Abstract
Background Physical activity levels in people with rheumatoid arthritis are lower than what are recommended for a healthful lifestyle. To support physical activity, health care professionals may use behavioral change techniques based on a biopsychosocial perspective. Investigating the implementation process may be relevant for understanding how these techniques translate to practice.
Objectives The study objective was to explore the experiences of physical therapists using behavioral change techniques to coach people with rheumatoid arthritis to health-enhancing physical activity in a 2-year trial, the Physical Activity in Rheumatoid Arthritis 2010 study.
Design This was an exploratory study with qualitative content analysis.
Methods Semistructured interviews were conducted with all 12 physical therapists in the study. They were asked about their experiences with an educational program and with their delivery of a health-enhancing physical activity intervention. Codes, subcategories, categories, and an overarching theme were derived from the transcribed interviews by use of qualitative content analysis.
Results The overarching theme (from clinical expert to guide) was based on 3 main categories: challenges in the coaching role, growing into the coaching role, and coach education and support. Early in the process, the physical therapists encountered challenges that needed to be addressed for a smoother transition into their coaching role. Assisted by education and support, they gradually adopted practices that facilitated their use of behavioral change techniques and promoted growth into the role of coach.
Conclusions Adapting to a new role is a challenging process for health care professionals; it requires relevant education and support. The experiences identified in the present study may inform future educational programs targeting the skills of health care professionals in promoting various health-related behaviors.
Recent alarming reports on public health and its association with lifestyle have led to an increased focus on multiple health-related behaviors, such as smoking cessation, healthful eating, and physical activity. To promote behavioral changes, health care professionals need to complement their medical knowledge with skills based on a wide biopsychosocial perspective.1,2 The biopsychosocial perspective is multifactorial, including biological, psychological, behavioral, environmental, and social determinants of health and disease.3,4 Psychosocial factors may modify, facilitate, or sustain diseases and contribute to variations among individuals as well as situations.4 Hence, these factors are important to understanding and influencing health-related behaviors.
Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that may lead to articular destruction, loss of function, and loss of muscle mass.5 Performing sufficient physical activity is crucial in the management of RA, and the effects have been studied, with overall positive outcomes.5,6 However, physical activity levels in people with RA seem to be at least as low as those in the general population and lower than what are recommended for a healthful lifestyle.7,8 For achieving increased physical activity, self-management interventions that include educational, behavioral, and cognitive approaches to influencing health knowledge, attitudes, and behaviors have been suggested.9 Programs based on cognitive-behavioral theory or social-cognitive theory (SCT) can facilitate behavioral changes10–12 and produce good outcomes.9
The Physical Activity in Rheumatoid Arthritis (PARA) 2010 study aimed to evaluate the implementation of health-enhancing physical activity (HEPA), defined as muscle strength training twice per week and 30 minutes of moderately intense physical activity 5 times per week.13 The latter can be replaced by 20 minutes of intense activity 3 times per week.13 The 2-year study targeted people who had RA and were not already meeting HEPA recommendations. Year 1 (intervention year) consisted of biweekly 1-hour support group meetings coached by physical therapists applying SCT principles. Year 2 contained optional group meetings arranged by the participants (ie, the people who had RA and were being coached by the physical therapists).
For preparing health care professionals to deliver a new, complex intervention in a new setting, both adequate knowledge and skills should be targeted.14,15 A review by van der Wees et al16 of physical therapists' implementation of clinical guidelines on back pain indicated that knowledge alone is not enough; rather, multifaceted programs that include problem solving and applied skills training are needed to produce change. In line with these findings and implementation of researchers' recommendations,17,18 the education and support used in the present study were based on SCT.
Physical therapists were educated on how to guide HEPA adoption and maintenance for 6 days before and during the PARA 2010 intervention. The education of the physical therapists was designed to increase their behavioral capability and self-efficacy for HEPA coaching. It included evidence-based knowledge about HEPA for people with RA as well as knowledge about theories underlying behavioral change techniques. Furthermore, the education included coaching skills and strategies to support HEPA behavior, role playing to practice challenging coaching situations, guidance in the use of logs for self-reflection on coaching behavior, and the use of handbooks outlining the topics for group meetings for both participants and coaches. More specifically, the coaches were expected to provide guidance on goal setting and self-monitoring of behavior, to provide feedback on behavior, to provide guidance on problem solving to help overcome barriers and prevent relapse, and to encourage peer support.19 These behavioral change techniques were based mainly on SCT. For example, the participants' self-efficacy regarding their ability to perform HEPA was incorporated into goal setting,19 and feedback on behavior was adjusted according to the participants' efficacy levels and progress.20 Video recordings were made at on-site visits during the intervention year to provide feedback on coaching behavior during support group meetings. Selected portions of the video recordings were posted on an assigned secure Internet site to allow the coaches to monitor and model the behavior of others. This Internet site also served as an interactive forum for the coaches.
The systematic use of behavioral change techniques to support HEPA is not part of mainstream practice for physical therapists.21 Even though they are generally receptive to evidence-based practice, they may be reluctant to expand the traditional biomedical approach to incorporate skills to support behavioral changes.22 Hence, little is known about physical therapists' perceptions of such combined tasks. Therefore, a qualitative investigation of their perceptions may be relevant to understanding how they translate to practice. The aim of the present study was to explore the experiences of physical therapists coaching people with RA to HEPA in a 2-year trial, the PARA 2010 study.
Method
Coaches and Participants
All 12 coaches from the PARA 2010 study were interviewed. They were all registered physical therapists, women, aged 25 to 59 years (mean=41.3), and had worked as physical therapists for between 2 and 32 years (mean=13.8). All but 2 had worked in rheumatology for up to 22 years (mean=5.8). Ten of the 12 had previously received education and training in behavioral medicine in addition to their physical therapy education. One coach completed only approximately half of the coaching sessions but was considered to have enough coaching experience for inclusion in the study.
Two hundred twenty people with RA were included at the onset of the PARA 2010 study. Each coach was assigned a number of people with RA, ranging from 5 to 73 in total, with 5 to 14 people with RA per group. The coaches and the participants gave written informed consent before the study commenced. More information on the specifics of the PARA 2010 project is available in the study protocol described by Nordgren et al.19
Data Collection
Semistructured face-to-face interviews were conducted with the coaches. A draft of the interview guide was developed and adjusted until consensus was reached among the authors. Subsequently, mock interviews were conducted with 2 of the coauthors, both physical therapists but not coaches, and final adjustments were made. The final version of the interview guide consisted of 2 main areas of inquiry: experiences of being a coach in the PARA 2010 study and experiences of the preceding education and training. The interview guide included open-ended main questions and follow-up questions (Tab. 1). Probing questions, such as asking the interviewees to elaborate on an issue and to describe specific situations, were used to elicit additional and richer information from them.
Interview Guide: Main and Follow-up Questionsa
The first author conducted all interviews, ranging from 39 to 74 minutes in length. The interviews were conducted within 1 month of the final support group meetings in all cases except one, in which the coach completed only the first 8 sessions. That interview was conducted 6 months after the last session. All interviews were audio recorded with a Dictaphone (Dictaphone Corp, Stratford, Connecticut) and transcribed verbatim. Seven of the interviews were transcribed by the first author, and 5 were transcribed by an assistant who was familiar with the transcription process. All interviews were conducted at the coaches' workplaces—in closed rooms located at clinics and offices throughout Sweden. The quotations presented in this article are condensations, in which ellipses signify that a portion of the text has been omitted and brackets include clarifications made by the authors.
Analysis Procedure
The analysis procedure was based on content analysis as described by Graneheim and Lundman.23 It was carried out in 7 steps: familiarization, condensation, coding, grouping and labeling, extracting a theme, contrasting, and refining (Tab. 2). Furthermore, subcategories and categories were compared with all available code groups (see below), and illustrative quotations were jointly selected by 3 of the authors. The preliminary results were also discussed by the coaches at a seminar, and their comments led to minor revisions.
Analysis Procedure
During the familiarization step, the authors gained an overall impression of the transcribed material. In the condensation step, careful consideration was taken not to change the meaning of what was expressed in the transcripts. Condensation was mainly done through reduction of redundancies or repetitions, and parts deemed not relevant to the meaning of the sentence were removed. At this step, any data considered irrelevant for the research question were discarded. In the coding step, the condensed meaning units were interpreted and expressed in a code. The codes represented labels of the meaning of the sentence; different sentences with similar meanings were merged into one code. The codes were analyzed and grouped into code groups, representing a higher level of abstraction than the individual codes. Connection to data was purposefully maintained at the grouping and labeling steps, in which content was expressed through categories and subcategories. Throughout the process, the meaning units and code groups were compared with the categories and subcategories. The theme extracted was intended to represent the latent content, expressing the underlying meaning and a common thread found in the categories and subcategories.
Role of the Funding Source
The authors acknowledge the support received from the Swedish Research Council, Combine Sweden, the Swedish Rheumatism Association, the Stig Thune Foundation, the Strategic Research Program in Health Care Research at Karolinska Institutet/Umeå University, and the Disciplinary Domain of Medicine and Pharmacy at Uppsala University as well as Karolinska Institutet for part-time financing of doctoral students.
Results
The analysis of the interviews provided 1 overarching theme, 3 categories, and 17 subcategories. The overarching theme (from clinical expert to guide) was based on the 3 categories (challenges in the coaching role, growing into the coaching role, and coach education and support) derived from the subcategories (Tab. 3).
Categories, Subcategories, and Quotations for the Theme “From Clinical Expert to Guide”a
The theme (from clinical expert to guide) suggested that the coaches were integrating their traditional role of clinical expert in rheumatology with the role of a guide coaching people with RA to adopt and maintain physical activity. The main categories indicated a progression that started with facing various challenges and then gradually moved to learning and growing into the role of coach. Education and support in topics related to coaching facilitated this progression.
Category 1: Challenges in the Coaching Role
A variety of different challenges emerged during adoption of the role of coach. They were associated mainly with the tasks to be performed and arose from several subcategories (described below).
Leading or following the group.
One challenge was knowing when to act as a teacher and when to simply follow the group, guiding the members to adopt and maintain physical activity. For example, when the group members inquired about physiological issues, the physical therapist adopted the role of teacher and delivered the information while subsequently questioning if this was the proper way to conduct the group meetings.
Individualized coaching.
It also was challenging to know how to motivate and tailor the guidance for each member of the group because of differences in, for example, motivation and previous history of physical exercise.
Group expectations about being directed.
The group members' expectation that the coach would be in charge and lead the group was yet another challenge because it was partly in conflict with the coaching role in this project. The group members wanted a chairperson or teacher to turn to for leadership, especially when group meetings did not work smoothly or failed to engage them.
Insecurity about task and role.
Further challenges included a variety of insecurities concerning the coaching role and the tasks that the coaches were expected to perform. For example, it was difficult to know when the coaching was done “correctly,” what constitutes good coaching, and what to do when the group members showed no interest in a certain topic or did not want to follow a set agenda.
Initial stress.
Early in the coaching process, stress was a challenge when the coaches were implementing the components of the preparation course in a real-world setting. One stressor was not always having enough time to offer content perceived as necessary during the group meetings. Other stressors were not knowing how to organize the group meetings and not knowing how to achieve good group dynamics.
Time frames and logistics.
Additional challenges included issues such as the time of day for the group meetings, meetings that were too short to cover the topics, how to handle pedometers, and other practical matters.
Category 2: Growing Into the Coaching Role
Category 2 described how the physical therapists started to incorporate and use different behavioral change techniques when coaching. Various subcategories (described below) illustrated how they embraced issues such as letting go of the leader/teacher role and felt confident in promoting behavioral change and maintenance, according to the intervention protocol.
Relinquishing steering and control.
Initially, the coaches felt as though they were trying to control the group meetings, acting as leaders or teachers. However, over time their control over the meetings and participants became less important and, instead, they let the needs and wishes of the participants guide the agenda. Overall, the participants were gradually taking more responsibility.
Promoting adoption of HEPA.
To promote the adoption of HEPA behavior, the coaches provided information and initiated discussions related to the topics of the intervention. This approach raised the participants' awareness of HEPA benefits and changes in behavior. The coaches were facilitating the participants' assumption of more responsibility for their own behavior as well as improving group dynamics and creating an open climate for the adoption of HEPA. Providing positive feedback on behavior was also described as an important factor in promoting the adoption of HEPA. The coaches emphasized the need to prepare themselves for the group sessions in order to be comfortable with the agenda and properly use behavioral change techniques to promote the adoption of HEPA.
Promoting maintenance of HEPA.
To promote the maintenance of HEPA, the coaches used behavioral change techniques that had been introduced in the preparation course. Methods such as positive reinforcement, how to overcome obstacles, planning and follow-up, and relapse prevention were used. The coaches also worked on informing the participants about the importance of having a long-term perspective for the maintenance of HEPA.
Confidence in coaching.
The coaches were gradually becoming comfortable with their tasks, acknowledging that the coaching role was new and different from mainstream practice in physical therapy. They were finding ways of coaching that suited them and their situations, and they accomplished what they considered to be important in group coaching. They also expressed feeling more like members of the group rather than a teacher or a lecturer as a result of increased contact with and confidence from the participants.
Adapting to the group.
Coaching was not a static venture that strictly followed the protocol and the handbook. It was individually adapted, with different approaches for different participants and situations. The group members also had opinions about how the group meetings should be conducted, and consensus was sought by the coach.
Using coaching skills in other contexts.
The coaches expressed that they had applied the knowledge acquired from the preparation course and from leading groups in their routine clinical practice. In addition, some of the behavioral change techniques and theories were already familiar to the coaches and had previously been used in other work-related situations.
Category 3: Coach Education and Support
Coaching required clarity regarding the tasks as well as a general understanding of the intervention, especially early in the coaching process. Feedback on coaching behavior and a feeling of inclusion provided by project management were other important components highlighted by the following subcategories.
Need for clarification of task and role.
The coaches called for a clearer structure on how to coach the groups as well as more comprehensive guidelines on how to proceed at the group meetings, especially at the start of the intervention. Attention to these details would have saved time and would have reduced stress.
Importance of feedback on coaching behavior.
Individualized feedback on performance was perceived as beneficial for self-examination of behavior, providing help for specific situations, revealing personal strengths and skills to develop for coaching, and providing practical tips to use in coaching and as an overall learning experience. Positive feedback on coaching behavior also provided greater confidence, resulting in reduced stress. Additional types of feedback that the coaches considered useful were role playing in the preparation course, watching themselves on videotape in real group settings, and using logs to register and reflect on their behavior during group sessions.
Feeling included in the project.
The coaches perceived that it was important to be part of the research project as a whole, not just the group sessions, and that the project was a joint effort in which both they and the research team achieved success. Support was available from project management if needed, and there was an open climate for discussion.
Pros and cons of printed study material.
Several positive and negative aspects of the printed material (eg, the handbooks used in the group sessions) were described. More specifically, the material was perceived as being relevant and supportive but, at the same time, difficult to prioritize. There were too many topics to be covered, and some of the material was repetitive. Some coaches had problems with the material because some topics were rejected by the group members.
Techniques and support not used.
Parts of the education and program, such as some “handouts” and instruments, were not used. The assigned Internet site was not used for support and interaction because no time was allocated for these tasks. Role playing at the last educational session was perceived to be too late and not relevant at that point.
Discussion
To our knowledge, this is the first study to explore the experiences of physical therapists using behavioral change techniques to coach people with RA to HEPA. The results indicated that the physical therapists adapted to the coaching role progressively, starting as a traditional clinical expert and moving into a coaching role. This progression presented several challenges but also resulted in professional growth, as described by the physical therapists. These results may be applicable to other professional groups and other health-related behaviors.
The physical therapists described several challenges that they experienced when practicing their new skills: feelings of insecurity, time pressure, and management of their own and group expectations. Such initial difficulties were not surprising because changing well-established behaviors in clinicians is a process that requires time and practice.18,24 Similar obstacles have been identified and classified as barriers for changes in health care professionals by the Cochrane Effective Practice and Organization of Care Group (EPOC).25 For example, our subcategories “initial stress” and “insecurity about task and role” corresponded to the EPOC barrier “clinical uncertainty,” and our subcategory “group expectations about being directed” corresponded to the EPOC barrier “patient expectations.”
The educational intervention was based on SCT and was designed to increase the physical therapists' behavioral capability and self-efficacy to deliver the coaching intervention. This approach provided not only knowledge but also skills training through role playing, home assignments of gradually increasing difficulty, observational learning, and feedback on coaching behavior. The results suggested a generalization of skills that indicated professional growth in the physical therapists; they expressed experiencing increased confidence and used the acquired skills in other clinical contexts.
Through increasing capability and self-efficacy in situations in which the physical therapists experienced challenges, behavioral changes could be facilitated. For example, the insecurity experienced when leading the group and adapting to various needs of group members could be managed through skills training, such as observational learning and modeling. Such training is likely to promote mastery learning and enhance behavioral capability concerning these experiences.26 Furthermore, the fact that the physical therapists indicated positive effects from role playing, observational learning, and feedback on coaching behavior provided some support for the usefulness of SCT in designing the educational program. These positive effects indicated that SCT could be used to reduce experiences detrimental to behavioral changes as well as enhance experiences beneficial to behavioral changes.
However, additional issues must be considered in the development of an educational program. A comprehensive educational program based on psychological models has a higher probability of changing clinical practice than a more limited program aimed at increasing knowledge.27 A crucial issue to consider, however, is that comprehensive educational programs demand resources, such as the quantity and the quality of the strategies delivered, to properly address experiences and promote behavioral changes.16 Problems in implementing such interventions in clinical practice should be expected because of the complex nature of changing behavior.
Methodological Considerations
Investigating experiences with a focus on barriers and facilitators was well suited to qualitative research methodology.25
Interviewing and using data from all physical therapists enhanced credibility by providing a variety of perspectives on the research questions. Furthermore, allowing multiple authors to be part of the analysis process promoted a deeper and broader understanding of the issues through triangulation. Multiple authors also assisted in the assessment of similarities and differences in the subcategories and categories. The comments from the physical therapists were used to check for respondent validity.
Dependability was affected by the evolving interview process, in which the interviewer naturally developed techniques to adjust to the various challenges presented by the interviews. However, the main and follow-up questions in the interview guide were used in all interviews. The fact that the interviewer was not a physical therapist probably decreased the risk of “filling in the gaps” and making assumptions about what the interviewees were expressing. On the other hand, it may have restricted the understanding of the jargon used and may have caused the interviewees not to express certain physical therapy–related concerns.
Transferability was not the primary aim of the present study, and the results describe what was experienced in this unique situation. However, there is a possibility that, given consideration of the context, culture, intervention, situation, and characteristics of the participants and research team, some of the results may be extracted to other contexts.23 For example, the findings of the present study could inform educational interventions and implementation when the purpose is to learn new skills. The findings may be relevant for other health-related behaviors, for other professions, and both inside and outside the health care sector.
A large amount of data was retrieved and exposed to interpretation in the present study. There is a risk that some of the data were overlooked or misinterpreted. However, the transparency of the method, analysis, and results may allow readers to make alternative interpretations.
Implications and Future Studies
The results of the present study provide an overall understanding of the challenges of incorporating the use of behavioral change techniques into established professional work modes and highlight the need for support and stress reduction during the implementation phase after education. Thus, our results may provide possibilities for improving educational programs aiming to change professional practice and behavior. Educational programs could reduce challenges, promote growth at an early stage, and optimize education and support. The categories provide suggestions on what could be addressed in an educational program, such as role playing, with specific feedback on behavior; how to manage the expectation of participants to be led; how to individualize coaching according to the needs of the participants; and how to handle practical issues. Addressing these issues could assist in adopting the coaching role and reducing stress while doing so, and further research could indicate the effectiveness of such educational programs. Furthermore, to integrate feedback, future research could include collaborative action research, in which the findings are applied directly to practice, with the aim of bringing about change.28 This approach is useful for refining and evaluating interventions.29
To verify our findings and connect them to outcomes, future research could quantitatively investigate processes and outcomes related to the experiences of the physical therapists in the present study. This research could be done through evaluating observational data on coaching behavior and corresponding physical activity levels of the participants in the support groups.
Finally, there is a need to evaluate the cost-effectiveness as well as the overall effectiveness of resource-demanding education and support systems, such as those used in the PARA 2010 study.
Conclusion
Exploring physical therapists' experiences is fundamental in understanding adoption of the coaching role. The results of the present study indicated a progression in which the physical therapists faced challenges but gradually grew into the role of coach, assisted by the education and support received. Furthermore, the results may inform future educational programs targeting health care professionals' skills in promoting various health-related behaviors. The next steps could be to quantitatively evaluate processes and outcomes and evaluate educational programs that address health care professionals' experiences and adoption of a new role. If these approaches are effective in improving the adoption of a new role, they could be further disseminated and generalized.
Footnotes
Mr Nessen, Dr Opava, and Dr Demmelmaier provided concept/idea/research design and writing. Mr Nessen provided data collection. Mr Nessen, Dr Martin, and Dr Demmelmaier provided data analysis. Dr Opava provided facilities/equipment and institutional liaisons. Dr Opava and Dr Martin provided project management, fund procurement, and consultation (including review of manuscript before submission). The authors acknowledge the participating physical therapists for contributing to this study by providing rich material from their experiences.
Ethical approval for this study was obtained from the Stockholm Regional Ethical Review Board.
The authors acknowledge support received from the Swedish Research Council, Combine Sweden, the Swedish Rheumatism Association, the Stig Thune Foundation, the Strategic Research Program in Health Care Research at Karolinska Institutet/Umeå University, and the Disciplinary Domain of Medicine and Pharmacy at Uppsala University as well as Karolinska Institutet for part-time financing for doctoral students.
- Received September 4, 2013.
- Accepted January 3, 2014.
- © 2014 American Physical Therapy Association
References
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