy in acute geriatrics wards: What (de)motivates patients? A qualitative study based on self-determination theory | BMC Geriatrics

Physiotherapy in acute geriatrics wards: What (de)motivates patients? A qualitative study based on self-determination theory | BMC Geriatrics

Comparison with existing literature

In 2020, Charfi et al. used the SDA to assess the prevalence of demotivation in a LTC facility for older people. Based on 30 participants, they obtained a demotivation rate of 43.3%, which is quite close to the rate observed in our quantitative study. Like us, they also found a correlation between demotivation and the level of dependency. It should be noted that in their study, the cut-off score for demotivation was set at 37/40 [17].

In their scoping review, Geelen et al. compiled studies regarding barriers and facilitators to physical activity of HOPs [18]. First, many of the barriers identified in the various studies correspond to some of the demotivating factors we have highlighted. Fear, weakness, fatigue and pain [12, 34,35,36], as well as lack of time due to organizational restrictions [37,38,39], are prime examples. The fact that the feeling of being controlled by HTMs [40] and the lack of control over one’s situation [41] have a negative influence on the mobility of HOPs also concurs with our results. Other interesting factors, although not included in our results, are bed comfort and the wearing of hospital gowns, which discourage patients from moving by themselves [12], the fact that physical activity is not perceived as a priority [41, 42] or even as indicated above a certain age or during hospitalization [39, 42, 43], and the lack of information received about physiotherapy [42], encouragement to move [36, 43] or meaningful activities [38].

Secondly, many of the facilitators highlighted in these studies are also included in our results as motivating factors. The main ones are the desire to enhance or maintain one’s function or independence [34, 36, 38, 40,41,42, 44, 45], to avoid the adverse effects of bed rest [34,35,36,37,38,39, 43, 45], to achieve health and well-being goals that enable a return home [39, 44, 45], and to keep moving [41]. The well-being induced by physical activity [34] and the human qualities of HTMs such as kindness, sense of humor and empathy [35] were also mentioned. The importance for patients of being properly informed [39], of being actors of their own care [40], their sense of self-determination [38], the provision by HTMs of meaningful activities [37] and their respect for their patients’ autonomy [35], are fully in line with the results of our study. In addition, other factors identified by these authors are staff encouragements to move [34,35,36, 39, 40, 42], their adequate assistance [35, 42] and their acknowledgement of the efforts made [38], as well as the incorporation into the organizational routine of physiotherapy sessions [41] and group sessions [42].

Overall, our findings are consistent with those of the various studies compiled by Geelen et al. in their scope review [18]. These studies about barriers and facilitators to physical activity of HOPs have without doubt highlighted many factors influencing the mobility of HOPs, but none of these studies relies on a theory of motivation to classify and analyze these factors. Therefore, our study provides a more comprehensive understanding of the factors influencing HOPs’ motivation to engage in ADLs and physiotherapy and helps to understand the interaction between these factors. Moreover, the identification of motivational factors according to SDT provides a more rigorous setting for the implementation of interventions aimed at enhancing HOPs’ self-determination.

During the course of our study, van Dijk et al. published a qualitative study investigating the barriers and facilitators to physical activity among HOPs according to the Theoretical Domains Framework (TDF) [46]. Overall, the findings of van Dijk et al. concur with those of our study. They pointed out that bed-centered care has an inactivating effect on patients (who adopt a passive attitude and continually wait for examinations, care and other routine events). They also concluded that patients’ lack of awareness of the importance of physical activity and of the ways in which they could stay active were barriers to physical activity during hospitalization, along with the strong sense of control and dependence experienced by patients, and the low availability of HTMs [46].

The analysis of factors influencing HOPs’ mobility according to TDF seems to be less precise in detecting relational factors: while fear is also a barrier to physical activity in the study of van Dijk et al., the feeling of safety as a facilitator was not mentioned. The same applies to symptoms related to the acute health situation, which represent a barrier to physical activity: only their medication management or their attenuation constitutes in their study a facilitator. For van Dijk et al. there is no question of the notion of respect of limits. Neither the importance of commitment from HTMs, nor the importance of the consideration accorded to HOPs were mentioned [46]. These differences may, however, be explained by the fact that our study focuses more specifically on participation in physiotherapy than on spontaneous physical activity during hospitalization. It is therefore logical that many factors related to physiotherapists were mentioned.

Overall, while TDF provide a more precise classification than SDT of the various obstacles and facilitators to mobility of HOPs, it seems less focused on interpersonal factors, which are key components of the need for affiliation described by SDT.

Strengths and limitations of the study

The main strength of our study is the use of SDT as a guide to classify and understand the motivational factors of HOPs to engage in ADLs and physiotherapy. Moreover, to our knowledge, this is the first study to use a theory of motivation to understand the factors influencing HOPs’ involvement in physiotherapy.

However, this study has a number of limitations. Firstly, we only collected data from a single Geriatrics Ward, so generalization of the results must be made with caution. In addition, motivation was not measured in patients hospitalized in other departments. Therefore, we cannot deduce that patients hospitalized in Geriatrics Wards are more demotivated than younger patients. Despite this, our results give a good indication of the prevalence of demotivation among HOPs. Regarding the relationship between demographic factors and motivation, we found that men and people residing in LTC facilities were more prevalent among the group “Demotivated for ADLs” compared to the group “Motivated for ADLs”. However, these differences are not statistically significant, which may be attributed to the relatively small sample size. The same applies to the relationship between demographic factors and motivation for physiotherapy.

Moreover, when it comes to quantitative assessment of motivation, the SDA is a simple tool based exclusively on the assessor’s perception of the actions performed by the person being assessed. As such, it does not take into account the intention that arises within the person prior to performing the action and is largely influenced by the patient’s functional capabilities. This could explain why participants who were more dependent for transfer and movement showed higher levels of demotivation. That said, while a test taking intention into account could provide a better assessment of motivation, it would also be very time-consuming and not suitable for people with significant cognitive impairment.

Furthermore, for ethical reasons, informed consent had to be requested from each participant, which meant excluding from our study a large number of patients whose cognitive impairment was too severe for the study to be understood (it was not always possible to consult the family). In a field such as geriatrics, where the prevalence of cognitive impairment ranging from mild impairment to dementia is 48% [47], it is essential to find ways of including people with cognitive impairment in research studies.

Lastly, hospitalization is an event that punctuates the lives of patients for a relatively short time. The acute nature of their health situation certainly influences their behavior during their stay, and the various parameters that modulate motivation. Therefore, it would be interesting to conduct the same type of study in the participants’ living environment. Implementing strategies to encourage older people’s involvement in ADLs seems to make even more sense in this context than during hospitalization. Finally, HTMs often have a broader view of the factors influencing their patients’ behavior than the patients themselves. Therefore, it would be interesting for future studies to include the HTMs perspective.

Perspectives on care

The key to self-determination: restoring worth

In people experiencing a functional decline associated with a loss of autonomy and independence, the feeling of consideration on the part of HTMs seems to be fundamental in patients’ perception of the worth attributed to them as a person. Even in geriatric environments, ageism is present in a systemic way, and is directly influenced by the anxiety about aging found in HTMs [48]. With stigmatization comes dehumanization, which leads the dehumanized patient to lowered self-esteem and therefore reduced involvement [49]. As HTMs, it is essential that our representations of aging change, and that our care is based on equality, respect and dignity. In concrete terms, this implies treating older patients as full-fledged individuals, and focusing on their preserved abilities rather than their deficits, in order to change our own perception of them [50]. This concept is essential in the hospital environment, and absolutely fundamental in institutions providing long-term care for older people. This study shows how desirable it is to develop living models in line with the movement of “Culture Change” [51].

Ensuring the understanding of the aims of physiotherapy: providing information

The results of our study showed the importance of reestablishing in HOPs the perception of the link between physiotherapy and the recovery of functional abilities. The strategies suggested by van Dijk et al. were the use of communication boards, as well as providing HOPs with information via brochures, television or face-to-face [46]. To promote self-determination and long-term engagement, it is more beneficial to establish goals with intrinsic content rather than goals with extrinsic content [22]. Therefore, HOPs should recognize how physiotherapy can assist them in achieving greater independence in their daily lives, rather than being told, for example, that their physician would be disappointed if they declined physiotherapy. It is also important that these goals come from the person themselves, so that the behavior is perceived as personally important [20]. Providing about a behavior perceived as uninteresting a justification that makes sense to the individual, while satisfying their needs for autonomy, competence and affiliation, enables the integration of this behavior [20]. In this sense, motivational interviewing techniques are particularly useful.

Promoting intrinsic motivation: fulfilling the three basic psychological needs

The results of our study confirm the importance for HOPs to fulfill their need for autonomy and independence, competence and affiliation. As developed above, therapists’ behavior can greatly enhance the feeling of affiliation through a relationship based on respect and consideration. Another strategy may be to include members of the HOP’s entourage, family or friends, in their guidance. However, it is important to respect each person’s autonomy, so that this support network does not become a care network [22]. Finally, the organization of group physiotherapy sessions during hospital stay could increase HOPs’ sense of affiliation, thanks to the support and encouragement they receive from people with whom they identify [52]. It is also essential that the various physiotherapy exercises suggested to HOPs do not set them up for failure. This means proposing appropriate challenges, providing positive feedback and using assessment tools that are not devaluing [20]. As for encouragement, while it may compensate for a lack of intrinsic motivation in some people [46], it would seem that if it is too directive, it can induce a feeling of control. On a broader level, the feeling of competence must be perceived not only during physiotherapy sessions, but across all ADLs. Providing a suitable environment to enable the individual’s sense of self-efficacy can promote their engagement in ADLs and in their care program. Therefore, it is necessary to provide equipment and space that are adapted to the specific needs of HOPs, and to restore the individual’s capacity of choice and free will with regard to their movements, meals, clothing, the time chosen for care, etc [22]. Making equipment available in the physiotherapy room and providing walking paths in the hallways could also enhance HOPs’ self-determination to move spontaneously [46]. Fostering the fulfillment of the three basic psychological needs through activities that are meaningful to HOPs is truly essential to their self-determination. Taking the time to communicate with them and get to know them enables us as therapists to suggest activities that HOPs can identify with and in which they genuinely wish to engage.

link

Leave a Reply

Your email address will not be published. Required fields are marked *