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Older Inpatients' Views on Group PT
There is uncertainty regarding older adults' attitudes toward participating in group exercise. Although some evidence suggests that in the community, older adults prefer to exercise alone with some instruction,[1, 2] others support the preference of group exercise with peers.[3] Little is known about the attitudes of hospitalized older adults toward group physiotherapy (GPT). Providing physiotherapy (also known as physical therapy) in a group setting has been shown to be effective in a variety of populations,[4, 5, 6, 7] and as a consequence of simultaneously treating multiple patients, therapist[8] and cost[9] efficiency are enhanced. Description of the patient experience is increasingly being recognized as a crucial element in the delivery of patient‐centered care and performance evaluation of health professionals and services.[10] Therefore, the purpose of this investigation was to explore older inpatients' experiences of GPT to assist with planning and designing future inpatient programs to maximize patient participation, satisfaction, and clinical outcomes.
METHODS
Recruitment
A subset of participants enrolled in a randomized controlled trial investigating the effects of a GPT and individual physiotherapy program on clinical outcomes in hospitalized older adults (ANZCTR number: 12608000580370) were asked during the initial consenting procedure if they would also consent to participating in an interview about their experiences of physiotherapy. Ethics approval was provided by hospital and university ethics committees, and all participants provided written informed consent prior to commencement.
Participants
Inclusion criteria were inpatients on aged care wards at a metropolitan rehabilitation hospital, aged 65 years or older, and willing to take part in GPT. Exclusion criteria were Mini‐Mental State Examination[11] scores <10, physically unable or behaviorally unsuitable for GPT, insufficient proficiency in English, and significant memory loss. The latter 2 criteria were to allow for in‐depth interviews. Sixteen participants consented to take part.
Group Physiotherapy Intervention
Participants attended exercise classes 3 times per week, with a maximum of 6 participants, and were led by a trained physiotherapist or allied health assistant (group instructor). In addition, all participants also received individual physiotherapy; the treating therapist determined the type, intensity, and duration of the treatment with input from their patient.
Data Collection
After undertaking at least 3 group classes, individual interviews were undertaken in a quiet room with an independent researcher (MR). Interviews were conducted and audio‐recorded using a digital voice recorder, and were transcribed verbatim by MR within 24 hours. An interview guide with open‐ended questions, created specifically for this study, was modified after preliminary analysis of the first interview (Table 1). Interviews continued until no new themes arose in the last 3 interviews; saturation point[12] was decided by reviewer consensus and reached at 12 interviews. The key outcome of interest was themes relating to participants' experiences of GPT. Interviews lasted between 5 and 45 minutes.
|
| Questions |
| How do you feel about attending the group PT sessions? |
| What aspects of the group PT sessions do you enjoy? |
| What aspects of the group PT sessions do you dislike? |
| What do you think about the level of supervision and support you receive in the group sessions? |
| What do you think about the amount of PT you receive in these group sessions? |
| What are the main differences between the exercise group and the individual sessions? |
| What did you expect to occur in the group sessions? |
| How do you feel when you see other people doing better than you in the group? |
| How do you feel when you see other people doing worse than you in the group? |
| In the future, what things could be changed to make group PT more enjoyable for you? |
| What other comments or feedback do you have? |
Data Analysis
Two reviewers independently completed line‐by‐line thematic analysis.[13] One reviewer used NVivo to support analysis,[14] and the other reviewer analyzed interviews manually. Text was coded,[15] and constant comparison was utilized to ensure later emerging codes were identified in earlier interviews.[15] Researchers then met to compare and discuss coding definitions and their results; similar codes that arose in multiple interviews were compared and grouped together to develop themes and subthemes, which were refined until consensus was reached. Interviews and themes were reviewed by a third researcher (AH) as part of a peer review process to minimize researcher bias.[16]
RESULTS
Eight females and 4 males aged 73 to 93 years (mean = 82.5 years, standard deviation = 7.1 years) participated in the interviews. After initially consenting to participate, 1 participant declined due to fatigue. Three participants were discharged prior to scheduling an interview. Analysis revealed 6 major themes and 10 subthemes (Table 2).
| Major Theme | Subtheme | Supporting Extracts |
|---|---|---|
| ||
| Participation and satisfaction | Happy to participate in group PT | It's been terrific. It's the best thing I've done since being here. I've been very happyyou should continue it, that's for sure. It's best for everybody. (Participant 1) |
| Group PT was a satisfactory alternative to individual PT | I rather enjoy it. I'm looking forward to it today. I can't see much difference [between the group and individual PT]. Couldn't be better. (Participant 3) | |
| Exercise and physical benefits | Happy with the content | I didn't find any of the exercises beyond my limits. I didn't realize how weak I was. After exercising, I found the muscles in my neck were tightandgetting a bit sore initially, but the more I did, the lesser it gotwith the arthritis, it is good to get it moving. (Participant 12) |
| Described physical benefits | Whatever I'm doing is helping with my balance and helping with general muscle things. I'm getting a little bit bettermy balance has improved. (Participant 4) | |
| Camaraderie and support | Enjoyment of the social aspects of group PT, feeling like they're in it together | The group is nice because we smile at each other and we grimacewe feel the same thingsit hurts or I'm tired. We sometimes have a bit of a laugh and sometimes have a bit of a moan. I think you enjoy it more if you've got others doing the same thing as you. [We] egg everybody on to do their best. (Participant 4) |
| Celebration of others' successes | One of the other ladies went home and I was really pleased for her. She'd been here for quite some time and I wished her well. (Participant 4) | |
| I just clap like mad for somebody who has done a better job next time I see them. [It] shows that they're trying harder. (Participant 3) | ||
| Self‐satisfaction and self‐awareness | Feeling good about their performance | I can walk to the toilet and walk around the ward. A few of them just can't. It made me think about life and how fortunate I've been. When I look around, there's a lot more that's worse off than me. (Participant 2) |
| I feel lucky. I'm better than the other ones.My legs are very bad but there's one who can hardly lift her legs. I'm very lucky. (Participant 8) | ||
| Motivation and drive for improvement | Self‐determination plays an important role in recovery, with physical benefits as an extrinsic motivator | I try pretty much as hard as I canI do the best I can and that's about all I can do, really. (Participant 4) |
| Part of the reason I'm here is just to try and improve my balance so that I don't fall over. (Participant 7) | ||
| Competition as extrinsic motivation | It's a bit of a challenge. I've only done 8 and they've done 10. Incentiveit becomes a bit like competition. (Participant 1) | |
| I try and do better than what they're doing. (Participant 5). | ||
| It's good to be together to do it, I think it gives you an incentive to work at it, push yourself a little bit. Competitiveness comes out[you have] got to push yourself a bit harder. (Participant 12) | ||
| Qualities of the group instructor | Knowledge and attentiveness of the group instructor | She knows I've got a bad back and I've got a bad arm so she says, You don't do that one, Don't forget, you mustn't do it if it hurts. (Participant 3) |
Themes
Attendance and Satisfaction
Participants were happy to attend GPT. Participants saw it as an opportunity to get out of the room (participant 4) and they valued the socialization.
Participants found GPT to be a satisfactory alternative to individual sessions. Participants described no difference in the level or type of physiotherapy in group and individual settings; both were valued for exercise content.
Exercise and Physical Benefits
Participants were happy with the content of GPT. Despite being high intensity, exercises were reported to be appropriate.
Perceived physical benefits were described. Reduced pain and stiffness, and improved balance and strength were described with GPT, which contributed to satisfaction.
Qualities of the Group Instructor
Knowledge and Attentiveness of the Group Instructor
These supportive qualities were described as important factors by participants. Some participants acknowledged the number of other participants in GPT; however, they perceived that the instructor was monitoring each person individually, constantly, and equally. Participants reported that group instructors modified or ceased exercises where appropriate, engendering trust (participant 5) and perceived that GPT was individualized and not inferior to individual PT.
Social AspectsCamaraderie and Support
Enjoyment of the Social Aspects of GPT: Feeling Like They're in It Together
Participants reported enjoying the company and support of their peers. They described camaraderie and did not feel alone in their experiences. Exercising with peers encouraged them to push themselves more than during individual physiotherapy.
Celebration of Others' Successes
Some participants expressed awareness of their support to others; seeing others improve and return home gave them encouragement.
Self‐Satisfaction and Self‐Awareness
Feel Good About Their Mobility and Health in the Group Setting
Participants made downward comparisons with others less mobile, which resulted in a realization, gratitude, and acceptance of their own health and physical abilities/limitations.
Self‐Determination and Extrinsic Motivators
Self‐Determination Plays an Important Role in Recovery, With Physical Benefits as an Extrinsic Motivator
Participants described self‐determination to exercise, some without peer influence. Physical benefits of exercise were an extrinsic motivator; participants felt that they were doing as best they could to achieve their goals.
Competition as an Extrinsic Motivator
Upward social comparisons were made with peers who participants perceived were performing better than them, which increased motivation to work harder. Self‐determination and competition were not mutually exclusive.
DISCUSSION
Participants were positive about GPT and reported experiencing physical benefits. Motivation was reported as an important factor in recovery, with improving mobility and competition as commonly described extrinsic motivators. Social comparisons made between participants were motivating and reassuring.
Group physiotherapy sessions are often a replacement for individual physiotherapy; therefore, it is important that participants feel they are receiving a suitable alternative. Individual physiotherapy has advantages over GPT including affording a more individualized assessment and treatment; a combination of both may be appropriate for many older inpatients. Although there is conflicting evidence of the exercise preferences of community‐dwelling older adults,[1] the results of this study are consistent with evidence supporting exercising with peers.[3, 17]
Self‐determination theory describes motivation existing along a continuum, from intrinsic motivation to extrinsic motivation then amotivation.[18] Participants described valuing the physical benefits of exercise (extrinsic motivation), similarly noted by survivors of stroke.[19, 20] For those who do not value exercise, group instructors may consider discussing its benefits during GPT. Competition may be stimulated through exercising with peers; therefore, group instructors should utilize this advantage of GPT over individual physiotherapy.
Participants feeling socially supported in GPT were similar to those reported by hospitalized older adults[21] as well as those undertaking exercise groups for cardiac rehabilitation,[22] terminal cancer,[23] and following lung transplantation.[24] Fostering a supportive environment may enhance the patient experience; therefore, physiotherapists should encourage GPT attendance and socialization (as appropriate) and actively acknowledge physical improvements.
The Social Comparison Theory suggests that people evaluate their abilities by comparing themselves to their peers.[25, 26] Participants who made upward comparisons, with those who they perceived were better than them[26] resulted in motivation to attain the level of their more mobile peers. Downward comparisons were also made with those who they felt were less mobile; these engendered feelings of gratitude and appreciation for their own health and promoted self‐esteem,[26] and have also been reported in other populations including those with spinal cord injury[27] and breast cancer.[28]
Study Limitations
Interviews were not conducted with those who received individual physiotherapy alone, and therefore no comparisons can be drawn regarding their experiences and satisfaction. Those who participated in interviews had already consented to participating in GPT; those who declined GPT were not part of the trial and therefore responses may have some bias. To minimize this bias, the interview guide included questions into positive and negative aspects of group and individual physiotherapy. Although community‐dwelling older adults perceive boredom, intimidation, and potential for injury to be barriers to participation in exercise,[29] future research should investigate why older inpatients decline GPT and methods for improving participation.
CONCLUSION
This study provides new evidence to support GPT for hospitalized older adults. Participants in this study enjoyed GPT and were motivated and supported by their peers. As GPT was valued by hospitalized older adults who participated in this study for its physical and social benefits, clinicians could consider replacing several individual treatment sessions with GPT as part of a weekly treatment schedule.
Acknowledgements
The principle investigator thanks E. Harris, C. Chenneaux, A. Shapiro, D. Kronemberg, R. Roose and B. Doyle‐Jones for running the exercise groups, and also extends her thanks and gratitude to all of the patients interviewed for their time and honesty.
Disclosures: Melissa J. Raymond was supported by an Australian Postgraduate Award scholarship and a Caulfield Hospital Research Trust Projects Grant 2008/2009.
- , , , , , . Personal and environmental factors associated with physical inactivity among different racial‐ethnic groups of U.S. middle‐aged and older‐aged women. Health Psychol. 2000;19(4):354–364.
- , , , . Physical activity preferences of middle‐aged and older adults: a community analysis. J Aging Phys Act. 1999;7(4):386–399.
- , , , . Older adults' preferences for exercising alone versus in groups: considering contextual congruence. Ann Behav Med. 2007;33(2):200–206.
- , , , , . Group versus individual approach? A meta‐analysis of the effectiveness of interventions to promote physical activity. Sport Exerc Psychol Rev. 2006;2(1):19–35.
- , , , , , . A high‐intensity functional weight‐bearing exercise program for older people dependent in activities of daily living and living in residential care facilities: evaluation of the applicability with focus on cognitive function. Phys Ther. 2006;86(4):489–498.
- , , , , , . The value of individual or collective group exercise programs for knee or hip osteoarthritis. Clinical practice recommendations. Ann Readapt Med Phys. 2007;50(9):741–746, 734–740.
- , , , . Circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: a controlled trial. Arch Phys Med Rehabil. 2007;88(8):955–963.
- , , , . A descriptive analysis of physical therapy group intervention in five midwestern inpatient rehabilitation facilities. J Phys Ther Educ. 2000;14:13–20.
- , , , et al. Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence. BMC Womens Health. 2009;9:26.
- . Service improvement and patient experience. Int Emerg Nurs. 2010;18(4):175–176.
- , , . “Mini‐mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.
- , . The Discovery of Grounded Theory: Strategies for Qualitative Research. Mill Valley, CA: Sociology Press; 1967.
- , . Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77–101.
- , . The NVivo Qualitative Project Book. London, United Kingdom: Sage; 2000.
- . A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant. 2002;36(4):391–409.
- , . Rigour and qualitative research. BMJ. 1995;311(6997):109–112.
- , , . How, where and with whom? Physical activity context preferences of three adult groups at risk of inactivity. Br J Sports Med. 2012;46(16):1125–1131.
- , , . Older adults' intrinsic and extrinsic motivation toward physical activity. Am J Health Behav. 2008;32(6):570–582.
- , , , . Qualitative analysis of stroke patients' motivation for rehabilitation. BMJ. 2000;321(7268):1051–1054.
- , , . Exercise perceptions among people with stroke: barriers and facilitators to participation. Int J Ther Rehabil. 2011;18(9):520–530.
- , , , . Interaction between clients and physiotherapists in group exercise classes in geriatric rehabilitation. Adv Physiother. 2009;11(3):145–153.
- , , , . Patients' experience of home and hospital based cardiac rehabilitation: a focus group study. Eur J Cardiovasc Nurs. 2009;8(1):9–17.
- , , , , . Exercise and relaxation intervention for patients with advanced lung cancer: a qualitative feasibility study. Scand J Med Sci Sports. 2012;22(6):804–815.
- , , , et al. Patients' expectations and experiences of rehabilitation following lung transplantation. Clin Transplant. 2014;28(2):252–258.
- . A theory of social comparison processes. Hum Relat. 1954;7(2):117–140.
- . Theory and research concerning social comparisons of personal attributes. Psychol Bull. 1989;106(2):231–248.
- , . Long‐term adjustment to physical disability: the role of social support, perceived control, and self‐blame. J Pers Soc Psychol. 1985;48:1162–1172.
- , , . It could be worse: selective evaluation as a response to victimization. J Soc Issues. 1983;39:19–40.
- , , , . Motivators, barriers, and beliefs regarding physical activity in an older adult population. J Geriatr Phys Ther. 2011;34(3):138–147.
There is uncertainty regarding older adults' attitudes toward participating in group exercise. Although some evidence suggests that in the community, older adults prefer to exercise alone with some instruction,[1, 2] others support the preference of group exercise with peers.[3] Little is known about the attitudes of hospitalized older adults toward group physiotherapy (GPT). Providing physiotherapy (also known as physical therapy) in a group setting has been shown to be effective in a variety of populations,[4, 5, 6, 7] and as a consequence of simultaneously treating multiple patients, therapist[8] and cost[9] efficiency are enhanced. Description of the patient experience is increasingly being recognized as a crucial element in the delivery of patient‐centered care and performance evaluation of health professionals and services.[10] Therefore, the purpose of this investigation was to explore older inpatients' experiences of GPT to assist with planning and designing future inpatient programs to maximize patient participation, satisfaction, and clinical outcomes.
METHODS
Recruitment
A subset of participants enrolled in a randomized controlled trial investigating the effects of a GPT and individual physiotherapy program on clinical outcomes in hospitalized older adults (ANZCTR number: 12608000580370) were asked during the initial consenting procedure if they would also consent to participating in an interview about their experiences of physiotherapy. Ethics approval was provided by hospital and university ethics committees, and all participants provided written informed consent prior to commencement.
Participants
Inclusion criteria were inpatients on aged care wards at a metropolitan rehabilitation hospital, aged 65 years or older, and willing to take part in GPT. Exclusion criteria were Mini‐Mental State Examination[11] scores <10, physically unable or behaviorally unsuitable for GPT, insufficient proficiency in English, and significant memory loss. The latter 2 criteria were to allow for in‐depth interviews. Sixteen participants consented to take part.
Group Physiotherapy Intervention
Participants attended exercise classes 3 times per week, with a maximum of 6 participants, and were led by a trained physiotherapist or allied health assistant (group instructor). In addition, all participants also received individual physiotherapy; the treating therapist determined the type, intensity, and duration of the treatment with input from their patient.
Data Collection
After undertaking at least 3 group classes, individual interviews were undertaken in a quiet room with an independent researcher (MR). Interviews were conducted and audio‐recorded using a digital voice recorder, and were transcribed verbatim by MR within 24 hours. An interview guide with open‐ended questions, created specifically for this study, was modified after preliminary analysis of the first interview (Table 1). Interviews continued until no new themes arose in the last 3 interviews; saturation point[12] was decided by reviewer consensus and reached at 12 interviews. The key outcome of interest was themes relating to participants' experiences of GPT. Interviews lasted between 5 and 45 minutes.
|
| Questions |
| How do you feel about attending the group PT sessions? |
| What aspects of the group PT sessions do you enjoy? |
| What aspects of the group PT sessions do you dislike? |
| What do you think about the level of supervision and support you receive in the group sessions? |
| What do you think about the amount of PT you receive in these group sessions? |
| What are the main differences between the exercise group and the individual sessions? |
| What did you expect to occur in the group sessions? |
| How do you feel when you see other people doing better than you in the group? |
| How do you feel when you see other people doing worse than you in the group? |
| In the future, what things could be changed to make group PT more enjoyable for you? |
| What other comments or feedback do you have? |
Data Analysis
Two reviewers independently completed line‐by‐line thematic analysis.[13] One reviewer used NVivo to support analysis,[14] and the other reviewer analyzed interviews manually. Text was coded,[15] and constant comparison was utilized to ensure later emerging codes were identified in earlier interviews.[15] Researchers then met to compare and discuss coding definitions and their results; similar codes that arose in multiple interviews were compared and grouped together to develop themes and subthemes, which were refined until consensus was reached. Interviews and themes were reviewed by a third researcher (AH) as part of a peer review process to minimize researcher bias.[16]
RESULTS
Eight females and 4 males aged 73 to 93 years (mean = 82.5 years, standard deviation = 7.1 years) participated in the interviews. After initially consenting to participate, 1 participant declined due to fatigue. Three participants were discharged prior to scheduling an interview. Analysis revealed 6 major themes and 10 subthemes (Table 2).
| Major Theme | Subtheme | Supporting Extracts |
|---|---|---|
| ||
| Participation and satisfaction | Happy to participate in group PT | It's been terrific. It's the best thing I've done since being here. I've been very happyyou should continue it, that's for sure. It's best for everybody. (Participant 1) |
| Group PT was a satisfactory alternative to individual PT | I rather enjoy it. I'm looking forward to it today. I can't see much difference [between the group and individual PT]. Couldn't be better. (Participant 3) | |
| Exercise and physical benefits | Happy with the content | I didn't find any of the exercises beyond my limits. I didn't realize how weak I was. After exercising, I found the muscles in my neck were tightandgetting a bit sore initially, but the more I did, the lesser it gotwith the arthritis, it is good to get it moving. (Participant 12) |
| Described physical benefits | Whatever I'm doing is helping with my balance and helping with general muscle things. I'm getting a little bit bettermy balance has improved. (Participant 4) | |
| Camaraderie and support | Enjoyment of the social aspects of group PT, feeling like they're in it together | The group is nice because we smile at each other and we grimacewe feel the same thingsit hurts or I'm tired. We sometimes have a bit of a laugh and sometimes have a bit of a moan. I think you enjoy it more if you've got others doing the same thing as you. [We] egg everybody on to do their best. (Participant 4) |
| Celebration of others' successes | One of the other ladies went home and I was really pleased for her. She'd been here for quite some time and I wished her well. (Participant 4) | |
| I just clap like mad for somebody who has done a better job next time I see them. [It] shows that they're trying harder. (Participant 3) | ||
| Self‐satisfaction and self‐awareness | Feeling good about their performance | I can walk to the toilet and walk around the ward. A few of them just can't. It made me think about life and how fortunate I've been. When I look around, there's a lot more that's worse off than me. (Participant 2) |
| I feel lucky. I'm better than the other ones.My legs are very bad but there's one who can hardly lift her legs. I'm very lucky. (Participant 8) | ||
| Motivation and drive for improvement | Self‐determination plays an important role in recovery, with physical benefits as an extrinsic motivator | I try pretty much as hard as I canI do the best I can and that's about all I can do, really. (Participant 4) |
| Part of the reason I'm here is just to try and improve my balance so that I don't fall over. (Participant 7) | ||
| Competition as extrinsic motivation | It's a bit of a challenge. I've only done 8 and they've done 10. Incentiveit becomes a bit like competition. (Participant 1) | |
| I try and do better than what they're doing. (Participant 5). | ||
| It's good to be together to do it, I think it gives you an incentive to work at it, push yourself a little bit. Competitiveness comes out[you have] got to push yourself a bit harder. (Participant 12) | ||
| Qualities of the group instructor | Knowledge and attentiveness of the group instructor | She knows I've got a bad back and I've got a bad arm so she says, You don't do that one, Don't forget, you mustn't do it if it hurts. (Participant 3) |
Themes
Attendance and Satisfaction
Participants were happy to attend GPT. Participants saw it as an opportunity to get out of the room (participant 4) and they valued the socialization.
Participants found GPT to be a satisfactory alternative to individual sessions. Participants described no difference in the level or type of physiotherapy in group and individual settings; both were valued for exercise content.
Exercise and Physical Benefits
Participants were happy with the content of GPT. Despite being high intensity, exercises were reported to be appropriate.
Perceived physical benefits were described. Reduced pain and stiffness, and improved balance and strength were described with GPT, which contributed to satisfaction.
Qualities of the Group Instructor
Knowledge and Attentiveness of the Group Instructor
These supportive qualities were described as important factors by participants. Some participants acknowledged the number of other participants in GPT; however, they perceived that the instructor was monitoring each person individually, constantly, and equally. Participants reported that group instructors modified or ceased exercises where appropriate, engendering trust (participant 5) and perceived that GPT was individualized and not inferior to individual PT.
Social AspectsCamaraderie and Support
Enjoyment of the Social Aspects of GPT: Feeling Like They're in It Together
Participants reported enjoying the company and support of their peers. They described camaraderie and did not feel alone in their experiences. Exercising with peers encouraged them to push themselves more than during individual physiotherapy.
Celebration of Others' Successes
Some participants expressed awareness of their support to others; seeing others improve and return home gave them encouragement.
Self‐Satisfaction and Self‐Awareness
Feel Good About Their Mobility and Health in the Group Setting
Participants made downward comparisons with others less mobile, which resulted in a realization, gratitude, and acceptance of their own health and physical abilities/limitations.
Self‐Determination and Extrinsic Motivators
Self‐Determination Plays an Important Role in Recovery, With Physical Benefits as an Extrinsic Motivator
Participants described self‐determination to exercise, some without peer influence. Physical benefits of exercise were an extrinsic motivator; participants felt that they were doing as best they could to achieve their goals.
Competition as an Extrinsic Motivator
Upward social comparisons were made with peers who participants perceived were performing better than them, which increased motivation to work harder. Self‐determination and competition were not mutually exclusive.
DISCUSSION
Participants were positive about GPT and reported experiencing physical benefits. Motivation was reported as an important factor in recovery, with improving mobility and competition as commonly described extrinsic motivators. Social comparisons made between participants were motivating and reassuring.
Group physiotherapy sessions are often a replacement for individual physiotherapy; therefore, it is important that participants feel they are receiving a suitable alternative. Individual physiotherapy has advantages over GPT including affording a more individualized assessment and treatment; a combination of both may be appropriate for many older inpatients. Although there is conflicting evidence of the exercise preferences of community‐dwelling older adults,[1] the results of this study are consistent with evidence supporting exercising with peers.[3, 17]
Self‐determination theory describes motivation existing along a continuum, from intrinsic motivation to extrinsic motivation then amotivation.[18] Participants described valuing the physical benefits of exercise (extrinsic motivation), similarly noted by survivors of stroke.[19, 20] For those who do not value exercise, group instructors may consider discussing its benefits during GPT. Competition may be stimulated through exercising with peers; therefore, group instructors should utilize this advantage of GPT over individual physiotherapy.
Participants feeling socially supported in GPT were similar to those reported by hospitalized older adults[21] as well as those undertaking exercise groups for cardiac rehabilitation,[22] terminal cancer,[23] and following lung transplantation.[24] Fostering a supportive environment may enhance the patient experience; therefore, physiotherapists should encourage GPT attendance and socialization (as appropriate) and actively acknowledge physical improvements.
The Social Comparison Theory suggests that people evaluate their abilities by comparing themselves to their peers.[25, 26] Participants who made upward comparisons, with those who they perceived were better than them[26] resulted in motivation to attain the level of their more mobile peers. Downward comparisons were also made with those who they felt were less mobile; these engendered feelings of gratitude and appreciation for their own health and promoted self‐esteem,[26] and have also been reported in other populations including those with spinal cord injury[27] and breast cancer.[28]
Study Limitations
Interviews were not conducted with those who received individual physiotherapy alone, and therefore no comparisons can be drawn regarding their experiences and satisfaction. Those who participated in interviews had already consented to participating in GPT; those who declined GPT were not part of the trial and therefore responses may have some bias. To minimize this bias, the interview guide included questions into positive and negative aspects of group and individual physiotherapy. Although community‐dwelling older adults perceive boredom, intimidation, and potential for injury to be barriers to participation in exercise,[29] future research should investigate why older inpatients decline GPT and methods for improving participation.
CONCLUSION
This study provides new evidence to support GPT for hospitalized older adults. Participants in this study enjoyed GPT and were motivated and supported by their peers. As GPT was valued by hospitalized older adults who participated in this study for its physical and social benefits, clinicians could consider replacing several individual treatment sessions with GPT as part of a weekly treatment schedule.
Acknowledgements
The principle investigator thanks E. Harris, C. Chenneaux, A. Shapiro, D. Kronemberg, R. Roose and B. Doyle‐Jones for running the exercise groups, and also extends her thanks and gratitude to all of the patients interviewed for their time and honesty.
Disclosures: Melissa J. Raymond was supported by an Australian Postgraduate Award scholarship and a Caulfield Hospital Research Trust Projects Grant 2008/2009.
There is uncertainty regarding older adults' attitudes toward participating in group exercise. Although some evidence suggests that in the community, older adults prefer to exercise alone with some instruction,[1, 2] others support the preference of group exercise with peers.[3] Little is known about the attitudes of hospitalized older adults toward group physiotherapy (GPT). Providing physiotherapy (also known as physical therapy) in a group setting has been shown to be effective in a variety of populations,[4, 5, 6, 7] and as a consequence of simultaneously treating multiple patients, therapist[8] and cost[9] efficiency are enhanced. Description of the patient experience is increasingly being recognized as a crucial element in the delivery of patient‐centered care and performance evaluation of health professionals and services.[10] Therefore, the purpose of this investigation was to explore older inpatients' experiences of GPT to assist with planning and designing future inpatient programs to maximize patient participation, satisfaction, and clinical outcomes.
METHODS
Recruitment
A subset of participants enrolled in a randomized controlled trial investigating the effects of a GPT and individual physiotherapy program on clinical outcomes in hospitalized older adults (ANZCTR number: 12608000580370) were asked during the initial consenting procedure if they would also consent to participating in an interview about their experiences of physiotherapy. Ethics approval was provided by hospital and university ethics committees, and all participants provided written informed consent prior to commencement.
Participants
Inclusion criteria were inpatients on aged care wards at a metropolitan rehabilitation hospital, aged 65 years or older, and willing to take part in GPT. Exclusion criteria were Mini‐Mental State Examination[11] scores <10, physically unable or behaviorally unsuitable for GPT, insufficient proficiency in English, and significant memory loss. The latter 2 criteria were to allow for in‐depth interviews. Sixteen participants consented to take part.
Group Physiotherapy Intervention
Participants attended exercise classes 3 times per week, with a maximum of 6 participants, and were led by a trained physiotherapist or allied health assistant (group instructor). In addition, all participants also received individual physiotherapy; the treating therapist determined the type, intensity, and duration of the treatment with input from their patient.
Data Collection
After undertaking at least 3 group classes, individual interviews were undertaken in a quiet room with an independent researcher (MR). Interviews were conducted and audio‐recorded using a digital voice recorder, and were transcribed verbatim by MR within 24 hours. An interview guide with open‐ended questions, created specifically for this study, was modified after preliminary analysis of the first interview (Table 1). Interviews continued until no new themes arose in the last 3 interviews; saturation point[12] was decided by reviewer consensus and reached at 12 interviews. The key outcome of interest was themes relating to participants' experiences of GPT. Interviews lasted between 5 and 45 minutes.
|
| Questions |
| How do you feel about attending the group PT sessions? |
| What aspects of the group PT sessions do you enjoy? |
| What aspects of the group PT sessions do you dislike? |
| What do you think about the level of supervision and support you receive in the group sessions? |
| What do you think about the amount of PT you receive in these group sessions? |
| What are the main differences between the exercise group and the individual sessions? |
| What did you expect to occur in the group sessions? |
| How do you feel when you see other people doing better than you in the group? |
| How do you feel when you see other people doing worse than you in the group? |
| In the future, what things could be changed to make group PT more enjoyable for you? |
| What other comments or feedback do you have? |
Data Analysis
Two reviewers independently completed line‐by‐line thematic analysis.[13] One reviewer used NVivo to support analysis,[14] and the other reviewer analyzed interviews manually. Text was coded,[15] and constant comparison was utilized to ensure later emerging codes were identified in earlier interviews.[15] Researchers then met to compare and discuss coding definitions and their results; similar codes that arose in multiple interviews were compared and grouped together to develop themes and subthemes, which were refined until consensus was reached. Interviews and themes were reviewed by a third researcher (AH) as part of a peer review process to minimize researcher bias.[16]
RESULTS
Eight females and 4 males aged 73 to 93 years (mean = 82.5 years, standard deviation = 7.1 years) participated in the interviews. After initially consenting to participate, 1 participant declined due to fatigue. Three participants were discharged prior to scheduling an interview. Analysis revealed 6 major themes and 10 subthemes (Table 2).
| Major Theme | Subtheme | Supporting Extracts |
|---|---|---|
| ||
| Participation and satisfaction | Happy to participate in group PT | It's been terrific. It's the best thing I've done since being here. I've been very happyyou should continue it, that's for sure. It's best for everybody. (Participant 1) |
| Group PT was a satisfactory alternative to individual PT | I rather enjoy it. I'm looking forward to it today. I can't see much difference [between the group and individual PT]. Couldn't be better. (Participant 3) | |
| Exercise and physical benefits | Happy with the content | I didn't find any of the exercises beyond my limits. I didn't realize how weak I was. After exercising, I found the muscles in my neck were tightandgetting a bit sore initially, but the more I did, the lesser it gotwith the arthritis, it is good to get it moving. (Participant 12) |
| Described physical benefits | Whatever I'm doing is helping with my balance and helping with general muscle things. I'm getting a little bit bettermy balance has improved. (Participant 4) | |
| Camaraderie and support | Enjoyment of the social aspects of group PT, feeling like they're in it together | The group is nice because we smile at each other and we grimacewe feel the same thingsit hurts or I'm tired. We sometimes have a bit of a laugh and sometimes have a bit of a moan. I think you enjoy it more if you've got others doing the same thing as you. [We] egg everybody on to do their best. (Participant 4) |
| Celebration of others' successes | One of the other ladies went home and I was really pleased for her. She'd been here for quite some time and I wished her well. (Participant 4) | |
| I just clap like mad for somebody who has done a better job next time I see them. [It] shows that they're trying harder. (Participant 3) | ||
| Self‐satisfaction and self‐awareness | Feeling good about their performance | I can walk to the toilet and walk around the ward. A few of them just can't. It made me think about life and how fortunate I've been. When I look around, there's a lot more that's worse off than me. (Participant 2) |
| I feel lucky. I'm better than the other ones.My legs are very bad but there's one who can hardly lift her legs. I'm very lucky. (Participant 8) | ||
| Motivation and drive for improvement | Self‐determination plays an important role in recovery, with physical benefits as an extrinsic motivator | I try pretty much as hard as I canI do the best I can and that's about all I can do, really. (Participant 4) |
| Part of the reason I'm here is just to try and improve my balance so that I don't fall over. (Participant 7) | ||
| Competition as extrinsic motivation | It's a bit of a challenge. I've only done 8 and they've done 10. Incentiveit becomes a bit like competition. (Participant 1) | |
| I try and do better than what they're doing. (Participant 5). | ||
| It's good to be together to do it, I think it gives you an incentive to work at it, push yourself a little bit. Competitiveness comes out[you have] got to push yourself a bit harder. (Participant 12) | ||
| Qualities of the group instructor | Knowledge and attentiveness of the group instructor | She knows I've got a bad back and I've got a bad arm so she says, You don't do that one, Don't forget, you mustn't do it if it hurts. (Participant 3) |
Themes
Attendance and Satisfaction
Participants were happy to attend GPT. Participants saw it as an opportunity to get out of the room (participant 4) and they valued the socialization.
Participants found GPT to be a satisfactory alternative to individual sessions. Participants described no difference in the level or type of physiotherapy in group and individual settings; both were valued for exercise content.
Exercise and Physical Benefits
Participants were happy with the content of GPT. Despite being high intensity, exercises were reported to be appropriate.
Perceived physical benefits were described. Reduced pain and stiffness, and improved balance and strength were described with GPT, which contributed to satisfaction.
Qualities of the Group Instructor
Knowledge and Attentiveness of the Group Instructor
These supportive qualities were described as important factors by participants. Some participants acknowledged the number of other participants in GPT; however, they perceived that the instructor was monitoring each person individually, constantly, and equally. Participants reported that group instructors modified or ceased exercises where appropriate, engendering trust (participant 5) and perceived that GPT was individualized and not inferior to individual PT.
Social AspectsCamaraderie and Support
Enjoyment of the Social Aspects of GPT: Feeling Like They're in It Together
Participants reported enjoying the company and support of their peers. They described camaraderie and did not feel alone in their experiences. Exercising with peers encouraged them to push themselves more than during individual physiotherapy.
Celebration of Others' Successes
Some participants expressed awareness of their support to others; seeing others improve and return home gave them encouragement.
Self‐Satisfaction and Self‐Awareness
Feel Good About Their Mobility and Health in the Group Setting
Participants made downward comparisons with others less mobile, which resulted in a realization, gratitude, and acceptance of their own health and physical abilities/limitations.
Self‐Determination and Extrinsic Motivators
Self‐Determination Plays an Important Role in Recovery, With Physical Benefits as an Extrinsic Motivator
Participants described self‐determination to exercise, some without peer influence. Physical benefits of exercise were an extrinsic motivator; participants felt that they were doing as best they could to achieve their goals.
Competition as an Extrinsic Motivator
Upward social comparisons were made with peers who participants perceived were performing better than them, which increased motivation to work harder. Self‐determination and competition were not mutually exclusive.
DISCUSSION
Participants were positive about GPT and reported experiencing physical benefits. Motivation was reported as an important factor in recovery, with improving mobility and competition as commonly described extrinsic motivators. Social comparisons made between participants were motivating and reassuring.
Group physiotherapy sessions are often a replacement for individual physiotherapy; therefore, it is important that participants feel they are receiving a suitable alternative. Individual physiotherapy has advantages over GPT including affording a more individualized assessment and treatment; a combination of both may be appropriate for many older inpatients. Although there is conflicting evidence of the exercise preferences of community‐dwelling older adults,[1] the results of this study are consistent with evidence supporting exercising with peers.[3, 17]
Self‐determination theory describes motivation existing along a continuum, from intrinsic motivation to extrinsic motivation then amotivation.[18] Participants described valuing the physical benefits of exercise (extrinsic motivation), similarly noted by survivors of stroke.[19, 20] For those who do not value exercise, group instructors may consider discussing its benefits during GPT. Competition may be stimulated through exercising with peers; therefore, group instructors should utilize this advantage of GPT over individual physiotherapy.
Participants feeling socially supported in GPT were similar to those reported by hospitalized older adults[21] as well as those undertaking exercise groups for cardiac rehabilitation,[22] terminal cancer,[23] and following lung transplantation.[24] Fostering a supportive environment may enhance the patient experience; therefore, physiotherapists should encourage GPT attendance and socialization (as appropriate) and actively acknowledge physical improvements.
The Social Comparison Theory suggests that people evaluate their abilities by comparing themselves to their peers.[25, 26] Participants who made upward comparisons, with those who they perceived were better than them[26] resulted in motivation to attain the level of their more mobile peers. Downward comparisons were also made with those who they felt were less mobile; these engendered feelings of gratitude and appreciation for their own health and promoted self‐esteem,[26] and have also been reported in other populations including those with spinal cord injury[27] and breast cancer.[28]
Study Limitations
Interviews were not conducted with those who received individual physiotherapy alone, and therefore no comparisons can be drawn regarding their experiences and satisfaction. Those who participated in interviews had already consented to participating in GPT; those who declined GPT were not part of the trial and therefore responses may have some bias. To minimize this bias, the interview guide included questions into positive and negative aspects of group and individual physiotherapy. Although community‐dwelling older adults perceive boredom, intimidation, and potential for injury to be barriers to participation in exercise,[29] future research should investigate why older inpatients decline GPT and methods for improving participation.
CONCLUSION
This study provides new evidence to support GPT for hospitalized older adults. Participants in this study enjoyed GPT and were motivated and supported by their peers. As GPT was valued by hospitalized older adults who participated in this study for its physical and social benefits, clinicians could consider replacing several individual treatment sessions with GPT as part of a weekly treatment schedule.
Acknowledgements
The principle investigator thanks E. Harris, C. Chenneaux, A. Shapiro, D. Kronemberg, R. Roose and B. Doyle‐Jones for running the exercise groups, and also extends her thanks and gratitude to all of the patients interviewed for their time and honesty.
Disclosures: Melissa J. Raymond was supported by an Australian Postgraduate Award scholarship and a Caulfield Hospital Research Trust Projects Grant 2008/2009.
- , , , , , . Personal and environmental factors associated with physical inactivity among different racial‐ethnic groups of U.S. middle‐aged and older‐aged women. Health Psychol. 2000;19(4):354–364.
- , , , . Physical activity preferences of middle‐aged and older adults: a community analysis. J Aging Phys Act. 1999;7(4):386–399.
- , , , . Older adults' preferences for exercising alone versus in groups: considering contextual congruence. Ann Behav Med. 2007;33(2):200–206.
- , , , , . Group versus individual approach? A meta‐analysis of the effectiveness of interventions to promote physical activity. Sport Exerc Psychol Rev. 2006;2(1):19–35.
- , , , , , . A high‐intensity functional weight‐bearing exercise program for older people dependent in activities of daily living and living in residential care facilities: evaluation of the applicability with focus on cognitive function. Phys Ther. 2006;86(4):489–498.
- , , , , , . The value of individual or collective group exercise programs for knee or hip osteoarthritis. Clinical practice recommendations. Ann Readapt Med Phys. 2007;50(9):741–746, 734–740.
- , , , . Circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: a controlled trial. Arch Phys Med Rehabil. 2007;88(8):955–963.
- , , , . A descriptive analysis of physical therapy group intervention in five midwestern inpatient rehabilitation facilities. J Phys Ther Educ. 2000;14:13–20.
- , , , et al. Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence. BMC Womens Health. 2009;9:26.
- . Service improvement and patient experience. Int Emerg Nurs. 2010;18(4):175–176.
- , , . “Mini‐mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.
- , . The Discovery of Grounded Theory: Strategies for Qualitative Research. Mill Valley, CA: Sociology Press; 1967.
- , . Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77–101.
- , . The NVivo Qualitative Project Book. London, United Kingdom: Sage; 2000.
- . A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant. 2002;36(4):391–409.
- , . Rigour and qualitative research. BMJ. 1995;311(6997):109–112.
- , , . How, where and with whom? Physical activity context preferences of three adult groups at risk of inactivity. Br J Sports Med. 2012;46(16):1125–1131.
- , , . Older adults' intrinsic and extrinsic motivation toward physical activity. Am J Health Behav. 2008;32(6):570–582.
- , , , . Qualitative analysis of stroke patients' motivation for rehabilitation. BMJ. 2000;321(7268):1051–1054.
- , , . Exercise perceptions among people with stroke: barriers and facilitators to participation. Int J Ther Rehabil. 2011;18(9):520–530.
- , , , . Interaction between clients and physiotherapists in group exercise classes in geriatric rehabilitation. Adv Physiother. 2009;11(3):145–153.
- , , , . Patients' experience of home and hospital based cardiac rehabilitation: a focus group study. Eur J Cardiovasc Nurs. 2009;8(1):9–17.
- , , , , . Exercise and relaxation intervention for patients with advanced lung cancer: a qualitative feasibility study. Scand J Med Sci Sports. 2012;22(6):804–815.
- , , , et al. Patients' expectations and experiences of rehabilitation following lung transplantation. Clin Transplant. 2014;28(2):252–258.
- . A theory of social comparison processes. Hum Relat. 1954;7(2):117–140.
- . Theory and research concerning social comparisons of personal attributes. Psychol Bull. 1989;106(2):231–248.
- , . Long‐term adjustment to physical disability: the role of social support, perceived control, and self‐blame. J Pers Soc Psychol. 1985;48:1162–1172.
- , , . It could be worse: selective evaluation as a response to victimization. J Soc Issues. 1983;39:19–40.
- , , , . Motivators, barriers, and beliefs regarding physical activity in an older adult population. J Geriatr Phys Ther. 2011;34(3):138–147.
- , , , , , . Personal and environmental factors associated with physical inactivity among different racial‐ethnic groups of U.S. middle‐aged and older‐aged women. Health Psychol. 2000;19(4):354–364.
- , , , . Physical activity preferences of middle‐aged and older adults: a community analysis. J Aging Phys Act. 1999;7(4):386–399.
- , , , . Older adults' preferences for exercising alone versus in groups: considering contextual congruence. Ann Behav Med. 2007;33(2):200–206.
- , , , , . Group versus individual approach? A meta‐analysis of the effectiveness of interventions to promote physical activity. Sport Exerc Psychol Rev. 2006;2(1):19–35.
- , , , , , . A high‐intensity functional weight‐bearing exercise program for older people dependent in activities of daily living and living in residential care facilities: evaluation of the applicability with focus on cognitive function. Phys Ther. 2006;86(4):489–498.
- , , , , , . The value of individual or collective group exercise programs for knee or hip osteoarthritis. Clinical practice recommendations. Ann Readapt Med Phys. 2007;50(9):741–746, 734–740.
- , , , . Circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: a controlled trial. Arch Phys Med Rehabil. 2007;88(8):955–963.
- , , , . A descriptive analysis of physical therapy group intervention in five midwestern inpatient rehabilitation facilities. J Phys Ther Educ. 2000;14:13–20.
- , , , et al. Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence. BMC Womens Health. 2009;9:26.
- . Service improvement and patient experience. Int Emerg Nurs. 2010;18(4):175–176.
- , , . “Mini‐mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–198.
- , . The Discovery of Grounded Theory: Strategies for Qualitative Research. Mill Valley, CA: Sociology Press; 1967.
- , . Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77–101.
- , . The NVivo Qualitative Project Book. London, United Kingdom: Sage; 2000.
- . A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant. 2002;36(4):391–409.
- , . Rigour and qualitative research. BMJ. 1995;311(6997):109–112.
- , , . How, where and with whom? Physical activity context preferences of three adult groups at risk of inactivity. Br J Sports Med. 2012;46(16):1125–1131.
- , , . Older adults' intrinsic and extrinsic motivation toward physical activity. Am J Health Behav. 2008;32(6):570–582.
- , , , . Qualitative analysis of stroke patients' motivation for rehabilitation. BMJ. 2000;321(7268):1051–1054.
- , , . Exercise perceptions among people with stroke: barriers and facilitators to participation. Int J Ther Rehabil. 2011;18(9):520–530.
- , , , . Interaction between clients and physiotherapists in group exercise classes in geriatric rehabilitation. Adv Physiother. 2009;11(3):145–153.
- , , , . Patients' experience of home and hospital based cardiac rehabilitation: a focus group study. Eur J Cardiovasc Nurs. 2009;8(1):9–17.
- , , , , . Exercise and relaxation intervention for patients with advanced lung cancer: a qualitative feasibility study. Scand J Med Sci Sports. 2012;22(6):804–815.
- , , , et al. Patients' expectations and experiences of rehabilitation following lung transplantation. Clin Transplant. 2014;28(2):252–258.
- . A theory of social comparison processes. Hum Relat. 1954;7(2):117–140.
- . Theory and research concerning social comparisons of personal attributes. Psychol Bull. 1989;106(2):231–248.
- , . Long‐term adjustment to physical disability: the role of social support, perceived control, and self‐blame. J Pers Soc Psychol. 1985;48:1162–1172.
- , , . It could be worse: selective evaluation as a response to victimization. J Soc Issues. 1983;39:19–40.
- , , , . Motivators, barriers, and beliefs regarding physical activity in an older adult population. J Geriatr Phys Ther. 2011;34(3):138–147.