Health Promotion Is a Part of Geriatric Physical Therapist Practice
All 14 focus group participants identified health promotion as important to geriatric physical therapist practice. Geriatric health promotion was defined as holistic by almost all (10/14) of the therapist participants. Therapists reported that they needed to incorporate the patients' physical, social, psychological, and mental characteristics when planning and implementing health promotion activities. The participants addressed a variety of health promotion areas with their patients including physical activity and exercise (the most frequent lifestyle behavior area addressed); chronic disease management; making referrals to outside physical therapists; diet/nutrition/weight control; fall prevention/screening; ensuring safe patient function; and psychological concerns (Table 2). For example, a therapist working in the inpatient setting addressed several topics related to lifestyle behaviors and chronic disease management:
I think for me, just because I work with wound care and cardiac patients the most, I would say I counsel on activity and heart health, nutrition, foot care, good follow-up with their overall health care providers, and smoking cessation. (Hospital physical therapist)
A therapist who worked in both inpatient and outpatient settings focused more on physical activity:
I would say just overall exercise, just increasing their activity level from what they do especially if they usually do nothing. (Hospital/outpatient physical therapist)
The participants recognized community prevention for older patients as a need but were not necessarily involved:
I think it's important to distinguish between health promotion for individuals and health promotion for groups or communities. You're hoping every physical therapist is doing health promotion with their client. But what are we doing for the community (sic older adults) as a whole? (Home care physical therapist)
Although this therapist felt that community health promotion is important, the participant went on to say that health promotion activities had a marketing side benefit:
...I feel if we go out there, and we go to a senior building and we do a screening for fall prevention, I think in some ways we are doing health promotion. We're not getting paid for it, but again it sounds really crassbut it's the way it has to be, it's a good referral source to get more business, it's marketing and isn't that what it's about? So basically, yes, we're getting more clients, which we need to stay in business, but we're also proving a service in the community too. That's my attitude. (Home care physical therapist)
Regardless of the setting, participants typically engaged in health promotion during the patient's physical therapist visit. These physical therapists during the course of the visit saw an opportunity to discuss health promotion activities that could enhance the patient's function and quality of life. For example, a home care physical therapist said,
Well one of the things I like to do is, besides just seeing them for the given diagnosis, I also like to think it's not enough just to rehab someone. Say they fell and fractured their hip. It would be a great idea to address why this happened in the first place since I've been given the opportunity to work with them to try to address some of the issues. The other thing that I do is I try to talk to them about exercising for the rest of their life. Because it's a quality of life issue. (Home care physical therapist)
The acute care environment also afforded opportunities for health promotion with a focus on prevention for older adults:
I think health promotion can also be looked at as prevention as well. A lot of us are seeing a patient after the fall, after the diagnosis, after a long hospital stay, but when it comes to health promotion you're promoting wellness for the rest of their life and hopefully preventing further incidents, further falls, preventing more progression of chronic disease. (Hospital physical therapist)
In summary, all therapist participants reported that health promotion was part of their older adult clinical practice during the course of a patient visit rather than involved in community-directed approaches. Although a diverse range of health promotion topics was identified, not surprisingly physical activity and exercise was the most frequently reported topic addressed (Figure 3).
Benefits of More One-on-One Time With the Patient
The amount of time a therapist typically has with a patient is a key reason for a physical therapist's multiple health promotion opportunities, as reported by 6 focus-group participants. Generally, these participants felt that the amount of time spent with their patients facilitated the building of meaningful and trusting relationships that allowed these therapists to approach patients in a holistic way:
I think in the hospital we're in a unique position because these patients come in and they have all these services, all these doctors and nurses but nobody spends more than 5 minutes with them interacting with them. We go in there and you spend 30–60 minutes with them and it gives them a chance to think and move and maybe they have questions about their condition, what's going to happen, so that's a unique position we're in to have that interaction. (Hospital physical therapist)
We are in the right position to do that [patient education]. The doctor sees them once every 6 weeks and we see them two times a week and we have our hand on them.. you are developing a relationship with them so we are able to do that [education]. (Outpatient physical therapist)
But that's where I get lucky because I'm with them in the home for an hour and you try to encourage them to talk and things come out and you'd be surprised.that's what it takes.just spending the time with them and letting them get comfortable with you. (Home care physical therapist)
One outpatient therapist reported that having more time with her patients enabled her to address the topic of alcohol abuse with a patient, “Maybe their physician is sending them to you because they are not sure what to do and since we spend more time with them we build that rapport that is necessary for those harder discussions.”
Half of the therapist participants reported that their health promotion efforts were better received when they were focused on the individual patient needs. This patient-centeredness involved active listening skills and including the patient's goals and context when making health promotion recommendations.
My therapy interactions right now, especially with geriatric patients, are much more of a conversation than it ever was before. When I was a new grad I had my script in my head and I went through it and their answers were always good. Now I tend to speak, but I ask more questions and wait for their answers and I am much better, I hope, at processing what their answers are before I ask the next question.... They understood my goal and respect what I can do. I respect where they are at and somehow we can set them up to go home or where they desire. It's more of a conversation and before it was a one-act play. (Skilled nursing facility physical therapist)
In addition to defining geriatric health promotion as holistic, this approach facilitated therapist confidence in making referrals to other health care providers:
I would say that I think of that [health promotion] as very holistic. Yes, I treat a very specific part of their health but I agree it's our job to also be informed about other specialties, other ways they can get into the system and also to recognize some part of a person's life that may not be healthy. And to promote, oh, you might want to go see a dietitian or you might want to go see your physician about blood work or whatever just to be knowledgeable about the whole person in order to promote health as a whole. (Hospital physical therapist)
According to study participants in different practice settings, having blocks of one-on-one time with patients helped develop trusting relationships that enabled them to focus on individual patient needs in a holistic manner and encouraged them to address difficult topics (Figure 4).
Factors That Impact Physical Therapist Provision of Health Promotion
Two general areas were identified as impacting the provision of health promotion. One area was related to the physical therapists' provision of health promotion; the second area described factors related to the individual patient's adoption of the recommended health promotion (Table 3).
Physical Therapist Facilitators and Barriers
Several key resources were identified as enabling effective health promotion efforts. Clinical experience enabled the identification of facility and community resources, thus improving the physical therapists' confidence in making appropriate recommendations (Table 3).
I do have a lot of resources based on my experience, based on my leadership [at my facility]. I get calls, I call people. I think it is what you make of it. Could I use more? Always. But I do use my peers a lot. [I use the] Illinois Physical Therapy Association, American Physical Therapy Association, all those memberships, all those different things to try and figure out different answers and different resources for patients or even for my own therapists. (Hospital physical therapist)
I think the resources that I have available are better and my knowledge of the resources are better. When I first graduated and moved to Chicago it was a new city to me so I didn't know who offered classes, where to find group programs, patient education materials that were available on line. I eventually found common questions and I said, well, this is a common question, and we'll just make a handout to give out. So I think that's really expanded as I've become more experienced. (Subacute rehab hospital physical therapist)
Facilities that had health promotion resources readily available, for example, a wellness center, exercise groups, facility-generated handouts, promoted health promotion delivery.
I am in the middle of everything so I am really spoiled. But I feel all the resources are at my fingertips except for the patients that have transportation issues or no one to help them. But for a majority of the patients as long as they have transportation, all they have to do is show up and the rest is taken care of for them. (Subacute rehab hospital physical therapist)
Therapist participants identified that lack of reimbursement, time constraints, and lack of time away from direct patient care interfered with their ability to provide health promotion.
... It is a question of time... because there are patients to be seen so as far as dedicating time to program development either to promote health with certain patient populations and/or to in-service my staff so they're more knowledgeable about health promotion, time is short and you have to be creative about how you get the information out to them. (Hospital physical therapist)
On another note, one therapist reported that continuity of care was part of the issue when thinking about recommending health promotion activities at an early point in the continuum of care.
I'm constantly discharging patients to OP therapy or home health therapy so they're not quite ready to be independent in the community setting so I feel like [the facility] has tons of community classes going on— arthritis, warm water exercise, chi gong, all these classes, but if I give them a paper and say in 3 months I think this would be a good idea, it's not going [to] happen, so it's just the timeliness of it to get the education. (Subacute Rehab physical therapist)
Recognition of Patient Barriers
The focus group participants described several patient-related factors that were viewed predominately as barriers to the patient's adoption of therapists' health promotion efforts (Table 4). Almost all participants talked about the importance of patient buy-in or patient ownership of the patient's health in making changes. These therapists reported that if patients did not own the problem, they were less apt to manage their health.
My personal philosophy is that I want to be able to help a patient manage their particular problem and have them take ownership and then manage it on their own. (Skilled nursing facility physical therapist)
A therapist who worked in both an acute care hospital and a skilled nursing facility added:
I think just really stressing the importance of compliance and the ownership part of it. I think that is something that can make or break our success with patients.
Almost all of the participants discussed importance of the patient's social factors facilitating or inhibiting health promotion efforts. Factors described as positive or negative were supportive families, financial resources that paid for health-promoting behaviors, and transportation access to recommended activities.
One of the challenges in health care, you know, we talk about this all the time about the health care crisis and accessibility to affordable health care and insurances. This huge middle class that not everybody's affluent but they're not poor enough for public aid but there are huge gaps and for a lot of older adults they ask themselves, “Do I buy a pair of shoes or do I get my heart medicine this week?” And so we have to be sensitive to that and listen to the patient and be able to get some kind of social services in to help those folks. (Skilled nursing facility physical therapist)
In addition to patient resources, therapists also felt limited by their own community resources.
I just had a conversation with a patient a couple days ago talking about doing an exercise program. She was an elderly woman and I just want her to continue on, and I asked her, “is there a senior group where you can exercise,” and she said, “No, no there's nothing.” Sometimes I get frustrated because she needs something where she's supervised. She's asked me, “How do I get there?” It is somewhat limiting at times with their decreased mobility, transportation, and there's just not a lot of groups out there. No one is making money doing groups, so there's not a lot out there for exercise with geriatrics. (Hospital physical therapist)
Table 4 and Figure 5 depict what these therapists thought were physical therapist and patient factors that influenced their provision of health promotion. Availability of resources—in the facility, from knowledgeable colleagues, and in the community—facilitated health promotion delivery. On the contrary, lack of resources negatively impacted health promotion implementation and adoption. Lack of time, reimbursement, transportation, community programming, and family support were perceived as health promotion barriers. Therapists also believed that lack of patient ownership and responsibility of health limited their health promotion recommendations.
This study sought to understand what physical therapists do when promoting health with their older adult patients. Study participants reported addressing a wide variety of health promotion topics. Health promotion efforts varied and reflected the practice setting. Participants practicing in acute care settings tended to focus on fall prevention, wound prevention, and factors contributing to patient hospitalization, whereas participants in outpatient settings generally focused on healthy, successful aging.
This study's findings agree with those of prior investigations of physical therapist health promotion practice in that physical activity and exercise are the primary focus of health promotion.16,17 Similar to the results of the survey by Rea et al,16 this sample of physical therapists made statements about physical activity most often and unlike her findings, nearly 30% of participants reported addressing smoking cessation. Almost half of the physical therapist participants in our study addressed psychological issues with their patients, similar to Rea and colleagues, who reported psychological well-being as an area addressed frequently. Our study results identified chronic disease management as the second most highly reported health promotion statement, a finding in agreement with Gahimer and Domholdt,17 who reported that information about illness was the most frequently provided patient education given to patients by their physical therapist. Content areas participants addressed but felt uncomfortable discussing with their patients included obesity, depression, alcohol abuse, elder abuse, and domestic violence.
Home exercise was the second most frequently reported patient education topic found by Gahimer and Domholdt,17 and in our study the physical activity and exercise recommendations frequently revolved around a patient's home exercise program. Although Lorig defined patient education as “any set of planned, educational activities designed to improve patients' health behaviors and/or health status,”32(pxiii) these recommendations embedded in the patient's home exercise program may have been focused on the rehabilitation goals and not on exercise goals related to health promotion. Physical therapists may be instructing patients in exercise that returns them to their prior level of function but not addressing the long-term benefits of physical activity.
The therapist participants in this study appeared to address the 3 areas identified by Dean33 as important for physical therapists in their role as health promoters—physical activity and exercise, nutrition and weight management, and smoking cessation. What is not known is the effectiveness of physical therapist health promotion counseling or the methods used by physical therapists to influence the adoption of healthy behaviors. Identification of what helps or hinders health promotion is also an important next step.
Facilitators and Barriers to Health Promotion
Physical therapists may have more time to spend with patients than other health care providers, which provides opportunities to address healthy behaviors with their patients. The physical therapist participants perceived that physical therapist can do health promotion because they see patients longer in a concentrated episode of care and therefore are more apt to build relationships as compared with other health professions such as physicians. Rea et al16 believed that more time allotted per patient was one area that had potential to promote health promotion practices among physical therapists. More time with patients was perceived as promoting holistic and patient-centered care, and to assess a patient's readiness to adopt healthy behaviors. Holistic, patient- centered care is reflective of adult learning strategies that may lead to greater success at health promotion.9
However, similar to other professions such as medicine34 and nursing,35,36 physical therapists may be overwhelmed with other job tasks and patient care needs and relegate health promotion to “a nice to do but not always done” category. Physical therapists in this study reported similar time constraints. However, Fruth et al18 reported that the amount of health promotion education delivered by outpatient physical therapists did not differ by the phase of treatment (ie, early, middle, or late stages of rehabilitation) or the length of individual treatment sessions.
In addition to time constraints, the lack of reimbursement was another barrier to delivering health promotion. The physical therapist participants in our study felt that lack of reimbursement or concerns about reimbursement were limiting factors when providing individual services as well as community health promotion services if labeled as health promotion. These findings are similar to nursing35 and physician34 studies that reported a lack of reimbursement and time constraints limited health promotion delivery. This concern with reimbursement is aligned with today's health care environment where health promotion and prevention of disability receive little funding.
Facility, community, and peer resources were identified as influencing health promotion activities with older adults, similar to resources physical therapist described by Rea and colleagues16 that also included available supportive material for patients, support from the patient's significant other or family, and access to high-quality referral sources. Physical therapist participants were aware of available community resources and frequently recommended community services to promote health with their older patients. However, recognition of patient barriers to services is important as it promotes therapist-patient problem solving in order for the patient to act on health promotion recommendations.37 Patient transportation has been frequently reported as a significant barrier in following through on physical therapist counseling in using community resources.37 In addition, older adults have reported that safety (eg, crime, traffic, uneven sidewalks) is an environmental barrier to physical activity and exercise, one area that was not identified by therapist participants.38
Participants largely described their provision of health promotion activities as being influenced by job experience and not from traditional physical therapist educational experiences. Few participants reported formal education (professional or continuing education) in health promotion. Although health promotion has been emphasized in several physical therapist professional documents,10,11 formal educational activities may be less effective or not memorable to the physical therapists in this study. Rather, clinical experience may be the more powerful tool in building skills that enable physical therapists to confidently and effectively promote health.
Limitations in this study include the small number of participants representing the scope of geriatric practice. Since some settings were represented by only 1 therapist, an accurate representation of health promotion activities was not achieved. However, study participants had a variety of entry-level physical therapist degrees and represented the traditional geriatric practice settings, thus offering readers a starting point when thinking about their own health promotion behaviors. Using focus group methodology may have unduly influenced or inhibited responses.31 In addition, the questions may have been too narrowly focused or not probing enough to fully capture participants' experiences. Data analysis was conducted by relatively inexperienced qualitative researchers, rendering an overly superficial analysis.
This study was the first step in development of a survey that will be administered nationally to physical therapists working with older adults. Our findings suggest that health promotion is done by physical therapists but specific information about content, delivery methods, perceived effectiveness, and therapist characteristics warrants further exploration.
Fourteen physical therapists from a variety of practice settings reported consistently practicing health promotion while treating older adults. A common belief among the participants was that health promotion was important to the physical therapy profession. Health promotion efforts and barriers varied on the basis of the practice setting. The main facilitator of participants promoting health was therapists' ability to build relationships with their older patients due to adequate one-on-one time with them. Although participants did not have data to demonstrate the effectiveness of their health-promoting efforts, all were confident in their ability to promote health with their older patients.
With the increasing numbers of older adults, health promotion is of vital importance to reduce health expenditures and disability. Physical therapists are at a critical juncture to identify their role to meet the growing health promotion needs of older adults. Today's therapists may be looking beyond the immediate rehabilitation of their patients and recognizing health promotion strategies to return these older individuals to active participation in society.
We thank Kathy Hall, PT, EdD, the physical therapists who participated in the focus groups, and the Northwestern University PT faculty, all of whom made this research study possible.
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Focus Group Interview Guide
1. How do you define health promotion?
2. Is health promotion important to you?
a. Why or why not?
b. Does it affect what you do with your patients?
c. What behaviors are most important to you to discuss with your patients? Why?
3. Do you promote healthy behaviors with your patients?
b. Estimated frequency?
c. With whom do you promote healthy behaviors?
d. How do you make that decision?
e. Reasoning behind actions?
f. How do you think you could promote health more? Would anything have to change?
4. Do you encounter any barriers to health promotion?
a. For example, lack of education, facilities, or not enough time in session
5. What areas of health promotion are most important to you?
a. Do you feel like you promote those areas more than ones that might be more relatable to the patients' condition?
6. Where did you learn about ways/strategies for health promotion with your patients?
a. Has it influenced your actions?
7. How confident are you in practicing health promotion?
8. Do you have any resources that help you promote health to your patients?
9. How do your patients usually respond to you recommendations?
a. Do you think that they have an impact?
focus groups; health promotion; older adults© 2012 Academy of Geriatric Physical Therapy, APTA