PHYSIOTHERAPY CANADA

Oosman et al. Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community 147 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 recognized in the Constitution Act of Canada6 – and tural safety and humility needs to also be adequately sup- Aboriginal is the term used by Statistics Canada and the ported so that they can apply it in the classroom and Truth and Reconciliation Commission of Canada. Indige- school. Diverse teaching approaches must be integrated nous is a general term that refers to Indigenous peoples throughout the curriculum to support the development around the world and is broader than the constitutional of cultural humility skills; this will ensure that Master of and legal definitions of Aboriginal. In this article, we use Physical Therapy (MPT) students are adequately pre- both terms, and we use Métis and First Nations to refer to pared to work with diverse Indigenous and other ethnic these two individual population groups. populations and to develop culturally safe environments in their future practice. Cultural safety in health care is achieved when clients perceive that the care that health care professionals pro- Clinical practicums and experiential learning ap- vide is equitable, respectful, inclusive, responsive, and proaches are highly valued in physical therapy profes- supportive of their individual needs.7 A culturally safe sional programmes and curricula because they enable health environment acknowledges the diverse historical, physical therapy students to apply their classroom learn- economic, and social environments that affect health ing in real-world, clinical situations.19 Building on these outcomes among Indigenous populations,8,9 but it also strengths, we designed a community-based practicum, in requires health care practitioners to be adequately edu- partnership with a Métis community, that was guided cated in providing services that respect this diversity.8 and informed by Métis community priorities, and we in- To achieve cultural safety, health practitioners need to tegrated a backbone of reflective practice and both stu- integrate a cultural humility approach into their profes- dent and community readiness. These unique elements, sional practice. Cultural humility is defined as “a life- we believed, were critical to supporting the students’ pro- long commitment to self-evaluation and self-critique” to fessional development in the areas of cultural humility “redress power imbalances in client-practitioner relation- and cultural safety while they learned in a Métis commu- ships.”10(p. 123) It requires health care professionals to sus- nity context. pend their assumptions about an individual that are based purely on generalizations about their culture, and Our goal was to study whether expanding the clinic look inward to examine where these generalizations and beyond the classroom and into a Métis community assumptions come from.11 would make the students more aware of their own identi- ties and worldviews, how they may be different from In practising cultural humility, practitioners from the those in that community, and how they shape their dominant culture can build on their awareness of their stereotypes and misperceptions of peoples from other own worldviews and engage in a lifelong process of hon- cultures. We believed that this learning would affect the est self-evaluation and self-reflection to examine what quality of care that students provided in their future role they can play in mitigating racism, discrimination, practice. and health inequities.12 Research suggests that diverse teaching and learning strategies beyond the classroom We expected that the students taking part in this Métis are important to support the development of cultural community-based practicum – actively participating in humility among health care professional students, partic- community events, interacting with community mem- ularly when working with Indigenous peoples.13–16 bers, and critically reflecting on their conversations and Explicit steps must therefore be taken in physical therapy experiences – would have a rich learning experience. This training programmes to support students in developing article reveals their perceptions of the impact of this cultural humility skills. practicum on their learning in the area of cultural humil- ity and cultural safety. The School of Rehabilitation Science at the University of Saskatchewan trains approximately 40 physical thera- METHODS pists per year, and it has been taking steps to increase the diversity of its student population.17 For example, the Research team Education Equity Program has been in place since 1996. Our research team consisted of two faculty members Six seats of the 40, or 15%, are designated for Indigenous students; this number represents their proportion of the (SO and SA), two Métis community members (LD, TJR), population of Saskatchewan. However, our students are and five first-year MPT students (JN, JP, LS, MS, KS). Both still predominantly white and middle class. They are less faculty members are non-Indigenous and Western- likely to be exposed to, or be aware of, diverse perspec- trained, and they have experience in community- tives on health and wellness outside the dominant West- engaged Indigenous health research, participatory action ern values and systems of thought (also known as the research, physical therapy, medical anthropology, inter- “Western paradigm”).18 vention research, and mixed-methods approaches to research and evaluation. Both Métis community mem- Similarly, the department’s faculty and staff are non- bers live and work in the community of Île-à-la-Crosse, Indigenous; thus, their professional development in cul- Saskatchewan; speak English, Michif, and Cree; and are

148 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 deeply rooted in their culture and the importance of team members (LD and TJR), thus ensuring that commu- passing on cultural teachings to the next generation. The nity ethical practices were integrated and respected. four of us work collaboratively to honour and privilege the Métis worldview in all elements of research and prac- Participants tice. However, we acknowledge that there are strong All students in the MPT programme at the University power differentials that exist between the academic and the community research team members, and we attempt of Saskatchewan, regardless of what year they are in, are to make Métis perspectives and worldview more visible. made aware of the Métis community-based practicum by the programme’s clinical coordinator. Those who are in- The student researchers were non-Indigenous, and terested in participating in the practicum clearly identify none were participating in the practicum at the time of themselves to the clinical coordinator. To date, six stu- this study. dents have participated in the practicum: four final-year students on a 6-week placement and two middle-year Study design students on a 4-week placement. We refer to these stu- This study was part of a student-team research proj- dents as practicum participants. ect, which was a requirement of the MPT programme. The practicum participants either engaged completely We (SO, SA, LD, and TJR) designed it as an intervention outside a health-based facility – that is, fully in the com- research project, whereby the practicum intervention munity – or engaged in a hybrid community–clinical used a community-engaged approach and incorporated placement (depending on whether a clinical physical several distinct but related factors that we believed were therapist was available in the community). Those partici- critical to its success. The student researchers were sup- pating in a community–clinical placement spent approxi- ported in ensuring that community members who had mately 2 days per week in a health facility (on a helped design and implement the practicum were conventional placement) and the other 3 days participat- engaged at all levels of the research project, thus integrat- ing in community activities. None of the participants ing Métis perspectives and worldview throughout. We in- were Indigenous or had previously visited Île-à-la-Crosse. tegrated four elements that we thought were essential for They were interviewed for this study at the end of their the participants to develop a culturally humble approach placement. to physical therapy practice: (1) community engagement with the practicum community, (2) a student practicum Community built on strong relationships with community and The community of Île-à-la-Crosse is the second oldest informed by community, (3) a backbone of reflective practice, and (4) a base of community and student readi- community in Saskatchewan. It is located 520 kilometres ness. We also built in the time to appropriately prepare northwest of Saskatoon and is situated on the west side the practicum participants to ensure that they would of Lac Île-à-la-Crosse, on the southern peninsula.4,21 The honour and respect the Métis community’s priorities. community was established in 1776 as an outpost for fur traders. French Canadian, English, and Scottish traders Five students self-selected to participate in the study settled in this region and developed intimate and long- as researchers so that they could learn about Indigenous lasting relationships with local First Nations women, health and qualitative health research, and they were su- creating the Métis population and community.22 The pervised by the primary author (SO). They were not in- population of Île-à-la-Crosse in 2016 was 1,295: 26% (345) volved in designing or implementing the intervention, aged 0–14 years, 47% (610) aged 15–49 years, and 26% but they participated in developing the research ques- (345) aged older than 50 years.23 A small proportion of tions and methodology and conducting data collection the population speaks Cree (7%), Dene (2%), and Michif and analysis. The research questions were as follows: (7%), whereas the large majority speaks English (97%).23 What are MPT practicum participant experiences engag- A full 95% of the population identifies as Aboriginal, of ing in a community-based practicum in a Métis commu- whom 18% identify as First Nations and 77% identify as nity and how does this type of practicum support the Métis.22,23 development of cultural humility? The impact of this intervention on MPT student education was explored Île-à-la-Crosse is a welcoming and open community, using phenomenologically descriptive methodology, with one that has developed strong relationships with many data gathered in exit interviews conducted after the prac- departments and colleges at the University of Saskatche- ticum was finished.20 wan through research partnerships and educational op- portunities. Physical therapists have also been keenly Ethics approval was obtained for all project activities welcomed and are respected in the community. from the University of Saskatchewan Behavioural Research Ethics Board (Beh-15-81). Community practices and proto- Our partnership with the community cols were followed, guided by the community research Two of the authors (SO and SA) have well-established relationships with members of the Métis community, which they have cultivated for the past 5 years. These

Oosman et al. Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community 149 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 relationships have been strengthened through research with the community and respecting the community in and collaboration. For example, these authors are carry- general. Emphasis was placed on their commitment to ing out two major research projects with seniors and building relationships in the community and incorporat- youth in the community. Research goals were developed ing the four Rs (respect, reciprocity, relevance, and collaboratively with community partners and focus on responsibility)25 into their practice. (The 4 Rs, originally health promotion across the life span. It is in the context described by Kirkness and Barnhardt, provide a frame- of these research projects, the associated research agree- work for understanding and engaging in Aboriginal ments, and, most important, the relationships in the research and practice ethics from an Aboriginal point of community that the idea of the community practicum view.) As practicum participants in our larger programme was created. of research, their travel and accommodation costs were subsidised by our research grants. We wish to point out that the idea of engaging MPT students in a clinical practicum in this community was The practicum born from dialogue initiated with community partners. The practicum participants were embedded in the They showed a keen interest in supporting the students in their learning and were instrumental in creating space research projects, described earlier, as a starting point for for this to occur. Although the practicum is certainly of engaging in the community. Broadly speaking, they were value to the students, the safety, health, and desires and tasked with building rapport and relationships with com- needs of the community were paramount. munity members while engaging in community events and, when appropriate, collaboratively designing and pi- Preparing for the departure loting mini health-promoting interventions. (Community The practicum participants were prepared in diverse events such as coffee houses, game nights, radio shows, bingo nights, talent shows, Michif festivals, crafting, ways for this northern community-based placement. In school events, school and community recreational activ- the first year of their physical therapy programme, they ities, aquafit, singing, and jigging were often planned and engaged in classroom learning, delivered primarily facilitated by community partners.) The participants through the mandatory Professional Practice 2 course as were given a community-based practicum orientation part of their general MPT programme. A portion of this manual, which included suggestions about whom they course focuses on Indigenous health. Learning was might speak to in the community to kick-start relation- layered throughout this course so that students gained ship building and generate community-driven ideas for knowledge about the history of colonization in Canada health promotion activities. and its impact on health and health care today; racism in the health care system; and how their own personal expe- The two Métis authors (LD and TJR) live in the com- rience, perspective, and awareness of these issues can munity, and they guided the participants in their initial affect their clinical practice. The participants received in- activities. They introduced them to key individuals who class content on cultural competence,1,12 cultural humil- were already organizing health-promoting initiatives in ity,12,16,24 and cultural safety.12 They completed readings the community. The participants could then build on on historical and contemporary Indigenous health care these activities, or they could support the design and issues, were exposed to Indigenous health-related podcasts implementation of new health-promoting activities, and videos, participated in inter-professional problem- guided by the community. based learning modules (titled First Nations Culture, Health and Healing), and heard from First Nations and One activity that was effective in reaching the broad Métis Elder guest lecturers. community promoted relationship building and commu- nity engagement: speaking on the local radio station. Par- Near the end of the course, the participants explored ticipants were invited to explain who they were and what their awareness of Indigenous culture and their perspec- they were doing in the community. Hosting a weekly tives on and biases toward Indigenous health through radio show became a key activity; it enabled the partici- reflective practice assignments and an in-class sharing pants to share health-promoting messages, garner input circle. A Community Health Workshop in the core neigh- from community members, and advertise the health- bourhood of Saskatoon, Saskatchewan, and a Racism in promoting initiatives they had set up. In fact, one pair of the Health System assignment were delivered to the participants initiated an aquafit programme at the final-year students, providing additional background on request of a community member who contacted them the social determinants of health and racism in the after hearing them on the radio. The concept of reciproc- health system. ity and giving back to the community by piloting mini health-promoting interventions was an expectation of All practicum participants received a 6-hour pre- the community practicums. departure orientation outlining their roles, our expecta- tions of them, ethical considerations, methodology, and The participants refined their reflective practice skills, the importance of respecting the pre-existing relationship which are introduced in the first year of the MPT

150 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 programme and developed throughout the programme. they informed the thematic analysis. This approach facili- They were instructed to write about their experiences tated a link among the community-based practicum ex- each day, including their feelings and observations about periences, the literature, and the projected impacts on these experiences, and submit them to their supervisor future practice among the participants, while allowing (SO) each week. SO reviewed these reflections, gave the for unanticipated observations to emerge. The thematic students written and oral feedback, and asked questions analysis was carried out iteratively by JN, JP, LS, MS, KS, for the students to consider. Critical reflection informed and SO. the participants’ professional development, critical think- ing, reflexivity, and learning, and it supported an inner A preliminary categorization process was conducted exploration of their identity and any preconceived as- using the strategy of detailed reading, selecting revealing sumptions they may have held. statements, and identifying representative sentences that revealed the meaning of the text. After individual analysis, The reflective practice component of this practicum is common patterns and themes were identified through critical for developing cultural humility and was thus an iterative discussion, and final themes were agreed on by essential element in its design. Weekly telephone meet- consensus. The list of final themes was brought back to ings between students and their supervisor were held, the larger research team for review. Data analysis was not and students could request a meeting as often as needed. completed until LD and TJR had read and approved the Meetings created space to discuss issues, clarify expecta- themes. Member checking established rigour in the study, tions, answer questions, and give overall support. Stu- ensuring the credibility, dependability, and confirmability dents were encouraged to develop action plans in of the data.27 response to the supervisor’s feedback to stimulate deeper thinking. LD and TJR engaged with the participants per- RESULTS sonally every day and supported them in their commu- The reflections of the practicum participants on their nity engagement activities. experiences in the northern Saskatchewan Métis commu- Data collection nity highlighted areas of learning that supported the The experiences of the practicum participants were development of cultural humility, and they were categor- ized into three main themes: (1) realizing Métis commu- captured in in-depth, semi-structured exit interviews that nity strengths, (2) learning from experiences and shaping took place at the end of the practicum. The interviews future practice, and (3) prioritizing relationships. lasted 45–60 minutes; they were conducted by the five student researchers (JN, JP, LS, MS, KS) and supervised Realizing Métis community strengths by SO. Each participant was interviewed by one student The enhanced knowledge gained by the participants researcher; this approach gave all student researchers the opportunity to conduct at least one interview and to about the structure and strengths of Métis community engage in the different aspects of qualitative research. practices centred on the passing of knowledge from El- ders to others. The community network and the support Before conducting the interviews, an information let- that the individuals give their families and friends was ter was emailed to the practicum participants, and we identified as a strength. One participant noted, “There’s obtained written or verbal consent. The interviews were lots of people who’ve been [living] there forever (for gen- conducted in person or by telephone, as requested by the erations), and they’re just a wealth of knowledge. . . . participants, and they were audio recorded; participants They have so much information, and historical informa- were given the opportunity to review their transcribed tion, especially if you connect with the Elders.” interview. The interview guide (see the Appendix) con- sisted of open-ended questions focused on exploring the Observations such as this suggest that the participants participants’ experiences, including their perspectives on explored in depth the social structures that exist in this the development of their cultural humility and cultural Métis community and recognized the strengths of the in- safety, as well as their learning about Métis perspectives tergenerational interactions and how they support health and ways of knowing and living. The exit interviews were among community members, even though they are dif- intended to capture the key learning elements from the ferent from the participants’ own experiences and com- practicum experience and the reflective practice compo- munity context. Such observations may also suggest that nent of the practicum intervention. Practicum partici- the participants recognized their lack of knowledge of pants received a small honorarium for their participation. Métis culture and the value of spending time with Elders to learn more about what it means to be Métis in this Data analysis community. This recognition of not knowing everything Thematic analysis was driven by a combined a priori about a topic – in this case, Métis culture – is a practice in humility.10 and open coding strategy.26 The concepts of cultural humility and safety were drawn from the literature, and The participants acknowledged the strong relationships along with the themes that emerged from the interviews, and supports in the family structures, and the community,

Oosman et al. Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community 151 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 as important strengths that they had not been fully aware there. . . . And people are really open to sharing their lives of before attending the practicum. For example, two parti- and their stories once they welcome you into their lives. cipants said, “The importance of community, like the role There’s a richness there, there’s a culture there . . . of the family and then extended family. . . . There’s just a amazing things to learn from the people. sense of community for health,” and “Community defi- nitely is structured to support one another . . . that was an These observations support the transformation in think- interesting health-related aspect that I learned while being ing from preconceived, negative notions of Métis people there.” Another participant reported, “It really gave me a and communities to the understanding of strong and good insight into how, I think, Métis communities work resilient Métis people with tremendous capacity for re- and support each other . . . where the grandparents are sourcefulness. responsible for child care.” Learning from experiences and shaping future practice These comments indicate that family and kinship Layering student observations and experiences with structures in the community were observed by partici- pants to be different than what they had initially ex- the demographics and literature on the social determi- pected to see and offer insight into the valuable role that nants of health (all of which were part of the preparation Elders play in teaching younger generations. They also for departure) suggests that the practicum participants reveal the diverse demands placed on the time of a Métis were starting to consider how the social determinants of older adult and Elder, demands that create potential bar- health can have a negative effect on health outcomes riers to engaging in their own health care. These com- among Métis people. This is captured in the following ments are examples of how new learning about the quote: strong interconnections between family members, and the importance of family, can support MPT practicum You start to see the other obstacles that Indigenous participants in future treatment planning when working communities face in terms of food security, or meal with Indigenous populations. planning, and how that’s going to tie into nutrition and growth, obesity, and chronic disease management. You’re Initial preconceived assumptions held by many parti- like, “Well, I can’t even get a tomato.” Or when you get cipants, such as negative stereotypes of the way of life of there and you see poverty . . . and you have somebody Métis community members, were identified as mis- who’s coming to you, but you actually can’t help them guided, leaving participants to reflect on their personal because they need another service provider that’s not biases and assumptions. For example, one participant there, or they don’t have the family support, . . . or they’ve stated, “There was a lot of preconceived notions I had got a priority that’s beyond my understanding. . . . You that were debunked,” and another said, know that those things all exist, but until you’re actually there, you don’t have any concept. I think it’s just kind of breaking down those barriers ’cause you just hear all the negative stereotypes. And actually Although the practicum participants explicitly shared living there and meeting the people first-hand and meeting their experiences and observations of the social struc- the leaders of the community and . . . in terms of assets that tures and interplay of the social determinants of health in they have . . . it just changes your perception of it. the community, they did not explicitly talk about con- cepts of power and privilege in their exit interviews. Per- This inner exploration of personal assumptions and haps some of these ideas were implicit in their realization biases among the participants is one of the first stages in of what community members must overcome to be well developing cultural humility. The participants’ experi- and healthy, or perhaps the participants need repeated ences gave them an opportunity to suspend any assump- exposure and critical reflection to recognize these con- tions they had held about Métis peoples and to view the cepts and reflect on them in their dialogue. community and community members from a new and different perspective than before their practicum. These The participants indicated that being in a northern new-found perceptions will inform the practicum partici- Métis community, where they were immersed for the pants’ future practice in cultural humility. whole of their practicum and could not “escape” to their home, their friends, or their comfort zone, was important The participants also noted the opportunity they had for their learning. One participant noted, “Just being im- to spend time learning about the Métis way of life, in- mersed up there . . . you see the good, and you see the cluding the challenges of living in a northern, rural com- bad. You can’t drive home every weekend to see your munity. They noted the resilience and resourcefulness friends . . . and experiencing the kind of difficulties too” – that the community members have developed. As one suggesting that the participants had to confront chal- participant noted, lenges that they were unfamiliar with. The Northern Saskatchewan that I experienced was Increased awareness was built among the participants nothing short of fantastic, beautiful, amazing, and the about how the social determinants of health affect the people were welcoming once they got used to us being community, how the unique Métis culture supports

152 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 health in the community, and how important it is to Métis context, thus informing their plans for setting up apply these concepts to professional practice. One partic- their future physical therapy practice. ipant reflected that “something you wouldn’t necessarily get anywhere else is seeing the . . . full social determi- Prioritizing relationships nants of health, global view of an individual as well as of The practicum participants began to realize that basic a community.” Another participant realized that human communication and relationship building were [you have the opportunity to see] the physical the basis of any and all interactions in the Métis commu- environment and . . . [the] food options or [the] job nity, as an important way to seek out, and learn from, the options and things. So you can see all of those community members themselves. The participants were encompassing aspects that are largely part of the social required to plan their daily activities on the basis of con- determinants of health. You can physically see them . . . versations, teachings, and events that were community it’s apparent, it’s obvious, it’s there. driven, thus building relationships with community members without the potential imposition of Western- These comments indicate that although the practicum based institutional structures or hierarchies. One partici- participants learned about the social determinants of pant came to realize that health in preparing for their departure, experiencing and learning about the diverse social determinants first-hand when you’re . . . part of somebody’s day to day, they feel had a strong impact on their learning. like they can approach you and ask you questions because you understand. You’ve seen it, so you know what they’re As the participants observed the diverse social deter- living with or what their life looks like. . . . So people begin minants at play in the community, they talked about to trust you, and I think that’s the biggest thing. their discomfort with terminology such as cultural com- petency, which centres on the development of awareness, Relationship building and sharing common experiences knowledge, and skills and implies that practitioners can in a community were valued and linked to creating trust reach a testable endpoint and sense of completion of a with the community members. task.12 For example, one practicum participant said, “I was like, yeah, I’m culturally competent. . . . I can define The participants also acknowledged the deep-rooted the Indian Act, great. Then you go up north and see what relationships that exist in the community and families: the Indian Act actually means.” Although this participant felt culturally competent before engaging in this practi- We would meet an Elder, and then you meet their niece, cum, this quote suggests the realization of a need for and then you meet their child, and then you meet their ongoing learning, reflection and action, all of which are brother-in-law, and then you meet, . . . so you get a wide encompassed in the term cultural humility.10 This sug- scope of a person’s [family life], not only parental heritage gests an increased likelihood that the participants will but also their children. honour a commitment to life-long learning and self- reflection when working with Indigenous populations These comments indicate that the participants ob- and, thus, may be more likely to create culturally safe served the value that the Métis community members health environments in their future practice. place on relationships. The participants talked about how relationships built outside a practitioner–client relation- The practicum participants repeatedly indicated the ship, and at a more human and community level, were important impact of their experiences on the develop- also valuable to their professional development – for ment of their professional practice skills and their future example, “I don’t think my [practice of] cultural compe- practice. For example, one participant indicated, “I feel tence was enhanced through my clinical practice . . . as like it was a very valuable opportunity in terms of being much as it was through my after-hours stuff, like going to able to immerse myself in Indigenous culture. And being community barbeques or going to high school volleyball able to take that forward into my professional career”; games.” another reflected that “without having this experience, planning for discharge for Aboriginal patients going back Several participants described their discomfort with to their Indigenous communities . . . would be 100% com- the freedom of developing their own daily schedule. One pletely different.” These comments suggest that the parti- noted, “We basically designed every day that we were up cipants were starting to practice cultural humility there. . . . We didn’t have a day plan at all; we had to because they were emphasizing the importance of learn- make it ourselves . . . that probably was a little bit of an ing from the community members, who are experts in obstacle.” The participants experienced first-hand that their lived experience,12 in shaping future practice. It is things were done very differently in the Métis community clear that the participants examined current professional than in their familiar, Western, urban clinical context. practices in relation to their experiential learning in a They became more comfortable toward the end of the practicum as they became more familiar with the com- munity and its members and were more engaged in

Oosman et al. Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community 153 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 community activities. Other participants talked about the apply a cultural humility approach. Practising cultural importance of putting themselves out there, leaving their humility in health care is an important first step to in- comfort zone, to maximize their opportunity for meeting forming and enhancing culturally safe health environ- people, building relationships, and learning how to prac- ments that support Indigenous peoples. tise in a more culturally humble way. A sample comment was, An important outcome of this study was the successful transformational learning experienced by the partici- That’s one thing that we’ve tried to do . . . is be out in the pants. Transformative learning has been defined as community, putting on different kind of clinics, being out “learning that transforms problematic frames of refer- to community suppers, putting together different kinds of ence,” such as assumptions, expectations, beliefs, mind- clubs and getting out and meeting people that way. sets and/or worldviews.30(p. 58) (Mezirow suggested that critical reflection on an individual’s assumptions and be- Participating in this unique, community-based practi- liefs is an important element of transformational learn- cum stretched the participants’ comfort level, nudging ing, followed by consciously reasoning and implementing them into situations that they would not encounter in plans to develop new ways of defining the world.30) As classroom or clinical settings. This discomfort may be the participants in this study developed respectful rela- what is needed to create opportunities for transformative tionships with community members and became aware learning and exploring cultural humility. of the strengths of Métis community, culture, health, and wellness, many of their initial assumptions and beliefs DISCUSSION about Métis people were brought into question. Several With this project, we set out to reveal whether a com- participants who initially admitted having negative stereotypes about the way of life and worldview of Métis munity-based practicum in the Métis community of Île- community living later acknowledged that these stereo- à-la-Crosse would enable the participants to develop types were misguided. cultural humility and recognize the need to enhance cul- turally safe approaches to care in their future physical Reflecting on the dichotomy between the participants’ therapy practice when working with Indigenous indivi- preconceived ideas and what they experienced allowed duals. Building on deep-rooted community relationships, them to view the community from a very different, designing the placements with active community engage- strengths-based perspective. This change in perspective ment, and intertwining the participants’ experience with alone provides evidence that the participants were devel- reflective practice ensured a rich, “in the community” oping a culturally humble practice.7,12 They could see the placement. Not only did our data reveal that the partici- value in the roles of diverse community members in the pants’ perspectives of the Métis people, including their health of family members and friends and the importance general health and wellness, were enhanced, we also ob- of community and “relationality.” These are all strong served that applying a cultural humility frame to the foundations of the Métis worldview and lived experience, design of the community-based practicum led to trans- and they gave the participants a different perspective than formational learning, engagement in reconciliation, and what they were familiar with or expecting. a response consistent with developing cultural humility among the participants.28,29 Not only did the participants critically reflect on their pre-existing, problematic negative stereotypes, many also In Canada, a need exists to augment the training of indicated their keen interest in applying their new under- MPT students to develop cultural humility skills as one standing to their personal and professional growth. The way to actively address the racism and discrimination experiences described in their exit interviews, such as that is prevalent in the health care system.1 Cultural those noted earlier, revealed that they could safely cri- humility requires individuals to critically reflect on how tique their own worldview and lived experience and iden- their own perspectives may differ from those of others tify how these could perpetuate preconceived or and to examine their role in the social structures and misguided generalizations about Métis peoples (or Indig- power relations that perpetuate health inequity.10,12 enous peoples as a whole). This critical reflection is a de- Through a process of reflection and self-critique, the par- fining element of practising with cultural humility.10,12 ticipants began to practise cultural humility by acknowl- edging their preconceived ideas of Métis communities The changes in thinking and perceptions that partici- and members. As the participants engaged with commu- pants identified, followed by plans to implement and nity members, they began to acquire new knowledge apply their learning to their future professional practice, about themselves and about Métis culture, health and provides evidence that transformational learning took wellness practices, and worldview. It became clear that a place during these practicums. We believe that this trans- community-based practicum in a Métis community, built formational learning is directly linked to the development on a strong partnership with the community, could cre- of cultural humility and cultural safety and that it was ate the context in which physical therapy students could supported by the four essential elements of the design of the community-based practicum: (1) community

154 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 engagement with the practicum participants, (2) a stu- this study is missing, the opportunity for transforma- dent practicum built on strong relationships with com- tional learning may be lost. munity and informed by community, (3) a backbone of reflective practice, and (4) a base of community and stu- Community and student readiness dent readiness. We suggest that if any one of these ele- This final element is, we believe, critical for nurturing ments is missing, then transformational learning, and the stage for developing cultural humility, may not occur. transformational learning and the development of cul- tural humility among participants. Community readiness, Community engagement defined by the willingness of Métis community members The design and implementation of the Métis to host the participants and guide them in implementing community-driven health-promoting interventions, was community-based practicum were supported and en- required for the success of this project. hanced by our deep-rooted relationships with Métis community members. Indigenous health education con- Student readiness was also essential to ensure that tent must be delivered in ways that respect Indigenous respectful and trusting relationships were maintained worldview and practice. Educators and physical thera- between the participants and community members. Stu- pists must be careful when implementing an Indigenous dent readiness was developed through the diverse pre- health curriculum and content to prevent any further departure activities and through the self-selection pro- harm to Indigenous peoples and their communities. A cess used for recruiting participants. MPT students who recent editorial in this journal highlighted the need to self-selected to participate already demonstrated a keen acknowledge that physical therapists have a responsibil- interest in learning more about cultural humility through ity to collaborate in addressing unmet needs among po- experiential learning in partnership with Métis commu- pulations around the world, including Indigenous nity members. Ensuring a high level of community and peoples in Canada, but we must do so in ways that do student readiness was essential to maintaining the safety, not perpetuate colonial practices and power imbalances, priorities, values, and wishes of the community. which could continue to perpetuate inequity.15 In this study, we collaborated with our Métis community part- An interesting finding was that as participants took ners to deliberately create a safe educational space that part in this unique practicum, some described their ini- honoured Métis knowledge, beliefs, values, and practices. tial discomfort and frustration with being in an unfamil- iar environment and in an unstructured learning Community-informed student practicum situation. They were not able to easily walk away from The practicum was designed with enough flexibility to these feelings or experiences and were forced to recog- nize that they felt uncomfortable. This discomfort was allow the community members to drive most of the parti- foreseen in the practicum design and has been found to cipants’ experiences. We respected Métis community be a critical component of personal transformation.30 perspectives and ensured that the Métis voice, knowl- The participants were given support, in a safe and edge, and worldview emerged and directed participants’ respectful way, to problem-solve their experiences activities, health promoting interventions and experi- through the reflective practice and conversational ele- ences. This, in turn, naturally led participants to apply ments of the practicum and at the same time maintain the four Rs of respect, reciprocity, relevance, and respon- their relationships with community members. This sense sibility while engaging with the community.25 of safety, for both participants and community members, was made possible by the essential community and stu- Backbone of reflective practice dent readiness elements of the practicum design and by The participants’ reflective practice was an essential applying the four Rs. part of their transformational learning experience. They The participants’ discomfort was also a result of being engaged in individual daily reflections but also decon- new to a community and being a minority in a new com- structed their reflections through regular feedback and munity. This, too, is a tremendously valuable experience weekly conversations with SO. The consistent written for trainees because they realized what it might feel like and oral feedback that the participants received was a to not fully understand the environment in which they necessary part of their reflective practice because it al- are living, giving them a glimpse into what some Indige- lowed them to be honest about their own beliefs and as- nous people may feel for much of their lives in the sumptions and created a safe space for them to not only Western-based systems trainees navigate every day. This acknowledge any negative stereotypes but also create an discomfort led to lasting change in the students’ learning action plan to address them. This has been described as a and professional development. first step in practising “allyship” with Indigenous com- munity members.31,32 Again, we believe that if any com- A timely outcome of these community-based practi- ponent of the reflective practice approach as described in cums is that they support reconciliation. As the nation is involved in critical dialogue about how everyone can respond to the Truth and Reconciliation Commission of

Oosman et al. Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community 155 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Canada’s final report, we find that the participants’ experi- sionals and the health care system in general. Addressing ences are aligned with several of the health-specific calls inequitable health outcomes among Indigenous popula- to action.29 Medical, nursing, and physical therapy schools tions requires physical therapy student practitioners to have been called on to help health care students and trai- engage in enhanced training in cultural humility. Profes- nees develop enhanced cultural competence and cultural sional physical therapy programmes place a strong value humility, thereby addressing the problem of cultural safety on clinical placements because they give students an in the health system.29 Realizing the strengths of the Métis opportunity for rich experiential learning that will community and valuing relationship building with its enhance their clinical and professional practice skills. members are steps in practising reconciliation. What this study adds This study had several limitations. First, the results were This study is the first of its kind to explore student based only on the exit interviews for the first six partici- pants who had completed the practicum at the time the practicums in a Métis community. It revealed the value project was undertaken. Further research is required to of giving MPT students the opportunity to develop cul- more fully capture the impact of this type of community- tural humility through experiential learning practicums based practicum on the development of cultural humility in this environment. The design of the practicum in- and safety among MPT students. Second, the fact that stu- cluded four essential elements that were shown to be dents self-selected to participate in these practicums could successful in supporting development of cultural humil- be considered a limitation because they are already identi- ity among MPT students and that should be considered fying and prioritizing Indigenous health as a topic of inter- when developing practicums in partnership with Indige- est; however, we believe that it is a strength because we nous communities. It also suggests that such practicums identified student readiness as an essential element for the are one step that Canadian MPT students and physical success of this type of placement. Finally, the length of time therapy schools can take in practising reconciliation. that participants lived in the community (4 and 6 weeks) might not be long enough to develop trusting and deeper REFERENCES rooted relationships in a Métis community; although more time may strengthen the participants’ transformational 1. Leyland A, Smylie J, Cole M, et al. Health and health care implications learning, this is not always possible within the MPT pro- of systemic racism on indigenous peoples in Canada. Mississauga: gramming and curriculum. Thus, providing MPT students Indigenous Health Working Group of the College of Family with numerous and diverse exposures within Indigenous Physicians of Canada and Indigenous Physicians Association of health contexts should be a curricular consideration for Canada; 2016. MPT programmes. 2. Sasakamoose J, Bellegarde T, Sutherland W, et al. Miyo-pimatisiwin CONCLUSION developing indigenous Cultural Responsiveness Theory (CRT): These Métis community-based practicums demon- Improving indigenous health and wellbeing. Int Indig Policy J. 2017;8 (4). https://doi.org/10.18584/iipj.2017.8.4.1. strated essential elements that support a cultural humil- ity approach to MPT professional development and the 3. Allan B, Smylie J. First Peoples, second class treatment: the role of practice of reconciliation by MPT students. Our results racism in the health and well-being of Indigenous peoples in Canada. highlight the success of (a) community engagement with Toronto: Wellesley Institute; 2015. the practicum participants, (b) a student practicum built on strong relationships with community and informed by 4. Statistics Canada. Aboriginal peoples in Canada: First Nations people, community, (c) a backbone of reflective practice, and Metis and Inuit [Internet]. Ottawa: Statistics Canada [cited 2018 Apr (d) a base of community and student readiness. More- 25]. Available from: http://www12.statcan.gc.ca/nhs-enm/2011/as- over, the results suggest that these key elements set the sa/99-011-x/99-011-x2011001-eng.pdf. stage for supporting MPT students in developing cultural humility skills. Graduating culturally humble physical 5. Morency J, Caron-Malenfant E, Coilmobe S, et al. Projections of the therapy practitioners is one step in decolonizing Cana- Aboriginal population and households in Canada, 2011 to 2036 da’s health care system and creating a more accessible [Internet]. Ottawa: Statistics Canada; 2015 [cited 2019 Jan 4]. and culturally safe health care environment for Indige- Available from: https://www150.statcan.gc.ca/n1/pub/91-552-x/91- nous peoples. 552-x2015001-eng.htm KEY MESSAGES 6. Constitution Act, 1982, being Schedule B to the Canada Act 1982 (UK), 1982, c 11. What is already known on this topic Indigenous populations in Canada often do not expe- 7. Jull JE, Giles AR. Health equity, Aboriginal peoples and occupational therapy. Can J Occup Ther. 2012;79(2):70–6. https://doi.org/10.2182/ rience culturally safe interactions with health care profes- cjot.2012.79.2.2. Medline:29507771 8. Gerlach AJ. A critical reflection on the concept of cultural safety. Can J Occup Ther. 2012;79(3):151–8. https://doi.org/10.2182/ cjot.2012.79.3.4. 9. Doane G, Varcoe C. The hard spots in family nursing: relational practice as connecting across differences. In: Varcoe GDC, editor. Family nursing as relational inquiry: developing health-promoting practice. Philadelphia: Lippincott Williams & Wlikins; 2005. p. 289– 331. 10. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor

156 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Underserved. 1998;9(2):117–25. https://doi.org/10.1353/ 23. Statistics Canada [homepage on the Internet]. Ottawa: Statistics hpu.2010.0233. Medline:10073197 Canada; c2017 [cited 2019 Jan 4]. Census profile, 2016 census: Île-à- 11. Moncho C. Cultural humility, part 1 – what is “cultural humility”? la-Crosse, Northern village [Census subdivision], Saskatchewan and 2013 [cited 2018 Apr 25]. In: The social work practitioner [Internet]. Saskatchewan [Province]. Available from: https://www12.statcan.gc. Available from: https://thesocialworkpractitioner.com/2013/08/19/ ca/census-recensement/2016/dp-pd/prof/details/page.cfm? cultural-humility-part-i-what-is-cultural-humility/. Lang=E&Geo1=CSD&Code1=4718067&Geo2=PR&Code2=47&Data=- 12. Beagan BL. Approaches to culture and diversity: a critical synthesis of Count&SearchText=Ile-a-la-Crosse&SearchType=Begins&- occupational therapy literature. Can J Occup Ther. 2015;82(5):272–82. SearchPR=01&B1=All&GeoLevel=PR&GeoCode=4718067&TABID=1 https://doi.org/10.1177/0008417414567530. Medline: 26590226 13. Hayward LM, Li L. Promoting and assessing cultural competence, 24. King J. Cultural evolution: a case cultural humility [Internet]. Ottawa: professional identity, and advocacy in Doctor of Physical Therapy Canadian Physiotherapy Association; 2014 [cited 2017 Nov 29]. (DPT) degree students within a community of practice. J Phys Ther Available from: https://physiotherapy.ca/cultural-evolution-case- Educ. 2014;28(1):23–36. cultural-humility. 14. Health Council of Canada. Canada’s most vulnerable: improving health care for First Nations, Inuit, and Métis seniors. Toronto: 25. Kirkness V, Barnhardt R. First Nations and higher education: the four Health Council of Canada; 2013. R’s – respect, relevance, reciprocity, responsibility. J Am Indian Educ. 15. Aboriginal Health Initiative Committee. Health professionals working 1991;30(3):9–16. with First Nations, Inuit, and Métis consensus guideline. J Obstet Gynaecol Can. 2013;35(6 Suppl 2):S1–S52. Medline:23870781. 26. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic 16. Cleaver SR, Carvajal JK, Sheppard PS. Cultural humility: a way of analysis: a hybrid approach of inductive and deductive coding and thinking to inform practice globally. Physiother Can. 2016;68(1):1–4. theme development. Int J Qual Methods. 2006;5(1):80–92. https://doi. https://doi.org/10.3138/ptc.68.1.GEE. Medline:27504041 org/10.1177/160940690600500107. 17. Proctor P, Oosman S. Physical therapy students embracing indigenous health curriculum in Saskatchewan. In: Physiotherapy 27. Mayan MJ. Essentials of qualitative inquiry. Walnut Creek, CA: Left practice, Vol. 5, 8. Ottawa: Canadian Physiotherapy Association; 2015. Coast Press; 2016. 18. Smith L. Decolonizing methodologies: research and Indigenous peoples. New York: Zed Books; 1999. 28. Gasparelli K, Crowley H, Fricke M, et al. Mobilizing reconciliation: 19. Wishart LHE, Swinamer J, Miller C. Entry-to-practice physiotherapy implications of the Truth and Reconciliation Commission report for curriculum: content guidelines for Canadian University programs. physiotherapy in Canada. Physiother Can. 2016;68(3):211–15. https:// Canadian Council of Physiotherapy University Programs; 2009. dx.doi.org/10.3138/ptc.68.3.GEE. Medline:27909369 20. Mayan MJ. Chapter 3: method. In: Mayan MJ, editor. Essentials of qualitative inquiry. Walnut Creek, CA: Left Coast Press Inc.; 2009. 29. Canada Truth and Reconciliation Commission. Truth and p. 34–56. reconciliation commission of Canada: calls to action. Winnipeg: The 21. Oosman S, Abonyi S, Jeffery B, et al. Healthy aging in place: Commission; 2015. environmental scan. Ile-a-la-Crosse, SK: University of Regina and University of Saskatchewan, Saskatchewan Population Health & 30. Mezirow J. Transformative learning as discourse. J Trans Educ. 2003;1 Evaluation Research Unit; 2013. (1):58–63. https://doi.org/10.1177/1541344603252172. 22. MacDougall B. Wahkootowin: family and cultural identity in Northern Saskatchewan Metis communities. Canadian Historical 31. Hojjati A, Beavis ASW, Kassam A, et al. Educational content related to Review. 2006;87(3):431. https://doi.org/10.1353/can.2006.0082. postcolonialism and Indigenous health inequities recommended for all rehabilitation students in Canada: a qualitative study. Disabil Rehabil. 2017:1–11. https://doi.org/10.1080/09638288.2017.1381185. 32. Bishop A. Becoming an ally: breaking the cycle of oppression in people. 2nd ed. London: Zed Books; 2002.

Oosman et al. Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community 157 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 APPENDIX: INTERVIEW GUIDE you understood/were exposed to prior to going on placement. SEMI-STRUCTURED INTERVIEW QUESTIONS FOR 4. Has your perspective of Indigenous health changed PRACTICUM PARTICIPANTS since your time in the community-based practicum in a Métis community? 1. Tell us about your experiences in your community- 5. If you had to do this practicum again, what (if any- based practicum in a Métis community. thing) would you change? And would you recom- mend this type of experience to other MPT students? 2. How did your research placement in the community If not, why not? And if so, why? support your clinical and professional practice devel- 6. What would have made this experience better? opment? 7. What do you think the role of physical therapy is in providing culturally safe health care to Northern 3. What aspects of your placement influenced your communities and Indigenous peoples? knowledge of Indigenous health? And influenced 8. Do you have anything else you would like to share your cultural humility and safety skill development? with us? a. Tell me/us something new that you learned on placement in the community that you didn’t feel

Clinician’s Commentary on Oosman et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Cultural safety is a way of interacting with others that re- other reports, including one from Brascoupé and Waters in the quires physiotherapists to be thoughtful, responsive, and hum- Journal of Aboriginal Health in 2009,4 which included recom- ble. It is the outcome of an interaction and can be measured mendations for cultural competency training for professionals only by the person receiving care. It is not something that health who deliver services to Indigenous populations and education care providers can self-determine. Thus, it places a responsibility on the history of Indigenous populations. The results of this for constant self-reflection and ongoing learning in the hands of training and education will begin the process of developing cul- each individual physiotherapist. As a profession, it requires phy- tural safety. siotherapists to work together to foster this competency and demonstrate it through their actions. The way physiotherapists A workforce representative of the population in Saskatche- provide care is as valuable as the clinical skills they perform wan would mean that 15% of physiotherapists in that province because if physiotherapists do not create a safe environment for would self-identify as Indigenous. If this were a reality, it would their clients, they may not come back to see again. contribute to the availability of culturally appropriate care. In this ideal situation, Indigenous physiotherapists would provide In some practice environments, physiotherapists make as- care to Indigenous clients, which would contribute to the reflec- sumptions about why a client did not come back. They label cli- tive process of all providers by providing an Indigenous lens ents non-compliant and place the blame on clients without through which to deliver care. considering for a moment that they might have contributed to the outcome. By integrating students into this project, Oosman Training related to cultural awareness, sensitivity, and com- and colleagues1 allowed students to gain a better understanding petency has been noted in previous work as a strategy for of the realities experienced by Indigenous people in Île-à-la- improving access to health care services for Indigenous popula- Crosse. Although this community has its own individual culture tions.5 More recently, cultural safety and cultural humility have and social structure, many Indigenous communities across Can- become common terms in the health care sector. It is important ada face similar circumstances as a result of colonization. to note that these terms are not interchangeable; rather, they are distinct concepts on a continuum. Cultural competency is the Creating safe spaces for Indigenous people to access health acquisition of knowledge about a group of people. Cultural safety care will occur if physiotherapists can operationalize Call to is the goal of an interaction and can occur only through self- Action 24 from the final report of the Truth and Reconciliation reflection on the part of the provider. Cultural humility is a tool Commission of Canada:2(p. 211) to support the reflective process, and that process was supported by the supervisor in this project. We call upon medical and nursing schools in Canada to require all students to take a course dealing with RELATIONSHIPS Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on In physiotherapy practice, it is important to remember that the Rights of Indigenous Peoples, Treaties and Aboriginal many Indigenous clients lack trust in mainstream systems. The rights, and Indigenous teachings and practices. This will colonial history of Canada has given Indigenous populations require skills-based training in intercultural competency. good reason to be apprehensive and untrusting. The Wellesley Institute published a paper in 2015 that describes this history.6 Oosman and colleagues1 took on a significant role in addressing As health care providers, physiotherapists represent a system this call to action. Immersing physiotherapy students in a Métis created by colonialism and founded on a foreign perspective of community, along with supports to create a safe learning environ- health. As Oosman and colleagues mention, racism and discrimi- ment, created an opportunity for transformational learning. This nation are attitudes that Indigenous people face when they type of learning is needed to shift the deeply rooted colonial biases access health care.1 It is physiotherapists’ responsibility to toward Indigenous people in Canada. However, as the researchers ensure that they demonstrate the competencies and values that identified, their success was likely influenced by the readiness the profession promotes by working to develop safe and trusting already demonstrated by the community and the students. With- relationships with Indigenous clients. out this readiness on the part of each party, there is the potential for harm. As one reflects on the positive outcomes resulting from The Canadian Physiotherapy Association has identified “en- the experiences of the students and the community members, a suring equitable access to physiotherapy” as a priority in its thoughtful assessment on the potential negative impacts must be 2018–2023 strategic plan.7 Equitable access is not only about en- undertaken before recreating this experience for other students suring that people in rural and remote areas have access to and other communities. Some communities will have identified essential physiotherapy services. It is also about ensuring that other priorities to support their members’ health and well-being. any individual requiring support to improve their quality of life can expect to be treated with respect and made an equal partner The Canadian Physiotherapy Association published a back- in developing a treatment plan that meets their unique needs. ground paper called “Access to Physiotherapy for Aboriginal Peoples in Canada.”3 It identifies the lack of culturally appropri- It is up to physiotherapists to create a new experience for ate care for Aboriginal peoples living in Canada and a limited Indigenous people accessing physiotherapy services. Phy- Aboriginal health care workforce as two of the many gaps in siotherapists must create a safe space for every client to have rehabilitative services. This finding is consistent with those of their concerns heard and engage in the process of understanding 158

Clinician’s Commentary on Oosman et al. 159 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 the client’s perspective, values, and beliefs in order to develop Truth and Reconciliation Commission [Internet]. Winnipeg: The an appropriate care plan together. Commission; 2015 [cited 2018 Oct 18]. Available from: https://web- trc.ca/. The students involved in this study demonstrated the willing- 3. Canadian Physiotherapy Association. Access to physiotherapy for ness all physiotherapists must have to engage in a cross-cultural Aboriginal peoples in Canada [Internet]. Ottawa: The Association; experience within the borders of Canada. Creating relationships 2014 [cited 2018 Oct 18]. Available from: https://physiotherapy.ca/ with the community outside the professional role allows people system/files/advocacy/access-to-physiotherapy-for-aboriginal- to learn about physiotherapists as individuals, separate from the peoples-in-canada-april-2014-final.pdf. system in which they work. This is an effective way to build trust, 4. Brascoupé S, Waters C. Cultural safety: exploring the applicability of and it will contribute to an effective therapeutic relationship that the concept of cultural safety to Aboriginal health and community both the physiotherapist and the client can learn from. wellness. J of Aboriginal Health. 2009;5(2):6–41. 5. National Collaborating Centre for Aboriginal Health. Access to health Katie Gasparelli, BSc, PT, MSc Rehabilitation services as a social determinant of first nations, Inuit and Métis Member, Indigenous Health Sub-Committee, Global Health [Internet]. Prince George, BC: The Centre; 2009 [cited 2018 Health Division, Canadian Physiotherapy Association; Oct 18]. Available from: https://www.ccnsa-nccah.ca/docs/ determinants/FS-AccessHealthServicesSDOH-EN.pdf. [email protected]. 6. Allan B, Smylie J. First peoples, second class treatment: The role of racism in the health and well-being of Indigenous peoples in Canada. REFERENCES Toronto: Wellesley Institute; 2015. 7. Canadian Physiotherapy Association. 2018–2023 strategic plan 1. Oosman S, Durocher L, Roy TJ, et al. Essential elements for advancing [Internet]. Ottawa: The Association; 2018 [cited 2018 Oct 18]. cultural humility through a community-based physical therapy Available from: https://physiotherapy.ca/our-mission-and-vision. practicum in a Métis community. Physiother Can. 2018;71(2):xxx–xx. https://doi.org/10.3138/ptc.2017-94. DOI:10.3138/ptc.2017-94-cc 2. Truth and Reconciliation Commission of Canada. Honoring the truth, reconciling for the future: summary of the final report of the

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 EDUCATION Promoting Professional Behaviours in Physical Therapy Students Using Standardized Patient Feedback Mary Anne Riopel, PhD, DPT, PT;* Bini Litwin, MBA, PhD, DPT, PT;{ Nicki Silberman, PhD, DPT, PT;{ Alicia Fernandez-Fernandez, PhD, DPT, PT{ ABSTRACT Purpose: Physical therapy (PT) students receive feedback on their professional behaviours from academic and clinical faculty. Another avenue for providing feedback to PT students is by using standardized patients (SPs). Very little research is available on the impact of SPs’ specific feedback on whether, and how, PT students learn professional behaviour, and what research is available has focused on clinical competencies, communities of practice, and broad assessments of professional behaviours. The purpose of this study was to record PT students’ perspectives on how combined verbal and written SP feed- back affected their professional behaviours. Method: The sample of convenience consisted of seven students enrolled in a PT professional education pro- gramme in the northeastern United States before starting their first full-time clinical experience. The students agreed to participate in an SP experience focused on professional behaviours. This study used a phenomenological approach to understand the students’ perspectives on receiving a combination of verbal and written SP feedback. Results: The students’ perspectives on receiving SP feedback were categorized into four themes: seeing through the pa- tient’s eyes; SPs offer unique contributions to student learning; timely, verbal feedback adds a deeper understanding of professional behaviours in prepara- tion for the clinic; and verbal feedback promotes student self-efficacy of professional behaviours. Conclusions: Using SPs’ written and verbal feedback in the curriculum can be a valuable tool for enhancing the development of PT students’ professional behaviour. Key Words: allied health occupations; education; professionalism; simulation training. RÉSUMÉ Objectif : les étudiants en physiothérapie reçoivent des commentaires sur leurs comportements professionnels de leurs professeurs théoriques et cliniques. Les patients standardisés (PS) sont un autre moyen d’obtenir de tels commentaires. Très peu de recherches indiquent si les étudiants en physiothérapie acquièrent des comportements professionnels après avoir reçu des commentaires des PS et précisent la manière dont ils le font. Les études publiées por- tent sur les compétences cliniques, les communautés de pratique ou les évaluations générales des comportements professionnels. La présente étude visait à consigner si, de l’avis des étudiants en physiothérapie, les commentaires écrits et verbaux des PS avaient une incidence sur leurs comportements profes- sionnels. Méthodologie : échantillon de commodité composé de sept étudiants inscrits à un programme de formation professionnelle en physiothérapie du nord-est des États-Unis avant leur première expérience clinique à temps plein, qui avaient accepté de participer à une expérience de PS axée sur les com- portements professionnels. La présente étude favorisait une approche phénoménologique pour comprendre les points de vue des étudiants à l’égard de la réception d’une combinaison de commentaires verbaux et écrits de la part des PS. Résultats : les chercheurs ont classé les points de vue des étudiants sur la réception des commentaires des PS en quatre catégories : regard des patients; apport unique des PS sur l’apprentissage des étudiants; ajout d’une compréhension plus approfondie des comportements professionnels en préparation à la clinique grâce aux commentaires verbaux; promotion de l’efficacité des comportements professionnels des étudiants grâce aux commentaires verbaux. Conclusion : l’inclusion des commentaires écrits et verbaux des PS dans le programme d’enseignement peut être précieuse pour perfectionner le comportement professionnel des étudiants en physiothérapie. Multiple documents have defined the domains of pro- training, PT curricula may lack explicit instruction in those fessional behaviour for physical therapists around the behaviours, and educators often report that students dem- world; examples include “Professionalism in Physical Ther- onstrate difficulty in the affective domain of learning.4–6 apy: Core Values” from the American Physical Therapy Association (APTA), the Canadian Physiotherapy Associa- Clinical instructors have identified several concerns tion’s Code of Ethics, and the Health and Care Professions with the professional standards demonstrated by PT stu- Council’s “Guidance on Conduct and Ethics for Stu- dents, including inappropriate personal behaviour, inap- dents.”1–3 Although it is important to develop professional propriate interactions with patients or colleagues, behaviours during physical therapy (PT) education and inappropriate responses to feedback, and failure to accept responsibility for unprofessional behaviours.4 In survey From the: *Department of Rehabilitation Sciences, Moravian College, Bethlehem, PA; {Department of Physical Therapy, Nova Southeastern University, Fort Lauder- dale, FL; {Department of Physical Therapy, Hunter College, New York, NY. Correspondence to: Mary Anne Riopel, Moravian College, SMRC 207, 1200 Main St., Bethlehem, PA 18018 USA; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Physiotherapy Canada 2019; 71(2);160–167; doi:10.3138/ptc.2018-04.e 160

Riopel et al. Promoting Professional Behaviours in Physical Therapy Students Using Standardized Patient Feedback 161 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 research of academics, a small percentage of respondents experience, and all their self-assessment scores increased expressed concerns about PT student professional beha- over their pre–SP experience scores.20 viours, such as not taking responsibility and showing non- verbal disrespect for others.6 Although these concerns are SP experiences are grounded in the ability to provide not widespread, all PT students are required to demon- experiential practice of professional behaviours using strate appropriate professional behaviours in the entry- patient scenarios to improve the self-efficacy of the clini- level PT curriculum, and providing direct feedback about cal application.11,21 As defined by Bandura, self-efficacy is professional behaviours is an effective way to facilitate the belief in one’s ability to influence events that affect such behavioural changes. one’s life.22 Kolb’s experiential learning theory, the basis for using SP experiences, describes the ability of learners Providing direct and immediate feedback about pro- to develop in four learning modes: concrete experience, fessional behaviours has been demonstrated to be a pre- reflective observation, abstract conceptualization, and ferred method of student learning in the clinic.7–10 PT active experimentation.23 Although PT students are able educators commonly use standardized patients (SPs) – to move fluidly between these modes, they tend to prefer defined as “simulated . . . or actual patients . . . who have active experimentation, which can be provided during an been trained to depict a patient case in a standardized SP experience.24 manner”11(p. 443) – to teach clinical skills, but little emphasis has been placed on using SP feedback for pro- PT students must develop self-efficacy as they perform fessional behaviours in the academic setting. As of 2009, and apply professional skills in clinical practice.22,25–27 33% of U.S. and Canadian PT programmes were using According to Bandura’s theory of social change, indivi- SPs in some capacity. Although 60% of those programmes duals may be aware of a need to change their behaviour reportedly provided some form of SP feedback after the but lack self-efficacy, which influences their ability to do simulated experiences, there is no consistency in, or so.25 Individuals with higher self-efficacy have been model of best practice for, giving SP feedback to PT stu- shown to exert greater effort, be more motivated, perse- dents.12 Written rubrics are the most commonly de- vere in their actions, and exhibit a strong drive to face scribed method.13–15 challenges.22 SP feedback experiences are enactive, al- lowing students to practice professional behaviours, and A 10-year review of literature published from 1996 to are thus more likely to foster change.28 Enactive experi- 2005 identified 69 studies that focused on the use of SPs ences, in which individuals experience an activity them- in teaching and learning in health care education.16 Of selves, are the most powerful means of improving self- those 69 studies, 55% focused on professional communi- efficacy; this is consistent with Bandura’s theory.28 By cation, although it is unclear how the feedback actually participating in SP experiences that challenge their pro- addressed student communication issues. A 2016 meta- fessional behaviours, PT students can develop self-effi- analysis examining the use of SPs in PT education yielded cacy in those behaviours. 14 articles describing 16 studies;17 10 addressed profes- sional behaviours, and 6 reported providing SP feedback Very little literature in the area of PT describes stu- to students.17 Of those 6 studies, 4 were randomized con- dents’ perspective on using SP feedback to develop their trolled studies emphasizing SP feedback on clinical com- professional behaviour. By applying the experiential petencies, 2 of which examined professional behaviours nature of SP experiences and the impact of feedback on in PT students after receiving SP feedback. self-efficacy, this study aimed to answer the question “How does providing verbal and written SP feedback Lewis and colleagues conducted survey research to influence students’ clinical professional behaviour, from examine PT students’ confidence in their interpersonal the perspective of the students?” Phenomenology was communication skills before and after an SP experience.18 used to understand the lived experiences of PT students After completing the SP case scenario, each student shared who had received verbal and written SP feedback after written feedback with a peer and with the SP. The students their SP experiences.29 The purpose of this qualitative reported an increase in self-confidence after the experi- study, therefore, was to record the students’ perspectives ence. Whether this perceived improvement carried over on how combined verbal and written SP feedback into the students’ clinical experiences is unknown.18 affected their professional behaviours. Hayward and Blackmer sought to develop professional METHODS behaviours in PT students using APTA’s core values1 as a In January 2015, students enrolled in the second year framework. In this study, students were placed in groups of four or five, and one student was randomly selected to of a professional doctor of PT programme in the north- complete a PT evaluation of an SP.19 Written feedback, eastern United States were recruited to participate in this including feedback on professional behaviours, was pro- study. Inclusion criteria required participants to be PT vided to the student assessor by a faculty member, stu- students who had no previous experience with SPs and dent peers, and the SP. The participants completed the had not yet completed a full-time clinical education APTA Core Values Assessment immediately after their SP experience. Participants had participated in part-time

162 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 clinical experiences emphasizing basic skills and patient All participants completed guided journal reflections communication. Of the 44 students in the class, 7 volun- immediately after their two SP experiences and again at teered and provided written informed consent to partici- the end of the first week of their clinical education experi- pate. The participants did not receive an incentive to ence (see Appendix 4 online). Journal reflections during participate in the study, and participation had no impact the first week were intended to explore how the SP feed- on their status in the programme, such as on grades or back may have affected their initial self-efficacy going clinical placements. Institutional review board approval into the clinical environment. Clinical placements oc- was obtained before initiating the study. curred during the next academic semester, 6–12 weeks after the SP experience. The primary researcher (MAR) developed two standar- dized case scenarios with the assistance of both a PT con- A focus group was conducted 4 days after the SP expe- tent expert in the area of clinical simulation and an rience. It was facilitated by an experienced qualitative re- experienced SP educator. The cases were developed to searcher, who was neither associated with the study nor portray individuals with musculoskeletal disorders pre- familiar to the students, using guided open-ended ques- senting to an outpatient clinical setting; the SPs’ re- tions (see Appendix 5 online). The focus group was audio sponses were designed to challenge the student taped with the permission of the students and later tran- participants’ professional behaviours (see Appendices 1 scribed by a research assistant using Sound Organizer, and 2 online). An experienced SP educator recruited and version 1.6.01.05240 (Sony Corporation of America, New provided training for four SPs 1 week before the students’ York, NY). Students were not identified by name during sessions with them. the focus group to ensure anonymity in the transcription. The focus group interview was concluded when the parti- In their training session, the SPs learned how to accu- cipants’ responses provided no new information, indicat- rately portray a case; give students unbiased, verbal feed- ing that data saturation was reached. back on professional behaviours; and use a written scoring rubric on professional behaviours. The written The primary researcher used an inductive process to scoring rubric, the Modified Standardized Patient Satis- initially analyze the narrative data derived from the focus faction Questionnaire (MSPSQ), guided the SPs in giving group transcript and the individual journals.32 Initial codes the students verbal feedback on their professional beha- were developed from each data source and then further viours (see Appendix 3 online). The MSPSQ is a version of analyzed and grouped into categories by individually eval- an SP satisfaction rubric that was developed for use with uating each coded source using Microsoft Excel 2016 (Mi- medical students and then adapted by content experts in crosoft Corporation, Redmond, WA). These categories simulation and PT education.30 It has demonstrated good were examined for meanings and themes by comparing si- internal consistency and agreement in previous research milarities and differences, first in the raw data and then conducted with SPs.31 between the data sources, using a constant comparative method to develop common themes.33 A second experi- The student participants were informed that they enced qualitative researcher (BL) independently verified would obtain a medical history of an SP with an orthope- the trustworthiness of the categories by reviewing the tran- dic diagnosis, but they were unaware that they would scripts and the themes generated from the coded data.32 receive feedback on their professional behaviours. The interviews were conducted in private treatment rooms in The qualitative methodological rigor and congruence a PT clinic. Each student was given 10 minutes to review of findings were examined further using additional the case and 20 minutes to complete a medical history means. The constant comparative approach was used to interview of the SP. Immediately afterward, each student find compatibility between the journal reflections and received individual verbal and written rubric feedback on the focus group data, thus confirming the credibility of their professional behaviours from the SP; the feedback the themes. Using multiple data sources (focus group session lasted 10 minutes. Each student completed the transcripts and journal reflections) provided triangula- process twice, with two different scenarios and SPs in the tion of the data used to generate those themes. The focus same day, with a 10-minute break between sessions. group facilitator (who was not associated with the study) examined the themes and concurred with the findings on The costs associated with the simulated experiences the basis of her focus group interactions, thus enhancing were reasonable because the only monetary requirement the dependability and confirmability of the findings. was to pay the professional SPs; the total expenditure for Rich, thick narratives served to support the themes as re- 8 hours of simulated experiences and 2 hours of SP train- layed from multiple participants and multiple data ing was US$968. Using professional SPs is not mandatory, sources. The primary researcher also used reflective jour- however, and using volunteer SPs would eliminate even naling to minimize potential bias from prior personal ex- this expense.17 We did not use a formal simulation lab, periences with students that may have been introduced which also kept the cost down; this may be important at into the qualitative analysis.32 some institutions.

Riopel et al. Promoting Professional Behaviours in Physical Therapy Students Using Standardized Patient Feedback 163 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 RESULTS bono clinic we don’t get that, and I’m sure [real] patients Four primary themes, which were threaded through- don’t want to really tell us their true feelings because they have to see us again or . . . they don’t want to jeopardize out the data sources, emerged from the data. There was the treatment. . . . We don’t get to know how the patient general agreement in the participants’ narratives, with no felt. apparent outliers. Participant 6 also noted, in a pre-clinical journal reflec- Seeing through the patient’s eyes tion, the unique benefit of receiving feedback from the Following their SP feedback experiences, the student SPs: participants observed the importance of building rela- Both of my SPs gave me constructive criticism that I have tionships with patients, understanding their perspective, never heard before from my classmates or from faculty. and making personal connections with them. Students They were very honest in their evaluations of my expressed in journal reflections that they had gained performance and gave me reasons as to why they scored insight into their patient’s emotions, enabling them to me the way they did. . . . I have never heard how a patient see things from the patient’s perspective and respond that I have been treating has been feeling objectively, so more effectively. As expressed by Participant 3, this was very interesting. I learned so much about how I interact with patients and display my professionalism. [The SP was] able to elaborate in areas that I was lacking. It helped me to realize how I may come off to certain The SP experiences incorporated formative verbal and patients and how important a first interaction can be. . . . I written feedback in what the students perceived as a learned how to approach different types of patients. Some non-threatening environment, seen by them as a vital patients look to [be] very comforted in their interaction, component of the learning process. Participant 6 fur- and I learned approaches to bring me there. ther explained during the focus group, “It’s always a lit- tle stressful hearing about your own performance, but Participant 2 gained insight into her patient’s affect I agreed with everything my SPs said, and it made from the feedback she received, explaining that she had me feel good to know that they felt at ease by my evalu- learned to “better deal with patients’ emotions, such as ation.” the anxiety or nervousness of being in a physical therapy office.” Participant 6 noted that the feedback from the Some students reported in the focus group having re- SP had “made me feel good to know that [the SP] felt at ceived faculty feedback on the clinical aspects of their ease by my evaluation. It is a great feeling when the performance during practical examinations, but no spe- patient is truly comfortable and knows that you care cific information about their professional behaviour. The about them.” SP feedback experience served to close this gap, as ex- pressed by Participant 1, who noted in a clinical journal In their journal reflections during their clinical experi- reflection, ences, students reported that their emotional and psy- chological connections with patients were a significant The standardized patient experience primed me for component of the therapeutic relationship, something interacting with real patients. I was more concerned with they recognized from the SP experiences. Participant 2 the patients’ response to treatment and [the] quality of stated that the SP experience had “made me realize the care they were receiving. I was concerned with doing the importance of not only gathering the information but the best that I can because I sincerely want them to find relief importance of building a relationship with the patient.” or get them back to performing the activities they miss doing. The standardized patient experience was a good Standardized patients offer unique contributions to reminder that we will be interacting with people with real student learning impairments, rather than the staged patient cases acted out by our PT professors in class. The student participants observed the unique contri- bution of SP feedback in relation to other learning techni- Timely verbal feedback adds a deeper understanding of ques such as part-time clinical experiences and practical professional behaviour in preparation for the clinic examinations. As Participant 4 described in a pre-clinical journal reflection, “It was actually nicer to work with Students appreciated participating in the SP experi- someone who you have never met before as it gives a ences and thought that the verbal feedback was a valu- sense of real professionalism and allows for no previous able addition to the written rubric they had received bias to occur.” because the rubric relies on numerical ranking rather than on open-ended narrative comments. Participant 4 Students also reported that the feedback that they had observed in a pre-clinical journal reflection, received from the SPs differed from feedback received from faculty or patients. As Participant 1 commented The SP provided incredibly productive feedback, which during the focus group, included much information that can be taken not only from session to session but as well in future endeavors. I’d say we actually got to hear from the [standardized] patient about our performance. Whereas . . . at our pro

164 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 The information was easy to read via [the rubric], and Students also expressed an increase in self-efficacy more in-depth discussions were helpful in targeting where as they interacted with patients during their clinical ex- the problems were. periences. As Participant 5 shared in a clinical journal reflection, As explained by Participant 1 in a pre-clinical journal reflection, “It was a good test of my professionalism as I think that I have done a good job of making a well since the patients challenged me on certain things. It relationship with most of my patients so far and done a was nice knowing I handled the situation well. I feel even good job of addressing their goals as well as the more prepared to treat ‘real’ patients in the future.” Par- therapeutic goals that I have set for them. I feel confident ticipant 5 also commented in a pre-clinical journal reflec- talking with patients and explaining their pathologies to tion, “I received a lot of useful feedback from both of the them. After the [SP] experience, I felt comfortable in many SP actors with both cases that I will utilize while working aspects of my interview process but also less confident in with real patients in the future, and now at our pro bono other areas. I feel like I have tried to use their feedback in clinic.” the best way I can. In many ways, it made me feel more confidence [sic] of my skills. Students also noted that their improvement between the first and second SP case scenarios was enhanced by DISCUSSION their ability to immediately apply the feedback from the In this study, PT students believed that receiving ver- first SP interaction. Participant 1 commented during the focus group, bal SP feedback along with a written rubric assessment about professional behaviours was beneficial. This bene- I thought that [it was] positive that you get . . . the rubric at fit is consistent with previous findings in the literature the end, and then you’re allowed to look at it, and it . . . about PT students’ experiences with SPs.34,35 Students gives you a visual of, These are the things that I did well, thought that the combination of verbal and written feed- these are the things that I need to improve on, and then back had enhanced their professional self-efficacy, which actually getting to talk with the person . . . and ask, “Okay, carried over into their clinical experiences. After receiving you marked me this on this . . . what did you mean by the SP feedback, students reported an improved ability to [that]?” . . . And then you could do the follow-up interact with patients, specifically gaining an apprecia- questions, which I thought was very helpful. tion for the patient–therapist relationship and the pa- tient’s perspective. Verbal feedback promotes student self-efficacy in professional behaviours The SP feedback also reinforced prior learning and enabled the students to focus on areas that needed The participants described how the SP experiences in- improvement. Branch and Paranjape recognized this by creased their self-efficacy in that they had improved their arguing that the use of feedback as a teaching tool allows ability to display professional behaviours and validated concepts and values from pre-existing knowledge to be them as professional PT students. This was evident in integrated into medical training.36 Branch and Para- both the focus group and the journal reflections. Partici- njape’s argument can be extrapolated to the training of pant 4 stated in a journal reflection, “It was the first time PT students. Our study showed that the heightened self- being actually alone in a room with a patient, feeling like efficacy gained from prior learning had been internalized it’s on us, like we have the power because there’s always and carried over into clinical practice, as evidenced in someone with us [teachers or clinical instructors].” This the students’ reports during their clinical experiences. As expressed sense of self-efficacy was important to this stu- mentioned earlier, very little previous research has ex- dent as she prepared for her clinical experiences. plored students’ perspectives of their self-efficacy in clini- cal placements after SP experiences.19 Increased self-efficacy was also shown by the students’ newfound insight into their strengths and limitations; As noted by Frye and colleagues, two-way communi- they noted increased confidence in interviewing the SPs, cation and learner-centered feedback is beneficial for interacting with patients in general, and finding that their student learning.37 In our study, students reported that prior coursework had, indeed, prepared them for patient combined verbal and written feedback had provided a care in the clinical setting. Participant 3 expressed in a learner-centered approach that enhanced their experi- journal reflection having gained a better perspective on ence, because the verbal feedback complemented and how she appeared to the patient: expanded on the written feedback. Students also com- mented that having an opportunity to apply feedback to I learned that I do have strengths and skills that make me a second case scenario improved their communication, a good interviewer, and this helped to increase my interview skills, and other professional behaviours. confidence. . . . It made me more confident in my interactions. It also made me feel a little bad that Students thought that having two experiential case sometimes I can come off to patients in negative ways, but scenarios challenging their professional behaviours I will improve. affected their ability to positively interact with patients.

Riopel et al. Promoting Professional Behaviours in Physical Therapy Students Using Standardized Patient Feedback 165 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Their narratives revealed that the SP feedback was con- pling may limit the findings’ transferability to other PT structive and authentic, and it prepared them for the professional education programmes. clinical environment through the focus on active experi- mentation. The SP essentially acts as a coach and as an Further research may be beneficial to examine the use educator who works one-on-one with a learner, provides of combined verbal and rubric assessments in varied con- feedback in context, and collaborates with the learner.38 texts. Research exploring the impact of verbal SP feed- Successful learning through coaching draws on a combi- back on professional behaviours at the culmination of an nation of concrete experience (feeling) and active experi- initial clinical experience is recommended to assess the mentation (doing).38 Research with medical students efficacy of this teaching strategy. using coaching found that students requested more spe- cific feedback, compared with more general ratings, dur- CONCLUSIONS ing their clinical rotations.39 The medical students’ Our study designed the SP experiences, including the preferences align with the results of this study, indicating that the PT students preferred the specific, constructive verbal and written feedback, to encourage the PT stu- feedback provided by the SPs.39 dents to develop or enhance their professional beha- viours with the expectation that this experiential learning Moreover, students positively contrasted receiving the would build on previously learned behaviours. The SPs’ SPs’ feedback with their previous experiences in practical verbal feedback supplemented the written rubric assess- examinations with faculty and during part-time clinical ment. Students perceived an increased self-efficacy in education settings, specifically noting the benefit of the their professional behaviours and improved therapeutic SPs’ verbal feedback. Simulated experiences create a dif- interactions with patients, which carried over into their ferent context from the traditional relationship between clinical experiences. Because PT students encounter students and faculty, enabling feedback to be given effec- many challenges to their professional behaviours when tively and developing a learning culture. Learning cul- they enter the complex clinical environment, it is impera- ture, as described by Watling and colleagues, is a means tive that academic programmes prepare them to success- of creating conditions that influence providing feedback fully meet those challenges. Using the combined verbal to learners.40 Students reported that not being graded on and written feedback from the SPs, which focuses on pro- the SP case scenarios was beneficial and non-threatening fessional behaviours in the professional PT curriculum, is compared with testing situations, such as practical exam- a valuable teaching strategy because it enhances the inations, thus affecting how they perceived the feedback. development of professional behaviour from the point of view of the students themselves. Students thought that using SPs was an effective means of receiving feedback about their professional be- KEY MESSAGES haviours in a safe learning environment. Their profes- sional behaviours were purposely challenged through the What is already known on this topic SP case scenarios to enhance development in those beha- Research on the impact of standardized patients’ viours and to re-create the conditions of the clinical envi- ronment. The authenticity of the SP encounters (SPs’) feedback to physical therapy (PT) students on their promoted learning and transfer of professional beha- professional behaviour is limited.18,19 PT students prefer vioural skills to similar or new situations.41 to receive direct, constructive feedback on their perfor- mance.24 Feedback from SPs is most commonly delivered This study had several limitations. First, there are through written rubrics, but there is no standard method potential inconsistencies in the SP feedback and in the for providing it.17 Research on the impact of SPs’ feed- standardization of the SP case scenarios. However, using back on professional behaviour has only been measured detailed case scenarios and having a single SP educator using SPs’ experiences, without investigating its influence train the SPs minimized these limitations. Another limita- on PT students’ professional behaviours during clinical tion is the lack of consistency in the timing of the students’ experiences.17 clinical experiences; some students had a longer period of time between the SP and the clinical experiences, possibly What this study adds affecting learning. A longer or shorter time period could This study adds to the current body of knowledge by influence students’ ability to fully maximize learning from the SP feedback. This variability in timing may also have providing evidence of the impact of combined verbal and influenced the students’ perspectives on their level of written SP feedback on PT students’ professional beha- preparation for the clinic. Finally, a small sample size with viours during clinical experiences. PT students encounter convenience sampling may have resulted in bias, because many challenges to their professional behaviours when the students who volunteered to participate may have they enter the complex clinical environment, so it is been more inclined to seek unique learning opportunities imperative that academic programmes prepare students than those who did not volunteer to participate. This sam- to successfully meet those challenges. This research sup- ports the use of combined verbal and written SP feedback

166 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 to encourage PT students to learn or enhance their pro- Rehabilitation. 2008;15(5):221–7. https://doi.org/10.12968/ fessional behaviour. ijtr.2008.15.5.29234. 19. Hayward LM, Blackmer B. A model for teaching and assessing core REFERENCES values development in doctor of physical therapy students. J Phys Ther Educ. 2010;24(3):16–26. https://doi.org/10.1097/00001416- 1. American Physical Therapy Association. Professionalism in physical 201007000-00003. therapy: core values [Internet]. Alexandria (VA): The Association; 2018 20. American Physical Therapy Association. Core values assessment. [cited 2017 June 2]. Available from: http://www.apta.org/Policies/ Alexandria (VA): The Association; 2013 [cited 2018 July 22]. 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Riopel et al. Promoting Professional Behaviours in Physical Therapy Students Using Standardized Patient Feedback 167 opinion of students? Adv Health Sci Educ Theory Pract. 2008;14 musicians. Med Educ. 2014;48(7):713–23. https://doi.org/10.1111/ (4):534–46. https://doi.org/10.3138/ptc.2018-04.e10.1007/s10459-008- medu.12407. Medline:24909533 9136-0. Medline:18798005 41. Collins A, Brown JS, Holum A. Cognitive apprenticeship: making 40. Watling C, Driessen E, van der Vleuten C, Lingard L. Learning culture thinking visible. Am Educator. 1991;15(3):6–11,38–46. and feedback: an international study of medical athletes and https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 PRIMARY CARE Enhancing Pelvic Health: Optimizing the Services Provided by Primary Health Care Teams in Ontario by Integrating Physiotherapists Sinéad Dufour, PhD, PT;*{{ Amy Hondronicols, PhD, PT;*§ Kathryn Flanigan, MN, NP{ ABSTRACT Purpose: The purpose of this review was threefold: (1) to outline the current landscape of service provision for two common pelvic floor disorders, urinary incontinence (UI) and pelvic organ prolapse (POP); (2) to describe common pelvic floor dysfunctions (UI and POP) and the associated evidence-based, con- servative care; and (3) to present the potential to integrate physiotherapists into inter-professional primary health care teams to optimize the provision of care for these disorders. Method: A literature review was undertaken and a case study was developed to describe evidence-informed conservative care for pelvic floor dysfunctions. Results: A variety of models exist to treat pelvic floor disorders. Physiotherapists and nurses are key care providers, and their scope and care provision overlaps. In Ontario specifically, both nurses and physiotherapists with additional postgraduate training in pelvic floor disorders are integrated into primary health care, but only to a very limited degree, and they are arguably well positioned to leverage their skills in their respective scopes of practice to optimize the provision of pelvic health care. Conclusions: Physiotherapists and nurses are shown to be key providers of effective, con- servative care to promote pelvic health. There is an opportunity to integrate these types of provider into primary care organizations in Ontario; this collabora- tive care could translate into improved outcomes for patients and the health care system at large. Key Words: inter-professional care; pelvic floor dysfunction; pelvic organ prolapse; primary health care; urinary incontinence. RÉSUMÉ Objectif : la présente analyse avait trois objectifs : 1) présenter le paysage actuel des services pour deux troubles courants du plancher pelvien, soit l’incon- tinence urinaire (IU) et le prolapsus pelvien (PP); 2) décrire des dysfonctions pelviennes courantes (IU et PP) et les soins conservateurs fondés sur des don- nées probantes qui s’y associent et 3) démontrer le potentiel d’intégrer les physiothérapeutes à l’équipe interprofessionnelle de soins de première ligne afin d’optimiser la prestation des soins pour ces troubles. Méthodologie : les chercheurs ont procédé à une analyse bibliographique et à une étude de cas pour décrire les soins conservateurs des dysfonctions pelviennes, prodigués en fonction de données probantes. Résultats : il y a divers modèles de traitement des troubles pelviens. Les physiothérapeutes et les infirmières sont les dispensateurs de soins clés; la portée et la prestation de leurs soins se recoupent. En Ontario tout particulièrement, les infirmières et les physiothérapeutes qui ont une formation avancée sur les troubles pelviens sont intégrés à l’équipe soignante de première ligne, mais seulement à un degré très limité, même si on peut avancer qu’ils sont bien placés pour faire valoir leurs compétences dans leurs portées respectives et optimiser la prestation des soins pelviens. Conclusion : il est démontré que les physiothérapeutes et les infirmières sont des dispensateurs clés de soins conservateurs pour la promotion de la santé pelvienne. Il est possible de les intégrer aux organisations de soins de pre- mière ligne en Ontario. Ces soins coopératifs pourraient améliorer les résultats cliniques des patients et de l’ensemble du système de santé. Despite a high prevalence of pelvic floor dysfunctions vide conservative pelvic health care. The purpose of this and the availability of clinical practice guidelines for effec- paper is threefold: (1) to describe the current landscape of tive conservative care, we believe that these conditions are providing care for two common pelvic floor disorders, uri- not managed well at the primary health care level in nary incontinence (UI) and pelvic organ prolapse (POP); Ontario. This perspective is corroborated by the interna- (2) to outline common pelvic floor dysfunctions (UI and tional literature.1,2 Given that primary care providers – POP) and the associated evidence-based, conservative namely, doctors, nurses, and physiotherapists – can pro- care; and (3) to present the potential to integrate phy- vide effective conservative management for many pelvic siotherapists into inter-professional primary health care floor disorders,3–6 organizations with such team members teams to optimize how care for common pelvic floor disor- are potentially well positioned to improve how they pro- ders is provided. From the: *School of Rehabilitation Science; {Faculty of Health Sciences, Department of Family Medicine, McMaster University; §Hamilton Family Health Team, Hamil- ton, Ont.; {The World of My Baby, Milton, Ont. Correspondence to: Sinéad Dufour, School of Rehabilitation Science, McMaster University, 1400 Main St. W, IAHS Rm. 403, Hamilton, ON L8S 1C7; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Physiotherapy Canada 2019; 71(2);168–175; doi:10.3138/ptc.2017-81.pc 168

Dufour et al. Enhancing Pelvic Health: Optimizing Primary Health Care Teams in Ontario by Integrating Physiotherapists 169 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 METHODS tion in primary health care may prevent its progression To determine the current landscape of service provision and may mitigate other health care problems and asso- ciated costs. for common pelvic floor disorders, we undertook a litera- ture review. Specifically, three databases were searched Urinary incontinence (MEDLINE, PubMed, and Google Scholar), and four sepa- UI denotes the involuntary leakage of urine; there are rate searches were performed in each one: (1) urinary incontinence AND conservative AND primary care, (2) pel- three common subtypes – stress, urge, and mixed – for vic organ prolapse AND conservative AND primary care, which conservative management is the recommended (3) urinary incontinence AND conservative AND access, treatment.6 Stress UI, which accounts for 50% of inconti- (4) pelvic organ prolapse AND conservative AND access. Lit- nence cases in Canada, involves the leakage of urine erature that reflected a conservative care approach at the when intra-abdominal pressure increases, such as during primary care level was identified – in particular, a rigorous physical exertion, sneezing, or coughing.4 The primary literature review exploring the provision of continence care mechanism of stress UI relates to suboptimal contractile service from an international perspective, including Can- properties of pelvic floor muscles, which most often ada.7 Recent clinical practice guidelines and systematic re- exhibit weakness, excessive tension, or impaired coordi- views were used to establish a basis for best practices in nation.15,16 treating UI and POP, and a case study was developed to describe how this evidence can be applied to a specific Urge UI involves urinary leakage immediately pre- situation. ceded by, or associated with, a sudden urge to void, and it represents 14% of reported UI. Symptoms of urgency DISCUSSION and frequency usually occur from involuntary contrac- tions of the bladder muscle (detrusor muscle) at the Pelvic floor dysfunction wrong time,17 and urge UI ultimately results from long- The pelvic floor is located at the caudal aspect of the standing overactivity in the detrusor muscle. Behaviours such as frequent, unnecessary voiding to compensate for abdomen; it is composed of the coccygeus muscle and a poorly functioning pelvic floor can establish an overac- the levator ani (pubococcygeus, puborectalis, and iliococ- tive bladder, which often leads to urge UI.9,18 Mixed UI is cygeus) muscles. It, along with ligaments and other con- a combination of stress and urge UI, and it accounts for a nective tissue, supports the pelvic organs (uterus, third of reported cases of UI.4 prostate, bladder, vagina, seminal vesicles, small bowel. and rectum). Although pelvic floor dysfunction affects in- The prevalence of UI in men increases with age – from dividuals across the lifespan, its prevalence is highest 15.5% among those aged 55–64 years to 24% among among adults with female internal sex organs. One of the those aged 65–74 years and 30% in those aged 75 years largest risk factors for pelvic floor dysfunction is the pro- and older.19 Moreover, UI in particular results in a high cess of childbirth. Vaginal birth causes trauma to the pel- economic burden because it is a factor for admitting vic floor,7,8 and additional complications from the use of many older adults to long-term care facilities.13 In addi- forceps are also common.9 Menopause is a risk factor for tion, the Cameron Institute estimates a personal financial pelvic floor dysfunction because of the drop in estrogen, burden of $1,400–$2,100 per year for incontinence.17 and other contributing factors include obesity and chronic coughing.10 Also, many children experience blad- Pelvic organ prolapse der and bowel dysfunction, which accounts for as much POP is defined as a downward movement of the pelvic as 40% of consultations with paediatric urologists.11 organs, which can result in herniation into or through the Of pelvic floor disorders, UI and POP are the most vagina (uterovaginal prolapse) or anal canal (rectal intus- prevalent. Both, however, are underreported because susception and rectal prolapse).20,21 An anterior prolapse many medical professionals believe that the signs and consists of bladder prolapse (cystocele) and uterine pro- symptoms of dysfunction are a normal part of ageing, lapse or vaginal apex (vaginal vault after hysterectomy). A especially after childbirth.12 These conditions contribute posterior prolapse includes the rectal ampulla dropping to social isolation, reduced mobility, a higher risk of falls, into the vagina (rectocele) and may include part of the and reduced quality of life.13 Among women with POP sigmoid colon herniating into the vagina.21 Prolapse is with similar objective measurements, those who are considered to be a neuromuscular condition resulting symptomatic have more depressive symptoms, distress, from trauma from vaginal childbirth and, to a lesser and a poorer quality of life.14 extent, obesity.22,23 Over time, weakness and poor neuro- muscular control through the thorax and pelvis result in With such sequelae of pelvic floor dysfunction, there is a lack of caudal support for the pelvic organs and strain a concomitant increase in using the health care system to to connective tissues, which provide cranial support.20 manage such symptoms medically and surgically. Conse- Ultimately, when support from the uterosacral ligaments, quently, identifying and managing pelvic floor dysfunc- vaginal walls, endopelvic fascia, and perineal membrane fail, prolapse occurs.20

170 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Assessment of pelvic floor dysfunction tings,20 a bladder diary can function as a springboard for An assessment of pelvic floor dysfunction consists of modifying voiding behaviours, changing habits,3 and tracking changes. initial investigations, a subjective interview, and an inter- nal physical examination. In one possible model for a pri- The physical examination includes a pelvic examina- mary health care setting in Ontario, a nurse practitioner tion to evaluate properties of the pelvic floor and pelvic (NP) with additional training in pelvic floor muscle organs.20 A digital examination assesses pelvic muscle assessment would carry out a comprehensive examina- function and typically includes a measure of strength and tion and communicate the results to a physiotherapist, coordination. The strength (power) of a muscle contrac- who would assume responsibility for aspects of evidence- tion is graded from 0 to 5 on the modified Oxford scale, based, conservative care. whereas muscle coordination is assessed by how and when the pelvic floor contracts in response to a voluntary A detailed history (subjective examination) consists of cough.20,27,28 The assessor can provide feedback on the questions about voiding frequency, post-voiding issues,4 quality of the muscle contraction to ensure that the patient fluid intake habits, pelvic girdle pain, obstetrics history, correctly carries out exercises for therapeutic purposes. urogynaecological history, and other sensory informa- Muscles are also palpated for presence of tenderness and tion. Reports of urine leaking during exercise, laughing, degree of muscle tone.29,30 or coughing may indicate stress UI, whereas sudden urgency with or without specific triggers may point to To assess for POP, the individual assumes a crook-lying urge UI. Validated patient questionnaires can assess the position, with the trunk flexed, while propped up on the severity and impact of UI on quality of life, such as the forearms. The individual is then prompted by the assessor Urogenital Distress Inventory and the Incontinence to perform a Valsalva maneuver (hold the breath and bear Impact Questionnaire, Short Form (IIQ–7).24 When POP down) so that the downward mobility of the pelvic viscera is symptomatic, patients may report a vaginal bulge or can be assessed. To determine whether a posterior pro- protrusion, vaginal laxity, heaviness or a dragging sensa- lapse is present, the assessor performs a rectal examina- tion, dyspareunia (difficult or painful intercourse), hesi- tion.31 These examination techniques are described tancy or change in urinary stream resulting from in Table 1. The Pelvic Organ Prolapse Quantification compression of the urethra, feelings of incomplete defe- (POP-Q) is the gold standard for staging prolapse, and the cation or manual removal of stool resulting from hernia- simplified version has near-perfect correlation with the tion of the bowel, recurrent urinary tract infections, and POP-Q.32 The external physical assessment may include nighttime voiding (nocturia).20 examining postural observation, external palpation, core strength and muscle recruitment, and muscle length. Initially, a urinalysis to rule out a bladder infection is important,4 but a bladder diary that covers 24 hours25 or Management of pelvic floor dysfunction 3–7 days3,4,25 elicits valuable information about fre- As we have indicated, evidence-based clinical practice quency, leakage, timing of voids, fluid intake, and bowel movements.19,26 Although rarely used in primary care set- guidelines have been developed to facilitate the delivery Table 1 Pelvic Examination Procedures for Urinary Incontinence and Pelvic Organ Prolapse31 Procedure Description Indicator of musculoskeletal Interrater dysfunction reliability* PERFECT manual P = power; positive test : <4 out of 5 Pelvic floor muscle weakness 0.48–0.77 muscle testing{ 0.17–0.56 E = endurance: time (s) that a maximum contraction can be sustained; Decreased muscular endurance 0.48–0.77 Pelvic floor muscle 0.29–0.65 tenderness positive test : <10 s 0.14–0.53 Identifying pelvic 0.76–0.91 organ prolapse R = repetition: no. of maximum voluntary contractions; Decreased muscular endurance 0.61–0.87 positive test : <10 repetitions F = fast contractions: no. of fast (1-s) maximum contractions; Decreased motor control positive test : <10 repetitions ECT = timing: sustained voluntary contraction with a cough; Pelvic floor muscle discoordination positive test: no contraction before cough26 Firm digital vaginal or anal palpation; positive test : pain28,29 Muscular tenderness, myofascial pain, or both Observing pelvic floor while patient performs Valsalva maneuver in supine; Weakened connective tissues of positive test : visualization of descent of posterior or anterior vaginal wall; uterine, pelvic organs bladder, or rectal descent30 *Reported as k. {Uses the modified Oxford grading scale : 0 = no contraction; 1 = flicker; 2 = weak squeeze, no lift; 3 = fair squeeze, definite lift; 4 = good squeeze with lift; 5 = strong squeeze with lift.

Dufour et al. Enhancing Pelvic Health: Optimizing Primary Health Care Teams in Ontario by Integrating Physiotherapists 171 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 of effective conservative care options for both UI and floor muscles (not just strength) and integrate the func- POP,6,32 using approaches with high and very high de- tion of the deep inner unit core muscles in a synergistic grees of efficacy. Managing UI differs depending on an and functional manner with the outer unit muscles using individual’s signs and symptoms and the impact on the a variety of postures and exercises.35 individual’s quality of life. For stress incontinence, pelvic floor muscle training can help build strength and volun- Current status of inter-professional care tary control. Modifying behaviour to alleviate stress UI in- Significant, high-quality evidence supports the assess- cludes avoiding bearing down during bowel movements and increasing one’s physical activity. Losing weight may ment and conservative management of pelvic floor dys- also reduce the severity of stress UI symptoms. function by both nurses and physiotherapists.1,2,7 In Canada, nurse continence advisors emerged in the 1990s Individuals may be able to effectively manage urge after receiving training in the postgraduate programme incontinence by modifying their behaviour to address administered by McMaster University.36 However, triggers and maladaptive voiding patterns. For example, despite the determined effectiveness of the care provided defensive voiding (urinating “just in case”) can lead to by nurses and nurse continence advisors, these specia- the dysregulation of bladder reflexes and, subsequently, lists have not been widely used in Canada.37 Physiothera- overactive bladder syndrome.16,18 Education and coun- pists have also been key in delivering care for pelvic floor selling techniques to assist in countering such habits and dysfunctions, but little has been written about the char- feelings of urgency reduces the impact of urge UI. Inter- acteristics of their services.7 It has been acknowledged ventions to reduce tone in the pelvic floor muscles include that the care provided by nurses and physiotherapists for manual release, trigger point therapy (internal strategies), continence care overlaps, specifically38 because both diaphragmatic breathing, muscle energy inhibition strate- types of provider engage in collecting a detailed patient gies, and stress reduction (external strategies). history, use bladder diaries, and assess pelvic floor mus- cle function. When the pelvic floor muscles are tight, engaging in training to strengthen the muscles – without paying From an international perspective, a variety of inter- attention to first correcting the resting tone – is likely a professional models have been explored and were de- misguided approach.16 Pelvic floor muscle training is a scribed in detail by Milne and Moor.7 To date, as far as multifaceted approach that moves beyond conventional we are aware, the efficacy of particular models of service “stability” or “core” training because it supports reducing provision have yet to be established, although inter- muscle tone through inhibition pathways, and improved professional models have been advocated.7 Moreover, strength may be indicated after tone is addressed. Thus, after examining continence service provision in primary it is important that clinicians have skills in assessing and care, Shaw and colleagues) concluded that a number of managing presentations along the broad continuum of barriers exist to providing first-line continence care.39 pelvic floor dysfunction. Specifically, these authors found that more than 60% of the family physicians who participated in their study had Enacting conservative care for POP includes lifestyle not received any education related to UI in more than counselling such as weight loss and avoidance of heavy 5 years. Moreover, although these participants offered lifting, providing education to lessen and prevent consti- some lifestyle strategies, there was very little evidence pation, and providing pelvic floor muscle training.32 A that they were provided with any information on pelvic randomized controlled trial showed that one-on-one floor muscle training.39 As such, we propose that in pri- training of the pelvic floor muscles improved endurance, mary care, access to and evidence-based conservative strength, and coordination of the levator ani muscles, management of pelvic floor disorders could be improved which in turn increased structural support for the pelvic by integrating physiotherapists and nurse continence ad- floor.33 A subsequent non-surgical option is the insertion visors into primary health care teams, thereby leveraging of a vaginal pessary; a ring shape has been used success- the existing inter-professional collaboration. fully in more than 80% of women.34 Delivering primary health care Pelvic floor muscle training is important for people Primary health care in Ontario is largely delivered with UI and POP alike, and it consists of more than con- ventional Kegel exercises; key elements are education through community health centres, Aboriginal health about the function of the pelvic floor muscles, their coor- access centres, family health teams (FHTs), and NP-led dination with the other inner and outer unit muscles, clinics (NPLCs). A priority in primary health care is inter- strength training, and building endurance.6 Patients professional care, defined as a comprehensive health ser- learn to activate their muscles first in isolation and then vice provided by multiple caregivers working collabora- by co-activating the core skeletal muscle groups, a move- tively to deliver quality care.40 Inter-professional care ment that fosters a functional use of the pelvic floor con- increases efficiency, improves patient experience and traction. The key principles of pelvic floor muscle outcomes, and is sustainable.40 These four types of teams training address multiple fitness parameters of the pelvic have improved inter-professional care as a consequence

172 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 of an expanded spectrum of care, which includes differ- Because many nurses, NPs, and physiotherapists in ent health care providers paying attention to the needs of FHTs work with populations who have chronic disease, people with chronic conditions.41 The FHT initiative they can identify early those people who are at high risk commenced in 2005, and there are now 184 FHTs serving of pelvic floor dysfunction and translate chronic disease 3 million people in Ontario.42 In NPLCs, the lead provi- self-management principles into treatment. Having a ders are NPs; a physician plays a collaborative role along nurse who specializes in continence care work alongside with a team of other clinicians such as registered nurses, family physicians can also improve detection rates of pel- dietitians, physiotherapists, and mental health workers.43 vic floor dysfunction.23 In such an environment, one cli- The first NPLC opened in 2007, and as of 2017, 25 NPLCs nician with the appropriate postgraduate training can now operate in Ontario.43 identify and assess pelvic floor dysfunction while another supports multimodal conservative management and NPs working in primary health care organizations communication within the patient’s circle of care. improve how evidence-based care is delivered by promot- ing health and preventing disease for individuals, families, On the basis of our clinical experience in FHTs (from and communities.44 In Canada, NPs have the legislative the NP and physiotherapist perspectives), we have seen authority to order and interpret diagnostic tests, perform the ease with which providers who already do internal internal pelvic exams, make and communicate medical pelvic exams can integrate an assessment of the pelvic diagnoses, and prescribe pharmaceutical agents.44 floor and associated tissues after completing brief post- Although NPs already perform internal pelvic exams, these graduate training. Moreover, we have seen how collabo- exams typically do not include assessing or treating the ration with a physiotherapist on the team regarding the pelvic floor and associated tissues. In Ontario, NPs can pelvic floor assessment findings supports the enactment gain this competency by taking additional postgraduate of evidence-based conservative care – for example, by training,45 although, to our knowledge, only a small pro- providing education, counselling on lifestyle issues, and portion of NPs have completed this training. prescribing exercise. A physiotherapist may have more time to devote to these effective therapeutic options than In 2013, the Ministry of Health and Long-Term Care in other members of the team, and this care structure Ontario announced the integration of physiotherapists would increase the resource and economic efficiency of into FHTs. In 2015, the first physiotherapists were hired primary health care.49 We propose that such a collabora- by selected teams to fulfil roles aligned with the greater tive model could also enhance access to treatment for pa- primary health care mandate and to expand access to tients with pelvic floor dysfunction, especially when cost physiotherapy for all Ontarians.46 The entry-level scope is a barrier to accessing private pelvic physiotherapy. of practice for physiotherapists in Canada includes asses- sing and managing muscular, neurological, and cardio- CASE STUDY pulmonary systems as well as giving a diagnosis.47,48 The A case study was developed as an example of how evi- ability to assess and treat the pelvic floor by internal examination is an additional skill performed by phy- dence-based practice can be integrated into collabora- siotherapists who have completed postgraduate train- tion in a primary health care team model. It is presented ing47 and who are rostered with or authorized by the in two parts, highlighting first assessment strategies and appropriate regulatory body.48 According to the list of then management strategies inclusive of collaboration physiotherapists registered with the College of Phy- between the NP and physiotherapist. siotherapists of Ontario (as of March 18, 2018), 810 phy- siotherapists are rostered to perform internal skills, and Ann is a woman aged 56 years with two children. She only 2 of them list employment in a primary health care is seeing the NP at her FHT because her issues with setting. incontinence have become worse. She is post-meno- pausal, with a BMI of 35, and has had constipation for Proposed delivery of inter-professional primary care 10 years. Given their scopes of practice, the efficacy of conser- Part 1 vative management, and their roles in primary health During her assessment with the NP, Ann says that she care settings, nurses and physiotherapists have a mean- ingful opportunity to leverage the collaboration that ex- controls her incontinence by avoiding fluid intake during ists in primary health care teams to enhance the the day. She describes episodes of urgently needing to provision of service for pelvic floor dysfunction; this in- void and occasionally not making it to the toilet in time. cludes improving access to care and delivering evi- She leaks urine when she laughs, coughs, and sneezes. denced-based care. Optimizing service provision means She usually wakes up six times a night to void. Ann has that at least one of the primary care providers on the no extended health benefits. She scores 80.9 out of 100 team would need to have postgraduate training related to on the IIQ–7, which reveals the significant impact of her UI and POP. incontinence symptoms. On objective examination, her pelvic floor muscles have increased tone and are graded

Dufour et al. Enhancing Pelvic Health: Optimizing Primary Health Care Teams in Ontario by Integrating Physiotherapists 173 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 1 out of 5 on the modified Oxford scale. She has a grade 2 KEY MESSAGES cystocele and rectocele. Ann is diagnosed with mixed UI and POP. What is already known on this topic Evidence supports the conservative care strategies for Part 2 Ann is referred to the physiotherapist at the FHT, pelvic floor dysfunctions provided by physiotherapists and primary care providers (family physicians and nurse who suggests a management plan that includes educa- practitioners). tion about the contribution of the pelvic floor muscles to continence and core strength. In the clinic, she learns What this study adds to relax her pelvic floor with diaphragmatic breathing, This study positions the integration of physiotherapists relaxation techniques such as a mindfulness-based body scan to reduce stress, and strategies to address urgency and nurse practitioners into primary health care teams as in the moment. She is also taught to integrate the cor- potentially increasing enactment of evidence-informed rect pelvic floor contraction, which she learned with the conservative care for patients with pelvic floor dysfunction. NP, with other inner unit core muscle contractions. After 4 weeks of practice at home, Ann reports that she REFERENCES gets up only twice in the night to urinate, and she is now confident that she can control feelings of urgency with- 1. Wagg A, Duckett J, McClurg D, Harari D, Lowe D. 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Bettez M, Tu LM, Carlson K, et al. 2012 update: guidelines for adult collaboration and optimize the provision of service for urinary incontinence collaborative consensus document for the pelvic floor disorders. Canadian Urological Association. Can Urol Assoc J. 2012;6(5):354–63. https://doi.org/10.5489/cuaj.12248. Medline:23093627 Our case study describes how a shared care approach helped Ann receive the care she needed with no addi- 5. Thüroff JW, Abrams P, Andersson KE, et al. EAU guidelines on urinary tional cost or duplicated examinations. With only a few incontinence. Eur Urol. 2011;59(3):387–400. https://doi.org/10.1016/j. visits to her NP and physiotherapist, Ann saw improve- eururo.2010.11.021. Medline:21130559 ment in her quality of life. She learned a number of stra- tegies to manage her incontinence, so that she could be 6. Dumoulin C, Hay-Smith EJ, Mac Habée-Séguin G. Pelvic floor muscle proactive and work to maintain her function. training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. The proposed model of conservative care builds on the 2014;2014(5):CD005654. https://doi.org/10.1002/14651858.CD005654. growing recognition of the need to manage chronic condi- pub2. Medline:24823491 tions and to prevent sequelae that affect people’s quality of life. Evidence supports the conclusion that primary care 7. Milne J, Moor K. An exploratory study of continence care services providers, specifically physiotherapists and nurses, can worldwide. Int J Nurs Studies. 2003;40(3):235–47. https://doi.org/ play an important role in successfully assessing and mana- 10.1016/S0020-7489(02)00082-2. Medline:12605946 ging incontinent patients with pelvic floor dysfunction. The existing structure of primary care teams in Ontario is 8. Herbert J. Pregnancy and childbirth: the effects on pelvic floor flexible enough to integrate these types of providers and muscles. Nursing Times. 2009;105(7):38–41. Medline:19326654 thereby provide timely, efficient, and expanded access to and enactment of evidence-informed care. 9. Smith LA, Price N, Simonite V, et al. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childb. 2013;13(59):1–9. https://doi.org/10.1186/1471-2393-13-59. Medline:23497085 10. Tegerstedt G, Miedel A, Maehle-Schmidt M, et al. Obstetric risk factors for symptomatic prolapse: a population-based approach. Am J Obstet Gynecol. 2006;194(1):75–81. https://doi.org/10.1016/j. ajog.2005.06.086. Medline:16389012 11. Dos Santos J, Lopes RI, Koyle MA. Bladder and bowel dysfunction in children: an update on the diagnosis and treatment of a common, but underdiagnosed pediatric problem. Can Urol Assoc J. 2017;11(1–2 Suppl 1):S64–S72. https://doi.org/10.5489/cuaj.4411. Medline:28265323 12. Schüssler-Fiorenza Rose SM, Gangnon RE, Chewning B, et al. Increasing discussion rates of incontinence in primary care: a randomized controlled trial. J Womens Health. 2015;24(11):940–9. https://doi.org/10.1089/jwh.2015.5230. Medline:26555779

174 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 13. Parvaiz M. Improving the care pathway for women with 30. Loving S, Thomsen T, Jaszczal P, et al. Pelvic floor muscle incontinence. Womens Health. 2015;11(2):105–8. https://doi.org/ dysfunction are prevalent in pelvic pain: a cross-sectional 10.2217/WHE.14.83. Medline:25776284 population-based study. Eur J Pain. 2014;18(9):1259–70. https://doi. org/10.1002/j.1532-2149.2014.485.x. Medline:24700500 14. Pizarro-Berdichevsky J, Hitschfeld MJ, Pattillo A, et al. Association between pelvic floor disorder symptoms and QoL scores with 31. Slieker-ten Hove M, Pool-Goudzwaard A, Eijkemans M, et al. Face depressive symptoms among pelvic organ prolapse patients. Aust N Z validity and reliability of the first digital assessment scheme of pelvic J Obstet Gyn. 2016;56(4):391–7. https://doi.org/10.1111/ajo.12467. floor muscle function conform the new standardized terminology of Medline:27135639 the international continence society. Neurourol Urodyn. 2009;28 (4):295–300. https://doi.org/10.1002/nau.20659. Medline:19090583 15. Tulikangas, P. Pathophysiology of incontinence and pelvic floor dysfunction. In: Culligan PJ, Goldberg RP, editors. Urogynecology in 32. Dumoulin C, Hunter KF, Moore K, et al. Conservative management primary care. London: Springer; 2007. p. 34–9. for female urinary incontinence and pelvic organ prolapse review 2013: summary of the 5th International Consultation on 16. Rosenblatt PL, Elkadry E. Diagnosing incontinence and pelvic floor Incontinence. Neurourol Urodyn. 2016;35(1):15–20. https://doi.org/ problems: an efficient, cost-effective approach for primary care 10.1002/nau.22677. Medline:25400065 providers. In: Culligan PJ, Goldberg RP, editors. Urogynecology in primary care. London: Springer; 2007. p. 40–59. 33. Hagen S, Stark, D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a 17. Cameron Institute. The impact of incontinence in Canada: a briefing multicentre randomised controlled trial. Lancet. 2014;383(9919):796– document for policy-makers [Internet]. Peterborough, ON: Canadian 806. https://doi.org/10.1016/S0140-6736(13)61977-7. Continence Foundation; c2014 [cited 2018 Jan 9]. Available from: Medline:24290404 http://www.canadiancontinence.ca/pdfs/en-impact-of- incontinence-in-canada-2014.pdf. 34. Bordman R, Telner D. Pessary insertion: choosing appropriate patients. Can Fam Phys. 2007;53(3):424–5. Medline:17872675. 18. Khullar V. Patient-reported outcomes and different approaches to urinary parameters in overactive bladder: what should we measure? 35. Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk Int Urogynecol J. 2012;23(2):179–92. http://doi.org/10.1007/s00192- stabilization. Man Ther. 2004;29:9(1):3–12. https://doi.org/10.1016/ 011-1526-9. Medline:22011932 S1356-689X(03)00131-0. Medline:14723856 19. Diokno AC, Estanol MV, Ibrahim IA, et al. Prevalence of urinary 36. Skelly J, Kenny K. The impact of the continence nurse advisor on incontinence in community dwelling men: a cross sectional continence care. Clin Eff Nurs. 1998;2(1):4–8. https://doi.org/10.1016/ nationwide epidemiological survey. Int Urol Nephrol. 2007;39(1):129– S1361-9004(98)80076-9. 36. https://doi.org/10.1007/s11255-006-9127-0. Medline:17086446 37. Borrie M, Bawden M, Speechley M, Kloseck, M. Interventions led by 20. Dietz HP. Pelvic organ prolapse: a review. Aust Fam Physician. nurse continence advisors in the management of urinary 2015;44(7):446–52. Medline:26590487 incontinence: a randomized controlled trial. CMAJ. 2002;166 (10):1267–8. Medline:12041843 21. Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ 38. Frahm J. The role of the physical therapist in incontinence: prolapse. Obstet Gynecol. 1996;88(3):470–8. https://doi.org/10.1016/ innovation and communication to improve patient care. Ostomy 0029-7844(96)00151-2. Medline:8752261 Wound Manage. 1998;43(1):47–53. Medline:9087065 22. Rodriguez-Mias NL, Martinez-Franco E, Aguado J, et al. Pelvic organ 39. Shaw C, Atwell C, Wood F, Brittain K, Williams K. A qualitative study prolapse and stress urinary incontinence, do they share the same risk of the assessment and management of urinary incontinence in factors? Eur J Obstet Gynecol Reprod Biol. 2015;190:52–7. https://doi. primary care. Fam Pract. 2007;24(5):461–7. https://doi.org/10.1093/ org/10.1016/j.ejogrb.2015.04.015. Medline:25984809 fampra/cmm041. Medline:17670805 23. Albers-Heitner P, Berghmans B, Joore M, et al. The effects of 40. Interprofessional Care Steering Committee. Interprofessional care: a involving a nurse practitioner in primary care for adult patients with blueprint for action in Ontario [Internet]. Toronto: Health Force urinary incontinence: the PromoCon study (promoting continence). Ontario; 2007 [cited 2018 Mar 28]. Available from: http://www.ontla. BMC Health Serv Res. 2008;8:84. https://doi.org/10.1186/1472-6963- on.ca/library/repository/mon/18000/276214.pdf. 8-84. Medline:18412964 41. Dufour SP, Brown J, Lucy SD. Integrating physiotherapists within 24. Uebersax JS, Wyman, JF, Shumaker SA, et al. Short forms to assess life primary health care teams: perspectives of family physicians and quality and symptom distress for urinary incontinence in women: the nurse practitioners. J Interprof Care. 2014;28(5):460–5. https://doi. Incontinence Impact Questionnaire and the Urogenital Distress org/10.3109/13561820.2014.915210. Medline:24797363 Inventory. Neurourol Urodyn. 1995;14(2):131–9. https://doi.org/ 10.1002/nau.1930140206. Medline:7780440 42. Ministry of Health and Long-Term Care. Family health teams [Internet]. Toronto: The Ministry; c2009–2017 [cited 2017 Oct 23]. 25. Naoemova I, De Wachter S, Wuyts FL, et al. Reliability of the 24-h Available from: http://www.health.gov.on.ca/en/pro/programs/fht/. sensation-related bladder diary in women with urinary incontinence. Int Urogynecol J. 2008;19(7):955–9. https://doi.org/10.1007/s00192- 43. Association of Ontario Health Centres. Nurse practitioner-led clinics 008-0565-3. Medline:18235981 [Internet]. Toronto: The Association; n.d. [cited 2017 Oct 23]. Available from: https://www.aohc.org/nurse-practitioner-led-clinics. 26. Rosenberg MT, Newman DK, Tallman CT, et al. Overactive bladder: recognition requires vigilance for symptoms. Cleve Clin J Med. 44. College of Nurses of Ontario. Nurse practitioner [Internet]. Toronto: 2007;74(Suppl 3):S21–9. 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Available from: https://opa.on.ca/wp-content/uploads/2015/12/ Physiotherapists-Primary-Health-Care.pdf. 29. Bo K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2005;85(3):269–82. Medline:15733051. 47. Canadian Physiotherapy Association. Description of physiotherapy in Canada [Internet]. Ottawa: The Association; 2012 [cited 2017 Oct 23].

Dufour et al. Enhancing Pelvic Health: Optimizing Primary Health Care Teams in Ontario by Integrating Physiotherapists 175 Available from: https://physiotherapy.ca/sites/default/files/ urinary incontinence in primary care in the Netherlands. PLoS One. site_documents/dopen-en.pdf. 2015;10(10):e0138225. https://doi.org/10.1371/journal.pone.0138225. 48. Physiotherapy Act of 1991. S.O. 1991, c. 37. Consolidation period: Medline:26426124 from Sept 1 2011 to the e-Laws currency date. https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 49. Holtzer-Goor KM, Gaultney JG, van Houten P, et al. Cost- effectiveness of including a nurse specialist in the treatment of

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 PRIMARY CARE Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project Sarah Oosman, BScPT, MSc, PhD;*{ Garnette Weber, BScPT;{ Morenike Ogunson, BPhysio, MPH;x Brenna Bath, BScPT, MSc, PhD, FCAMPT * ABSTRACT Purpose: Our aim was to reveal client and provider perspectives on the impact of enhancing access to physical therapy services in a primary health care community-based setting. Method: Clients of The Lighthouse Supported Living facility in Saskatoon, Saskatchewan, who accessed physical therapy ser­ vices over a 4-month pilot period and health care providers (physical therapists and a nurse practitioner) provided qualitative data (through interviews and an online discussion board). Client demographics, health condition, perceived function, quality of life, and satisfaction were obtained through chart review and questionnaires. Results: Forty-seven clients ranging in age from 21 to 72 years (mean 47 y) participated in the pilot project. Most presented with a musculoskeletal issue (85.1%). Analysis of the qualitative data gathered from client and provider participants revealed the following four overarching themes: (1) complex health challenges, unmet needs; (2) overcoming access barriers and impact of physical therapy services; (3) respecting and respond­ ing to context and environment; and (4) moving forward to enhance access to physical therapy care. Conclusions: Individuals experiencing homelessness and poverty face diverse barriers to accessing physical therapy services, including transportation, cost, wait times, and geographical location. Clients who accessed physical therapy services at The Lighthouse perceived a positive impact on their overall health, function, and wellness. Key Words: health care quality, access and evaluation; health equity; homeless persons; primary health care; social determinants of health; qualitative research. RÉSUMÉ Objectif : révéler les points de vue des clients et des dispensateurs de soins sur l’amélioration de l’accès aux services de physiothérapie dans un établissement communautaire de soins de première ligne. Méthodologie : Les clients de l’établissement Lighthouse Supported Living de Saskatoon, en Saskatchewan, qui ont eu accès à des services de physiothérapie dans le cadre d’un projet pilote de quatre mois et les dispensateurs de soins (des physiothérapeutes et une infirmière praticienne) ont fourni des données qualitatives (dans un contexte d’entrevues et de babillard en ligne). L’information sur la démographie, l’état de santé, la fonc­ tion perçue, la qualité de vie et la satisfaction était tirée des dossiers et des questionnaires. Résultats : quarante-sept clients de 21 à 72 ans (moyenne de 47 ans) ont participé au projet pilote. La plupart avaient un problème musculosquelettique (85,1 %). L’analyse des données qualitatives fournies par les clients et les dispensateurs participants a fait ressortir quatre thèmes dominants : 1) problèmes de santé complexes, besoins non satisfaits; 2) conquête des obstacles à l’accès et retombées des services de physiothérapie; 3) respect du contexte et de l’environnement et adaptation à ces caractéristiques; et 4) maintien pour amé­ liorer l’accès aux soins physiothérapiques. Conclusion : les personnes en situation d’itinérance et de pauvreté affrontent divers obstacles pour accéder à des services de physiothérapie, y compris le transport, le coût, les temps d’attente et le lieu géographique. Les clients qui ont obtenu des services de physiothérapie au Lighthouse ont perçu un effet positif sur leur santé, leur fonctionnement et leur bien-être globaux. Many communities, health professionals, and health Housing as a social determinant of health affects authorities face the challenge of providing equitable diverse aspects of an individual’s development and health services to people living in a low socioeconomic ability to achieve optimal health.1,5,6 Approximately status environment. Diminished access to health care 235,000 Canadians (0.7%) are estimated to experience services can influence health and is negatively com- homelessness in a year.3,6 In Saskatoon, Saskatchewan, pounded by the overwhelming impact of the social deter- approximately 0.2% of the population (450 people) self­ minants of health.1 Individuals living in poverty, reported being homeless in 2015,7,8 45% of whom iden­ particularly those who experience homelessness, are tified as Indigenous.7 In Canada, the term Aboriginal among the most vulnerable populations in society.2–4 has historically been used to describe three distinct From the: *School of Rehabilitation Science, College of Medicine; {Saskatchewan Population Health and Evaluation Research Unit; x School of Public Health, Univer­ sity of Saskatchewan; {Saskatchewan Physiotherapy Association, Saskatoon, Sask. Correspondence to : Sarah Oosman, School of Rehabilitation Science, University of Saskatchewan, 104 Clinic Pl., Health Science Bldg., Saskatoon, SK S7N 2Z4; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Physiotherapy Canada 2019; 71(2);176–186; doi:10.3138/ptc.2017-85.pc 176

Oosman et al. Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project 177 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 groups of First Peoples, including First Nations, Inuit, Saskatoon Health Region (SHR) recognized the complex and Métis, as recognized by the Constitution Act of health care needs and high rates of emergency depart­ Canada.9 Currently, Indigenous is the preferred collec­ ment visits by residents of The Lighthouse, and it re­ tive term inclusive of Indigenous peoples globally and sponded by providing temporary funding for a part-time, is broader than the constitutional and legal definitions on-site nurse practitioner, a registered psychiatric nurse, in Canada. In this article, we use Indigenous when a special care aid, and paramedics.34 referring to any Aboriginal group in Canada and Aboriginal when referencing the literature. We use A great need for an on-site physical therapist was iden­ Métis and First Nations when referring to those popula­ tified by the nurse practitioner and strongly supported by tions specifically. The Lighthouse’s general manager and addictions council­ lor. The Canadian Physiotherapy Association (CPA) recog­ Homeless individuals have poorer health outcomes nizes the value of providing a primary care physical than the general population, and they often experience a therapist, but funding was not provided by the SHR to disproportionate burden of health challenges.2,3,10,11 support this additional clinician. The nurse practitioner Chronic health conditions such as diabetes, musculoskeletal contacted the Saskatchewan Physiotherapy Association disorders, hypertension, and chronic obstructive pulmonary (SPA) in December 2015 about this need, and, in response, disease are prevalent among homeless adults.2,3 Adults who the SPA partnered with a local private clinic (CBI Health experience prolonged homelessness have age- and sex- Group) to conduct a pilot project in which the clinic standardized mortality rates that are approximately three to would “donate” four physical therapists to provide health five times higher than those of the general population.12–15 care services to residents of The Lighthouse once a week Given this high disease burden and the higher morbidity for approximately 4 months. and mortality rates, providing enhanced access to primary and preventive services, including physical therapy, is there­ The objective of this pilot project was to determine the fore critical for this population.16–20 value of providing enhanced access to physical therapy services in a community-based primary health care set­ Primary health care attempts to bring community- ting. This project aimed to explore (1) the perceptions of based health care services to a broader range of indivi­ The Lighthouse residents of the influence of enhanced duals across diverse socioeconomic levels. This approach access to physical therapy on their overall function and is defined as a person’s first point of contact with the health and (2) the perceptions of the health care provi­ health care system, and the goal is to provide improved ders (physical therapists and nurse practitioner) of the access to health care in the community, focusing on value of integrating physical therapy into the on-site health promotion and injury prevention.21 By focusing health care services offered at The Lighthouse. on improving patients’ access to needed care and ensur­ ing that their health needs are being met in timely, mean­ METHODS ingful, and efficient ways, primary health care models often mitigate access challenges while attenuating down­ SPA and project partnership stream health care costs.22–24 The SPA, a branch of the CPA, is the provincial profes­ Physical therapists are primary health care profes­ sional association, and it represents more than 400 mem­ sionals who can support health promotion interventions, ber physical therapists in Saskatchewan. Its mandate is to as well as the treatment and prevention of injury and dis­ advance the delivery of physical therapy services among ease, at both the individual level and the community diverse populations in Saskatchewan. Its vision is to be level.25,26 When people have timely access to community- the collective voice for physical therapy in Saskatchewan, based, primary health care physical therapy and rehabili­ with a commitment to promoting the profession; foster­ tation services, it can result in positive health outcomes ing excellence and innovation in practice, education, and and cost effectiveness,26 reduce the number of emergency research; and advocating for equitable access to physical visits,27 reduce the length of hospital stay, and extend the therapy services for the population. SPA activities main­ length of time that an individual can remain independent tain strong relationships and communication among with a high quality of life.26,28–32 physical therapy members and clinics. In Saskatchewan, unfortunately, physical therapists After it was approached by the nurse practitioner from are not currently part of inter-professional primary The Lighthouse, the SPA sent out a request to members health care teams; this situation leaves a gap in health who might volunteer their services. CBI Health Centre re­ care access for individuals experiencing homelessness sponded to the request and donated physical therapists and poverty. The Lighthouse Supported Living is a non­ and hours to this initiative, thus commencing a partner­ profit housing provider that offers emergency shelter, ship among the SPA, The Lighthouse, and CBI Health supportive living, and affordable housing in Saskatoon; it Centre. provides housing, food services, and employment in a supportive community for anyone in need.33 In 2015, the

178 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Evaluation team treating the more complex health conditions that were All four authors were involved in the evaluation of this anticipated among the client participants. One mentor physical therapist had 20 years of private, orthopedic pilot project, and all are physical therapists. Two authors clinical experience, and the second mentor physical ther­ (SO, BB) serve as board directors on the SPA Board and apist had 10 years of public, primarily cardiorespiratory one author (GW) is a project manager with the SPA. Two and neurology clinical experience. This second public of them (SO, BB) are also on the faculty of the School of practice mentor physical therapist had experience work­ Rehabilitation Science at the University of Saskatchewan, ing with homeless individuals and those living in poverty and they bring experience in Indigenous health, access to through her experience working at a local inner-city health care services, cultural humility, community engage­ hospital. The part-time, on-site nurse practitioner was in­ ment, and mixed-methods approaches to research and volved with all aspects of this project, including coordina­ evaluation. One author (GW) is an independent consul­ tion of physical therapy treatment sessions with the tant, and one (MO) is a graduate student who brings an client participants and was also identified as a provider international lens to the work. This diversity of perspec­ participant. Provider participants and mentor physical tives and experience was a strength of this evaluation. therapists shared their perspectives through an online focus group discussion (described later). The Lighthouse The Lighthouse provides long-term supported hous­ Study design This study was designed as a pre-session–post-session ing, an emergency shelter for women and men, and indi­ vidual emergency beds. The reasons why clients access (in this case, a physical therapy treatment session) single- emergency shelter include evictions, financial challenges, group design in a programme evaluation context. It was concurrent disorders, domestic challenges, and addic­ reviewed by the Research Ethics Board at the University tions. The Lighthouse offers a safe place for them to sleep of Saskatchewan and met the requirements for ethics and store their belongings, and it provides a range of sup­ exemption because it focused on programme evaluation. ports for finding employment and securing safe long- It was conducted in compliance with the institutional term housing. It also offers affordable living suites, where ethics board’s standards. Consent for participation in this individuals who can live independently, but who require project was obtained from all participants. The Light­ some assistance, can have a safe and sustainable place to house management approved the implementation and live and call home. Finally, it provides a Stabilization evaluation of this pilot project. Unit – a supervised, secure place to sleep for those under the influence of drugs or alcohol. Clients of The Light­ Data collection and measures house have access to regular meals and an on-site coun­ A total of 47 client participants volunteered for this sellor, nurse practitioner, and support staff. pilot project. Quantitative data report on all 47 partici­ Participants pants, whereas qualitative data were drawn from a sub- All The Lighthouse residents had access to the primary sample of these individuals. health care team located there. Residents self-referred to Quantitative measures physical therapy services or were referred to physical ther­ For each client participant, demographic information, apy services by the on-site nurse practitioner. Posters were placed throughout the facility, and an information sheet health condition, and number of visits were collected about accessing physical therapy services was placed in from a chart review (de-identified) completed by the on- the mailboxes of all residents. The nurse practitioner pro­ site physical therapists. Pre- and post-session data were vided regular health care services to residents who self- collected after each session using the EuroQOL Five- referred or were referred by other staff, and she made reg­ Dimension questionnaire (EQ-5D-5L),35 the Patient- ular visits to residents’ apartments. She had been provid­ Specific Functional Scale (PSFS),36 and a modified Visit- ing these services for several months before the project Specific Satisfaction Instrument (VSQ-9).37 Responses to began, and she referred the highest priority residents to the pre-session questionnaires were obtained verbally from the physical therapy services. The residents who chose to the client participants, with provider participants recording access them were identified as client participants. responses directly on the questionnaires. Responses to the post-session questionnaires were obtained verbally from Provider and mentor physical therapists volunteered the client participants by the nurse practitioner. for this study. Four provider physical therapists were do­ nated by a CBI Health Group, Saskatoon, clinic and pro­ The EQ-5D-5L is a simple, self-administered instru­ vided hands-on services at The Lighthouse Supported ment that assesses health-related quality of life in five Living facility. These provider physical therapists were socially relevant domains: mobility, self-care, usual activ­ new graduates in their first 3 years of practice. Two vol­ ities, pain–discomfort, and anxiety–depression.35,38 The unteer mentor physical therapists provided mentorship PSFS is a measure that allows clinicians and patients to to the provider participants as a way to support them in focus on patient-specific activities that are difficult to

Oosman et al. Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project 179 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 perform.36 Participants identify personally important ac­ transcript of the discussion was downloaded from the tivities that are difficult to complete and rate their ability itracks software for use in analysis. to complete them on a scale ranging from 0 to 10.36 Patient satisfaction was measured using the VSQ-9,39 Data analysis modified for use in a physical therapy practice context.37 Quantitative data were analyzed using IBM SPSS Sta­ Qualitative measures tistics for Windows, version 22.0 (IBM Corporation, Ar­ Semi-structured interviews were conducted by a mem­ monk, NY) to develop a descriptive analysis of all the demographic and baseline measures. Available posttest ber of the research team in a private area. All client partici­ measures included frequencies and valid percentages for pants were invited to participate in a one-on-one semi- categorical variables and means and standard deviations structured interview lasting 15–45 minutes, although only for continuous variables. The EQ-5D-5L scores were ad­ seven participants chose to do this. Each interview was justed on the basis of utility weights available for a sam­ conducted using itracks interview software (itracks, Saska­ ple of the Canadian general population.35 toon, SK), with questions presented on a computer screen and read aloud. Responses to closed-ended questions Qualitative data were analyzed using thematic analysis were recorded on the computer and open-ended ques­ of the transcribed data. The thematic analysis was carried tions were audio recorded using the software. Audio re­ out iteratively by SO, MO, and BB. A preliminary categori­ sponses to each question could be replayed, deleted, and zation process was conducted using the strategy of de­ re-recorded if the participant chose. Audio recordings tailed reading, selecting revealing statements, and were downloaded from the software and transcribed. Par­ identifying representative sentences. After individual ticipants were asked about their experience with the phys­ analysis, common patterns and themes were identified ical therapy service(s) they had received. (The interview through iterative discussion. questions are provided in Appendix 1 online.) RESULTS Online focus group discussion with the provider parti­ cipants (n = 5) and mentor physical therapists (n = 2) took Quantitative results place at the completion of the pilot study using itracks bul­ A total of 47 client participants volunteered for this letin board focus group software (itracks, Saskatoon, SK). The discussion took place using an asynchronous online pilot project (see Table 1 for their characteristics). The format over 3 days. An online discussion guide was drafted majority were men (70.2%) with an average age of by all the authors and was facilitated by one of the authors 47 years. The number of clinical visits per participant (GW). (It can be found in Appendix 2 online.) Table 1 Demographic and Clinical Characteristics of Participants (N = 47) All provider and mentor participants were emailed an invitation to participate in the discussion; the email in­ Variable No. (%)* cluded a link to set up a secure password and access the discussion board. Questions were preprogrammed with Gender 33 (70.2) specific post times using the itracks online forum soft­ Male 14 (29.8) ware, with new questions available for participants to dis­ Female cuss each day. Participants were also given the ability to 21–72 comment on the previous day’s discussion. The partici­ Age 18 (38.3) pants submitted written responses using either compu­ Range, min–max, y 14 (29.8) ters running web browsers or mobile devices set up with < 50 15 (31.9) the itracks mobile app. The asynchronous nature of the  50 discussion allowed provider and mentor participants to Missing 21 (44.7) actively participate at a time convenient to them. 5 (10.6) Total physical therapy sessions 21 (44.7) The participants’ responses to questions were not in­ 1 fluenced by other participants as a result of the setup of 2 40 (85.1) the discussion. The participants were required to submit 3 2 (4.3) their responses to the questions before making other par­ 1 (2.1) ticipants’ responses visible. However, once a participant’s Condition categories{ 2 (4.3) response had been submitted, other responses were dis­ Orthopaedics 2 (4.3) played; this allowed the participants to comment on Neurology 3 (6.4) them, thereby creating a threaded online discussion. Cardiorespiratory Some of the participants chose to submit private re­ Mobility and balance sponses, which were viewable only by the moderator. A Women’s health Other *Unless otherwise indicated. {Categories are not mutually exclusive; participants could report more than one condition.

180 Physiotherapy Canada, Volume 71, Number 2 3.5 3 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 2.5 Mean scores 2 1.5 1 0.5 0 Self-care Usual activities Pain/discomfort Anxiety Mobility Dimensions of EQ-5D-5L Mean pre-session Mean post-session Figure 1 Pre- and post-session mean EQ-5D-5L values. Note: Lower scores are associated with improved health dimensions. EQ-5D-5L = EuroQOL Five-Dimension Questionnaire. ranged from 1 to 11, and approximately 54% of partici­ one nurse practitioner, and two mentor physical thera­ pants had repeat visits (defined as >1 visit). Participants pists) revealed the following four overarching themes: presented with diverse chronic conditions across numer­ (1) identifying complex health challenges and unmet ous health systems; the majority (85.1%) presented with needs, (2) overcoming access barriers and impact of physi­ an orthopedic issue. cal therapy services, (3) respecting and responding to con­ text and environment, and (4) moving forward to enhance PSFS and EQ-5D-5L access to physical therapy care. Because of the volume of missing data (only two parti­ Theme 1: Identifying complex health challenges and cipants completed the post-test PSFS), only the pre-visit unmet needs data are presented. The mean pre-session PSFS score was 50.72 (SD 33.44). Only 33 of the participants (70.2%) com­ Client participants identified chronic pain, reduced pleted the pre-session EQ-5D-5L, and 17 (36.2%) com­ mobility, urinary incontinence, and dizziness as condi­ pleted the post-session test. Figure 1 shows the weighted tions that affected their activities of daily living, function, mean pre- and post-session scores for each of the EQ­ and quality of life. Provider participants identified a 5D-5L domains. Mean pre-session EQ-5D-5L values in range of unmet health care needs and gaps in the contin­ the pain–discomfort (3.05) and mobility (2.58) domains uum of care: are higher than those in the other domains, indicating lower perceived functioning. I really began to realize how easily this population “slips through the cracks” and go [sic] without the care that they Satisfaction need. By not having access to certain health services, like See Table 2 for the VSQ-9 results. Note that item 1 in physical therapy, most live with the pain or disability that comes with their condition and have little knowledge as to the VSQ-9 (“Getting through to the clinic by phone”) did how they can control their pain and improve their day to not apply to this population, thus it is not reported here. day function. (Provider participant) Only 16 (34.0%) participants completed the modified VSQ-9. The majority of them rated all areas as “very Theme 2: Overcoming access barriers and impact of physical good” to “excellent”; the personal manner of providers therapy services ranked the highest (75.0% were rated as excellent) and explanation of assessment results ranked the lowest Client participants identified cost, transportation, and (31.3% rated as excellent). wait time as barriers to accessing physical therapy care. Having access to physical therapy services onsite and free of Qualitative results charge at The Lighthouse alleviated these barriers. One said, Analysis of the interviews (completed with 7 of the 47 That is why this physical therapy [at The Lighthouse] is client participants) and online asynchronous focus group great because I’m on a low income and there is no way I discussion (completed with the four physical therapists, can afford private physio.

Oosman et al. Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project 181 Table 2 Participants’ Satisfaction (VSQ-9 Results; N = 16) No. (%) of participants https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Satisfaction Waiting time Time spent Answers to Explanation of Advice and Technical Personal Overall rating after arriving with care questions* assessment information about skills of manner of visit provider provider providers Excellent 10 (62.5) 7 (46.7) results exercise and 10 (62.5) Very good 5 (31.3) 9 (56.3) 5 (33.3) activities 9 (56.3) 12 (75.0) 3 (18.8) Good 1 (6.3) 3 (18.8) 3 (20.0) 5 (31.3) 4 (25.0) 2 (12.5) 2 (12.5) Fair 3 (18.8) 7 (43.8) 7 (43.8) 2 (12.5) 2 (12.5) 1 (6.3) Poor — 1 (6.3) — 2 (12.5) 5 (31.3) 1 (6.3) — — 2 (12.5) 3 (18.8) — — — 1 (6.3) — — — — Note: Dashes indicate no responses in this category. *For this item, n = 15. Another added, “There is no way in the world that I can the client participants. They noted that more traditional, go out of the community . . . or [go to] a hospital . . . for or typical, outpatient physical therapy treatment plans physio. No, I cannot afford it, and therefore I have to go did not always fit in this context. As one provider partici­ without it.” pant said, “The types of treatment I tended to focus on were different than a typical private practice caseload. . . . Even when alternative, publicly funded services were I tried to focus on education and self-management stra­ available, wait times were still a barrier. However, this tegies and less on true biomechanical care.” pilot project addressed wait times. One provider partici­ pant stated, Considering The Lighthouse as a facility outside the health care sector, it was necessary to adapt to the types An older lady who sustained a recent humeral fracture of tools that could be used during physical therapy treat­ could not afford [private] physical therapy services and ments. One provider participant identified “working with was awaiting treatment at [public clinic], but couldn’t get the bare essentials and having to improvise quickly. . . . in for several months so was being seen at The Lighthouse. Working outside of box in a different environment.” Client participants identified the multidimensional Provider participants indicated the need to also adapt impacts of having enhanced access to physical therapy the focus of their treatments and prioritize complex health services, including enhanced knowledge and awareness presentations in the context of the challenges faced by the of health-promoting activities to support function and client participants. For example, a provider participant said, independence. For example, one client participant noted, A primary concern for me were the obviously multifactorial, Seeing a physiotherapist at The Lighthouse has affected me, complex situations these clients found themselves in. Some it has taught me some different types of physio to do so I can days, clients were too preoccupied with not knowing if they start regaining my muscles and bending properly . . . [to] were going to have a bed to sleep in that night to worry help me to get fit. I’m gonna keep working with the team as about their poor posture contributing to their low back or long as possible . . . [to] start to do things on my own. shoulder pain. Theme 3: Responding to context and environment Provider participants described how they prepared This theme has two distinct sub-themes: adapting themselves to treat individuals who had a significantly different lived experience than the providers themselves. care to respect context and environment and building on One said, resiliency. [Demonstrating] compassion, empathy, and the true Adapting care to respect context and environment desire to go into a setting like The Lighthouse without Client participants repeatedly identified that having prejudice and provide patients with the treatment that they deserve [was necessary]. No matter the experiences physical therapy services available at The Lighthouse was or life events that may have brought them to where they not just convenient but also enabled them to access care are, they deserve access to care. in an environment that was familiar and comfortable. Provider participants highlighted various adaptations Another added, “Coming from such a different back­ they had made to physical therapy treatment to ensure ground than most of the residents, there was a lot that I that they were better meeting the diverse health needs of just couldn’t even imagine let alone fully understand.”

182 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Building on resiliency Physical therapists can play a critical role in addressing The strengths and resiliency of the client participants many of these health inequities by providing timely, rele­ vant, and meaningful treatment,19 working to narrow the became clear to many of the providers. One remarked, gap in health disparities in vulnerable populations, par­ ticularly if they are working in a primary health care con­ The resiliency of these clients was inspiring. The significant text.25,26 In Saskatchewan, the value and impact of injuries that some residents had . . . and continued to work having physical therapists as part of primary health care through were shocking. Despite everything that was teams have not been fully realized. This study revealed happening to them, most of them were very positive the participants’ perspectives on the impact of enhancing individuals. The Lighthouse residents would generally rate access to physical therapy services in a primary health themselves much healthier than I would have rated them. care context at The Lighthouse Supported Living facility in Saskatoon. These experiences stimulated the provider partici­ pants to reflect on the importance of social accountabil­ Client participants presented with diverse health con­ ity, health equity, cultural safety, and cultural humility: ditions, including neurological, cardiorespiratory, ortho­ “[We felt responsible] to truly believe and advocate for pedic, and women’s health conditions as well as mobility equal access for all, no matter the client’s socioeconomic and balance challenges. These conditions are consistent status, ethnicity.” with previous findings linking homelessness to an in­ creased risk of chronic pulmonary and musculoskeletal Theme 4: Moving forward to enhance access to physical disorders2,41 and to disproportionately higher rates of in­ therapy care adequately controlled hypertension and diabetes.2,42,44 There is a great need to provide homeless individuals The client participants offered insights into elements with increased access to rehabilitation specialists to that would be critical to maintaining enhanced access address complex and chronic condition management.44 to physical therapy care at The Lighthouse. Some noted that physical therapy sessions could be offered more reg­ Primary health care teams should include physical ularly and more than just 1 day per week: “Lots of people therapists as team members because they can mitigate work, too, so maybe have some [physical therapy ser­ the impact of chronic health challenges on overall func­ vices] like in the evenings, like programming nights.” tion, mobility, and health among individuals experien­ cing homelessness and poverty. Integrating a primary Provider participants expanded on these ideas, sug­ health care team (nurse practitioner, registered psychiat­ gesting other enhancements that would support or allow ric nurse, special care aid, paramedic, and physical thera­ clients to engage in augmented self-management activ­ pist) at The Lighthouse was associated with a 24% ities: “Having a consistent team of service providers [in­ reduction in emergency department visits in the SHR cluding physical therapists] who could really build from Lighthouse residents.34 Examples of physical ther­ relationships with this community would be helpful.” apy services that likely contributed to this reduction include providing proper walking aids, treating dizziness, Several of the provider participants reflected on their and providing fall prevention strategies and respiratory role and position at The Lighthouse and concluded that rehabilitation exercises. being successful as a physical therapist in this unique set­ ting required background knowledge and practical ex­ If the time allotted to the project had been longer, periences in similar settings. One said, “In a lot of aspects more progress could have been made mitigating the I did not feel prepared going into that setting, especially impact of chronic health challenges. Providing enhanced emotionally and culturally. Going into The Lighthouse for access to physical therapy services for homeless indivi­ my first day, I was nervous and had no idea what to duals may enhance their quality of life while at the same expect.” time curbing the high number of emergency department visits and associated costs. The provider participants also shared their challenges with collecting completed and detailed surveys and ques­ Client participants strongly valued having access to tionnaires from the client participants. One said, “I did physical therapy services at The Lighthouse. Approxi­ find it difficult to complete all of the intake paperwork . . . mately 19% (n = 3) and 63% (n = 10) rated satisfaction with the clients tended to get impatient with all of the ques­ physical therapy services overall as very good or excellent, tions.” Another added, “Some [clients] had difficulty respectively. Our results confirmed that such access alle­ reading or did not understand the questions and there­ viated the physical barriers (e.g., cost, transportation, geo­ fore required assistance.” graphical location, wait times)44,45 to accessing services faced by people living in poverty. Providing physical ther­ DISCUSSION apy services in a primary health care setting at The Light­ The challenges and stressors of daily living for home­ house also increased access for individuals who were not homeless but who were living at a lower socioeconomic less individuals are completely different from those of the general affluent population.6,40 Such challenges have a negative impact on overall health and health outcomes among the homeless and vulnerable populations.2–4

Oosman et al. Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project 183 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 level. At least one client participant who could not afford comfortable they became. We suggest that more consis­ to pay for physical therapy services in a private clinic set­ tent and regular interaction between providers and cli­ ting, who was not a resident at The Lighthouse, sought ents be encouraged to build trust and optimize patient physical therapy services there because of the long wait satisfaction in this community-based environment. times at regular publicly funded clinics. The provider participants noted that enhanced train­ Individuals living in socially disadvantaged contexts ing in primary health care settings and about homeless also face the competing challenges of meeting their daily, individuals would have been beneficial to their profes­ basic human needs. They are more likely to place the sional and clinical practice in this study. Several Light­ basic human needs of food and shelter above any health house clients self-identified as Indigenous, and this led issues of mobility, pain, strength, or function.46 The client the provider participants to emphasize that augmented participants in this study articulated the challenge of cultural safety and cultural humility was an area in which focusing on physical therapy treatment in a food inse­ they were in need of further professional development. It cure, impoverished, or homeless context. Providing phys­ is well documented that individuals who are homeless, ical therapy services directly at The Lighthouse enabled who live in poverty, or who identify as Indigenous have them to access services opportunistically and in a way had negative experiences with hospitals and health care that matched their lifestyle. In fact, during this study, providers in the past.50–52 The sense of distrust that these 45% of the client participants accessed physical therapy experiences have built up could be at least partially alle­ services more than three times. viated if health care providers were to receive training to critically acknowledge and purposefully address their Bringing physical therapy services to the people, underlying attitudes and beliefs and to build a culturally where people live, work, and play, is foundational to pri­ safety health environment.52–54 mary health care and an important consideration for ad­ dressing health inequities and disparities among the It is interesting that although the provider participants homeless and vulnerable populations. The interdisciplin­ did not necessarily receive enhanced training in primary ary interactions were an important aspect of the delivery health care contexts, they realized the importance of of services. For example, during the referral process, the modifying or adapting their usual physical therapy nurse practitioner would discuss with a provider partici­ practice to account for the complexities and particular pant background information about a client participant characteristics of their client participants. Providing com­ and past health care interactions, thereby enabling the prehensive, consistent, and progressive levels of physical provider to deliver care with greater consideration for the therapy care to the client participants was not always client’s social determinants of health and health history. possible; those who were homeless were transient and thus not always able to be on site when the physical After the physical therapy assessment and treatment, therapists were. This was not a surprise to our team the provider participant sometimes shared treatment re­ because the challenge of providing consistent, continu­ commendations with the nurse practitioner; this facilitated ous care to homeless individuals has been reported in further care and follow-up during interactions between a other cities in Canada.55,56 In fact, Aldridge and collea­ client and the nurse practitioner, who was present at the gues suggested that Canada’s health care system must facility more consistently. One client participant was visit­ coordinate a cross-sectoral response, in conjunction with ing from a northern community and saw a provider partici­ providing enhanced services, to address the health in­ pant at The Lighthouse during that time. Later, a nurse equities that exist among homeless individuals.57 practitioner from the home community contacted the nurse practitioner at The Lighthouse to obtain a copy of In our study, a single treatment and only baseline the rehabilitation exercises provided by the provider partic­ measures were often all that could be provided and ob­ ipant to support the client’s rehabilitation. tained. The provider participants were challenged to adapt their usual care practices to holistically address the The satisfaction ratings of the physical therapy ser­ complex health challenges of the client participants. For vices in this study were slightly lower in the categories of example, they prescribed functional exercises but had communication and education; 43.8% and 31.3% of the limited time for instruction and progression, and offering client participants rated “explanation of assessment re­ physical therapy services once per week (a provision in sults” as very good or excellent, respectively. We attribute this study) did not align with the transient lifestyle of the these relatively low scores to the limited time that provi­ client participants. The client participants’ ability to ders had to develop relationships with the client partici­ remember the exercises and keep the exercise documents pants. Relationship and rapport building is well known to or equipment while being homeless or living in poverty positively influence client perceptions of quality of care, was another challenge. Further research is required to ensuring that clients feel heard and supported as they determine whether a more flexible interdisciplinary and navigate their health challenges.47–49 cross-sectoral approach to providing physical therapy services (e.g., drop-in or walk-in health care centres, Interestingly, the provider participants reported that the more time they spent at The Lighthouse, the more

184 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 evening hours) would increase the ability of Lighthouse CONCLUSION residents to access care in a more consistent, relevant This study confirmed that individuals experiencing and appropriate way. homelessness and poverty in Saskatoon face diverse bar­ Although drawing general conclusions from this riers to accessing physical therapy services. Client partici­ study may not be possible, our findings meaningfully pants who accessed physical therapy services at The clarify the important role of physical therapy in a pri­ Lighthouse perceived that it improved their overall mary health care setting (outside a health facility) and health, function, and wellness. Our findings suggest that among individuals who are homeless or living in pov­ providing physical therapy services in the community, erty. We anticipate that the findings can be used to where people live, access food, and socialize, may be an advocate for the critical role of physical therapists on effective way of enhancing access to care among indivi­ inter-professional health care teams, in places that are duals who are homeless or poor. The transient nature of easily accessed by individuals experiencing homeless- individuals living in contexts of homelessness and pov­ ness. Our team, in partnership with the SPA, plans to erty is often unpredictable and uncertain and makes the use the data from this study to lobby provincial and appointment-based approach to delivering services a local governments to increase the physical therapy posi­ barrier to care. Finally, as physical therapists expand tions in these community contexts. We anticipate that their role into primary health care settings in low socio­ our findings will be used by health care administrators economic contexts, enhanced professional development when planning the location and type of community­ and support should be provided to ensure that these clin­ based care offered to homeless individuals. Moreover, icians provide meaningful care that effectively addresses our results highlight the importance of providing appro­ the health needs of underserved populations. priate and necessary educational and professional development support for physical therapists working in KEY MESSAGES primary health care settings and with individuals who are homeless and living in poverty. What is already known on this topic Homelessness is a social determinant of health that This study has some important limitations to high­ light. First, the transient lifestyle of The Lighthouse resi­ has a negatively impact on overall health and function. dents, language barriers, and respect for patient time led Individuals experiencing homelessness face unique bar­ to inconsistent and infrequent physical therapy treat­ riers to accessing relevant, timely, and appropriate health ment sessions; this made it a challenge to obtain ade­ care (including physical therapy), which perpetuates quate and consistent quantitative measures. Second, this health disparities. Different models of primary health study was limited to a 4-month time frame because of care have been created to reduce the strain on down­ the availability of the donated physical therapy services. stream health care use and costs, improve access to Third, the sample size was small because we relied solely health care, and reduce wait times. However, little is on The Lighthouse residents who self-selected to see the known about the role of physical therapy in such primary physical therapist. Fourth, many of the questionnaires health care teams and its impact on the health and func­ were administered by the provider participants and the tion for the homeless and poor. nurse practitioner verbally by asking the questions and recording the responses; this was a result of the client What this study adds participants’ low literacy rates and limited comprehen­ Physical therapists are well equipped to optimize func­ sion of the questions. This may have resulted in a social desirability bias, whereby responses were influenced by tion, mobility, and overall health in primary health care the patient–provider relationship. Ideally, the question­ contexts, and they have a strong role to play in this area. naires would have been administered by the research Our results reveal that the client participants were satisfied personnel, but resources for the study were limited and overall with having access to physical therapy services at locating participants presented challenges. The Lighthouse Supported Living facility, and they be­ lieved that it had a positive impact on their general health Finally, analyzing the provider and client participant and well-being. There is a need for health care services to perceptions data together might be viewed as a limitation be delivered in non-traditional ways to better meet the because of the mixed sources. However, we saw this as a opportunistic lifestyles and unmet health needs of indivi­ strength because we were looking for similarities and dif­ duals experiencing homelessness and poverty. Moreover, ferences within and between the two groups’ (client and physical therapists should have access to better support provider) perceptions of their experiences together. and more professional development opportunities as they These types of data strengthen the analysis and provide expand their practice into primary health care contexts diverse perspectives that inform the analysis and the con­ and when working with underserved populations. clusions that can be drawn. This may in turn enhance the transferability and relevance of this work to others.

Oosman et al. Enhancing Access to Physical Therapy Services for People Experiencing Poverty and Homelessness: The Lighthouse Pilot Project 185 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 REFERENCES on Social Determinants of Health. Geneva: World Health Organization; 2008. 1. Raphael D. Social determinants of health: an overview of key issues 22. Sanmartin C, Ross N. Experiencing difficulties accessing first-contact and themes. In: Raphael D, editor. Social determinants of health. 2nd health services in Canada: Canadians without regular doctors and ed. Toronto: Canadian Scholars’ Press; 2009. p. 2–19. recent immigrants have difficulties accessing first-contact healthcare services: reports of difficulties in accessing care vary by age, sex and 2. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in region. Healthc Policy. 2006;1(2):103–19. 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https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 PAEDIATRIC PHYSIOTHERAPY Developing and Validating a Step Test of Aerobic Fitness among Elementary School Children Rebecca M. Hayes, MD;* Dylan Maldonado;{ Tyler Gossett, MS;{ Terry Shepherd, PhD;{ Saurabh P. Mehta, PhD, PT;§ Susan L. Flesher, MD¶ ABSTRACT Purpose: The tests to estimate aerobic fitness among children require substantial space and maximum effort, which is often difficult for children. We developed a simple submaximal step test (Step Test of Endurance for Pediatrics, or STEP) and assessed its reliability, validity, and ability to estimate aerobic fitness among elementary school children. Method: Children aged 5–10 years completed the STEP with a protocol consisting of 0.1-, 0.2-, and 0.3-metre (4, 8, and 12 in.) step heights. Participants underwent treadmill testing with open circuit spirometry to determine actual maximal oxygen consumption (V˙O2max). Intra-class correlation coefficients (ICCs) assessed test–retest reliability of the STEP and its component tests. Multivariate linear regression as- sessed the associations between the STEP and V˙O2max, adjusting for potential covariates such as age, sex, BMI, and comorbidity count. Results: The STEP showed excellent reliability (ICC ! 0.92; N = 170), irrespective of effort level during testing. Significant effort issues and collinearity among the independent variables led us to exclude children aged 5–6 years (n = 45) from the regression analysis. The final regression model for children aged 7–10 years with adequate effort (n = 111), as defined by a respiratory exchange ratio of 1.0 or more, showed that the STEP, sex, and BMI were significantly predictive of V˙O2max (R 2 = 0.51). Conclusions: This new, effort-independent step test can estimate the aerobic fitness of children aged 7–10 years. Regression equa- tions to estimate V˙O2max from the STEP were provided. Key Words: cardiorespiratory fitness; physical fitness; paediatrics; validation; V˙O2; reproducibility of results. RÉSUMÉ Objectif : les tests d’évaluation de la capacité aérobique chez les enfants exigent beaucoup d’espace et un effort maximal, et les enfants éprouvent souvent de la difficulté à les exécuter. La présente étude visait à mettre à l’essai un simple test sous-maximal de la marche d’escalier (test de la marche d’escalier pour établir l’endurance en pédiatrie, ou STEP, selon l’acronyme anglais) et à en déterminer la fiabilité, la validité et la capacité à évaluer la capacité aérobi- que des enfants du primaire. Méthodologie : des enfants de cinq à dix ans ont effectué le STEP selon un protocole qui incluait des marches de 0,1, 0,2 et 0,3 mètre (4, 8 et 12 pouces). Les participants ont effectué une épreuve d’effort sur tapis roulant avec spirométrie en circuit ouvert pour déterminer leur consommation maximale réelle d’oxygène (V˙O2max). Les chercheurs ont utilisé les coefficients de corrélation intraclasse (CCI) pour évaluer la fiabilité test- retest du STEP et des tests qui le composaient. Ils ont utilisé la régression linéaire multivariée pour évaluer les associations entre le STEP et le V˙O2max, ra- justée pour tenir compte de covariances potentielles comme l’âge, le sexe, l’indice de masse corporelle (IMC) et le nombre de comorbidités. Résultats : le STEP était d’une excellente fiabilité (CCI ! 0,92; n = 170), quel que soit le niveau d’effort utilisé. Des problèmes relatifs à l’importance de l’effort et la colinéa- rité entre les variables indépendantes ont incité les chercheurs à exclure de l’analyse de régression les enfants de cinq et six ans (n = 45). Le modèle de régression final des enfants de sept à dix ans qui faisaient un effort approprié (n = 111), défini par un ratio d’échanges gazeux minimal de 1,0, a révélé que le STEP, le genre et l’IMC étaient très prédictifs du V˙O2max (R 2 = 0,51). Conclusion : ce nouveau test de la marche d’escalier qui n’est pas lié à l’effort peut éva- luer la capacité aérobique des enfants de sept à dix ans. Les chercheurs ont fourni les équations de régression pour évaluer le V˙O2max à partir du STEP. The FitnessGram is the most widely used assessment better cardiovascular status in children as well as its of youth fitness in the world, and it is used in more than potential to decrease all-cause mortality in adults.3–5 Aer- 67,000 schools in all 50 U.S. states.1,2 It measures aerobic fitness as well as muscular endurance, muscular strength, obic fitness can be accurately quantified in a laboratory flexibility, and body composition.1 Aerobic fitness, defined setting by measuring maximum oxygen uptake (V˙ O2max) as the ability of the body to deliver oxygen to the muscles with a maximal graded exercise test.6–8 The FitnessGram to be used for energy, is perhaps the most important part uses field-based assessments to estimate V˙ O2max because of the assessment because of its positive association with a laboratory test is not practical for assessing a large number of children. Three field tests are available to From the: *Department of Internal Medicine and Pediatrics; ¶Department of Pediatrics; {Joan C. Edwards School of Medicine; {Department of Exercise Science; §Department of Physical Therapy, Marshall University, Huntington, W.Va. Correspondence to: Rebecca M. Hayes, Department of Internal Medicine and Pediatrics, Byrd Clinical Center, 1249 15th St., Suite 2055, Huntington, WV 25701, USA; [email protected]. Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft. Competing Interests: None declared. Physiotherapy Canada 2019; 71(2);187–194; doi:10.3138/ptc.2017-44.pp 187

188 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 estimate V˙ O2max among children: the Progressive Aerobic sample was that of convenience and consisted of partici- Cardiovascular Endurance Run (PACER), the One-Mile pants aged 5–10 years from local elementary schools and Run, and the One-Mile Walk Test. local YMCA youth programmes. Flyers were distributed to schools and the YMCA for participant recruitment All three available field tests have limitations that clini- from July 2015 to September 2016. Participants were in- cians must take into consideration. The PACER is a 20- cluded if they were within the age range and able to safely metre shuttle run and thus requires an appropriate participate in physical activity, which was determined by amount of space.9 Both the One-Mile Run and the One- their regular participation in physical education classes Mile Walk Test require an area that can accommodate a in school and a lack of restrictions on performing any long-distance run–walk, which is often unavailable. The level of physical activity. PACER and One-Mile Run require children to give maxi- mum effort, which translates to poor reliability and valid- Participants were excluded if they were participating in ity of test results in young children.1 Consequently, a concurrent fitness programme or had a health history V˙ O2max standards from the PACER and One-Mile Run that precluded safe participation (long QT syndrome, have not been developed for children aged younger than hypertrophic cardiomyopathy, or an uncontrolled seizure 10 years participating in the FitnessGram. Although the disorder). Children with conditions such as asthma and One-Mile Walk Test is a submaximal exercise test, it has attention deficit disorder could be included if they met the not been validated in children aged younger than criteria for participation. Parents provided all the partici- 13 years.1 Therefore, clinicians cannot assess aerobic fit- pants’ information via a questionnaire. ness in most elementary school students, and this is a limitation of the FitnessGram. Procedures All data collection took place during a single visit to an Aerobic fitness testing of elementary school children should be easy to implement and should require minimal exercise physiology lab located at the university. A resources. Step tests meet this goal, requiring much less trained exercise physiologist obtained the demographic, space than the previously discussed walk and run tests. health-related, and anthropometric data and conducted The literature describes few step tests for children, and all fitness tests. these tests have practical drawbacks regarding imple- mentation. Jankowski and colleagues developed a system Height was measured to the nearest 0.01 metre (0.5 in.) for heart rate monitoring with step testing for children using a wall-mounted measuring rod (the seca 220, seca, aged 6–12 years, but this test was never validated against Chino, CA) and weight to the nearest 0.2 kilogram (0.5 lb) V˙ O2max.10 In addition, the intense physical exercise in this using a medical scale (the seca alpha 770, seca, Chino, test caused extremely high heart rates in 201 children, so CA). BMI in kg/m² was calculated using these two mea- the testing was discontinued.10 Garcia and colleagues surements. evaluated a step test in children aged 10–15 years11 that required them to walk down steps backward, which A simple, effort-independent STEP protocol was cre- could be difficult and even dangerous. ated (see the Appendix for details). Participants stepped to a 22-step-per-minute metronome cadence. An incre- Unlike these tests, the Step Test of Endurance for mental protocol consisting of 0.1-, 0.2-, and 0.3-metre (4-, Pediatrics (STEP) is a simple submaximal exercise step 8-, and 12-in.) step heights was used. Participants test to expand the ability to easily estimate aerobic fitness stepped for 2 minutes at each step height, and heart rate in children aged 5–10 years. The STEP uses incremental was measured after each step height by 10-second aus- step heights with a lower step rate, rather than a single cultation. The average heart rate from each of the three 0.3-metre (12 in.) bench, to allow for gradual exertion. step heights was used for data analysis. The STEP was Specifically, we examined the test–retest reliability, stan- repeated after a rest period of 15 minutes on the same dard error of measurement (SEM), and concurrent valid- day to reduce the influence of timing of meals, diurnal ity of the newly developed step test for this age group. variation, and other non-exercise influences on heart Second, we aimed to assess the independent association rate; 15 minutes of rest is more than adequate for heart between the STEP and V˙ O2max and develop a regression rate to return to baseline resting heart rate in children.12 equation to extract an objective index of aerobic fitness (V˙ O2max) using performance on the STEP. Actual V˙ O2max (mL·kgÀ1·minÀ1) was obtained by exer- cise testing to exhaustion with open-circuit spirometry METHODS on a treadmill.7,8 Testing was performed 15 minutes after the second STEP. Before testing, all participants were ha- Participants bituated to treadmill walking. Speed was determined on The university institutional review board approved the the basis of an individual participant’s stride length and was maintained for the duration of the test. Grade was study. Written, informed consent and child assent were started at 0% and was increased by 2% every minute until obtained from parents and participants, respectively. The volitional exhaustion. V˙ O2max was assessed using a meta- bolic measurement system (TrueOne 2400, Parvo Medics,

Hayes et al. Developing and Validating a Step Test of Aerobic Fitness among Elementary School Children 189 Sandy, UT). Before the test, the systems were calibrated nificant associations (p < 0.05) with the V˙ O2max. We used with known concentration sample gases. V˙ O2max results SAS, version 9.4 (SAS Institute Inc., Cary, NC) for all the were accepted only if a participant was showing evidence analyses. of fatigue and achieved a respiratory exchange ratio https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 (RER) of 1.0 or higher.6 The test administrator provided RESULTS constant verbal encouragement to the participants dur- A total of 170 children aged 5–10 years (mean 7.7 [SD ing exercise testing by saying encouraging phrases and acknowledging their efforts. 1.5] years; 87 boys and 83 girls) participated in the study. During the data collection, we clearly observed concerns Statistical analysis with children aged 5 and 6 years exerting adequate efforts Descriptive statistics were calculated for boys and girls during the STEP protocol. This resulted in only 139 of the participating children being able to complete the study for the demographic and anthropometric characteristics with usable data (RER ! 1). Of the children aged 5–6 y, as well as for the STEP trials and V˙ O2max. Means and stan- 37.8% (17 of 45) had unusable data, whereas of the chil- dard deviations were calculated for the continuous data, dren aged 7–10 years, only 11.2% (14 of 125) had unusa- and frequency counts were provided for the categorical ble data. Therefore, results are outlined considering these data. The Shapiro–Wilk test was used to confirm normal age subgroups. Of the 139 children with usable data, 28 distribution of continuous data. (aged 5.8 [SD 0.4] years; 16 boys and 12 girls) were aged 5–6 years, and 111 (aged 8.1 [SD 1.1] y; 58 boys and 53 The intra-class correlation coefficient (ICC) examined girls) were aged 7–10 years. the within-day reproducibility of the STEP results and esti- mated V˙ O2max between the first and second trials. The ICC Tables 1 (subgroup with adequate effort irrespective values, with 95% CI, were calculated separately for two of their age; n = 139) and 2 (total sample; N = 170) show subgroups: (1) the subgroup of children who showed ade- the results of test–retest reliability of the heart rates for quate effort, as evidenced by the RER of 1.0 or more, irre- the three step heights, the average heart rate for the three spective of their age group, and (2) the total sample, step heights, and the V˙ O2max obtained through the regres- irrespective of their effort level, as shown by RER. ICC va- sion analyses (described later in this section). The ICC va- lues of more than 0.9 are considered to be indicative of lues for the components of the STEP as well as excellent reliability.13 The SEM for the STEP (average heart the average of these components were 0.92 or more, with rate) was calculated because it was one of the predictor the lower bound of the 95% CI also more than 0.89, sug- variables assessed in the regression model outlined later. gesting adequate reliability. In particular, the step test We also examined the agreement between the scores of average heart rate assessed in the subgroup with ade- the two STEP trials using the Bland–Altman technique. quate effort showed an ICC value of 0.98. The SEM asso- ciated with the step test average heart rate was 2.2 beats A graph of differences in STEP scores between two trials per minute (BPM). Even when we examined test–retest was plotted against the average score of the STEP across reliability for children in the two subgroups based on age the two trials. Subsequently, the limits of agreement (LOA) (irrespective of their effort level), the ICC values were 0.90 were calculated and plotted such that LOA represented or more for the components of the STEP and the average the mean difference (SD 2) of the mean difference heart rate of the three steps in the test, suggesting accept- between two scores. The Bland–Altman technique has able reliability (results of this analysis are not shown in been described in detail elsewhere.14 We examined the Tables 1 and 2). concurrent relationships of the STEP, V˙ O2max, and BMI using Pearson correlation coefficients (rs). Values of Table 1 Test–Retest Reliability of the STEP for Children Aged 5–10 r > 0.70, r ! 0.50–0.70, and r < 0.50 were considered to sug- Years Who Showed Adequate Effort (n = 139) gest high, moderate, and low concordance, respectively.15 Test ICC 95% CI SEM We performed backward stepwise regression analyses using V˙ O2max as the dependent variable and age, sex, Heart rate BMI, step test average heart rate, and comorbidity count (number of medical conditions present) as independent 0.1 m (4 in.) step 0.94 0.92, 0.96 N/A variables. The presence of collinearity between indepen- dent variables was considered significant if the condition 0.2 m (8 in.) step 0.96 0.94, 0.97 N/A number (CN) was more than 30,16 in which case we did not pursue regression analysis. The CN was computed by 0.3 m (12 in.) step 0.96 0.95, 0.97 N/A obtaining the square root of the largest versus smallest ei- genvalue, where the eigenvalues reflected variances of Average of 3 steps 0.98 0.97, 0.99 2.20 the principal components of the predictor variables.16 The final model included only the variables that had sig- V˙O2max estimated by step test 0.87 0.82, 0.90 2.98 STEP = Step Test of Endurance for Pediatrics; ICC = intra-class correlation coefficient; SEM = standard error of measurement; V˙O2max = maximum oxygen consumption; N/A = not applicable.

190 Physiotherapy Canada, Volume 71, Number 2 Table 2 Test–Retest Reliability of the STEP for the Total Sample, trials. The mean differences between these two scores (1.237 Irrespective of Effort Level (N = 170) BPM) and LOA are shown in the graph. Given this very nar- Test ICC 95% CI SEM https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 row mean difference, the children appeared to show no Heart rate learning effect from the beginning the first session to com- Differences between Step Test Average Heart Rate (BPM) for pleting the second session. The correlations among the step Trials 1 and 2 0.1 m (4 in.) step 0.92 0.89, 0.94 N/A test, measured V˙ O2max, and BMI were moderate for both boys and girls (rs = –0.60 and –0.59, respectively; p < 0.001). 0.2 m (8 in.) step 0.94 0.92, 0.97 N/A The sample size (n = 28) for the subgroup of children 0.3 m (12 in.) step 0.95 0.93, 0.96 N/A aged 5–6 years was inadequate, and their data showed significant collinearity between the putative independent Average of 3 steps 0.97 0.97, 0.98 2.63 variables (CN > 30). Therefore, we included only the group aged 7–10 years in the regression analyses to exam- V˙O2max estimated by step test 0.83 0.77, 0.87 3.32 ine the association between V˙ O2max and the STEP. Descriptive statistics for the children aged 7–10 years STEP = Step Test of Endurance for Pediatrics; ICC = intra-class correlation who were included in the regression analyses (n = 111) coefficient; SEM = standard error of measurement; V˙O2max = maximum oxygen are shown in Table 3. Table 4 shows the final model for consumption; N/A = not applicable. the regression analyses, assessing the relationships between V˙ O2max and sex, BMI, and step test average heart Figure 1 shows the Bland–Altman plot for the agreement rate. No collinearity was observed between the indepen- between the scores of the step test average heart rate across two assessments for children aged 7–10 years who showed dent variables (CN = 17.4). Age and comorbidity count adequate effort. The x-axis represents the mean of the step did not demonstrate significant associations with V˙ O2max test average heart rate obtained across the two trials for all the children, whereas the y-axis shows the differences between the step test average heart rates across these two 10.00 Mean (+2SD) 5.00 Mean 0.00 –5.00 Mean (–2SD) –10.00 80.00 100.00 120.00 140.00 160.00 180.00 200.00 Mean of Step Test Average Heart Rate (BPM) for Trials 1 and 2 Figure 1 Bland-Altman plot showing agreement between the two trials for the average step test heart rate.

Hayes et al. Developing and Validating a Step Test of Aerobic Fitness among Elementary School Children 191 Table 3 Demographic Characteristics and Performance of Children Aged DISCUSSION 7–10 Years with Adequate Effort (n = 111) The aim of this study was to develop an effort-inde- Mean (SD)* pendent step test to estimate aerobic fitness, V˙ O2max, in children aged 5–10 years. Our results provide preliminary https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Variable Boys Girls p- (n = 58; 52%) (n = 53; 48%) value{ support for the reproducibility and validity of the STEP as well as for estimating V˙ O2max using the results of the STEP Age, y 8.29 (1.08) 8.55 (1.12) 0.23 for children aged 7–10 years. The test demonstrated BMI, kg/m2 17.56 (3.5) 17.53 (3.87) 0.96 excellent within-day test–retest reliability, with an ICC of Comorbidity count{ 0.09 (0.28) 0.13 (0.39) 0.48 0.98. The coefficient of determination for the regression Ethnicity, frequency (%) 0.49 model was of an acceptable level (R2 = 51%), indicating Caucasian 44 (39.70) 40 (36.00) African American 8 (7.20) 4 (3.60) 0.15 that the final model is sufficiently accurate. Hispanic 1 (0.90) 3 (2.70) 0.08 Other 5 (4.50) 6 (5.40) 0.020 The calculated ICC values for the STEP, irrespective of Absolute V˙O2max,§ L·minÀ1 1.14 (0.26) 1.09 (0.25) 0.25 Relative V˙O2max,§ mL·kgÀ1·minÀ1 34.62 (6.20) 32.56 (6.12) 0.16 age group or effort level, were excellent (ICC > 0.90), sug- RERmax 1.06 (0.05) 1.08 (0.05) 0.32 VEmax (L/min) 38.62 (9.51) 39.56 (10.14) 0.21 gesting that the STEP elicits performance that is highly VECO2 33.71 (3.23) 34.27 (2.74) VEO2 36.01 (3.79) 36.36 (3.90) reproducible over two separate occasions on the same FEO2 17.43 (0.34) 17.48 (0.33) day. The SEM is a function of SD and ICC values of the *Unless otherwise indicated. {Indicates difference. test in a given sample. Lower variability and higher ICC {Comorbidities reported: attention deficit disorder, asthma, heart murmur, environmental allergies. values for a test in a given sample results in a lower SEM. §V˙O2max obtained from treadmill test. V˙O2max = maximal oxygen consumption; RERmax = maximal respiratory In our study, the calculated SEM for the STEP in children exchange ratio; VEmax = maximum minute ventilation; VECO2 = ventilator equivalent for carbon dioxide; VEO2 = ventilator equivalent for oxygen; aged 7–10 years was 2.3 BPM. This is relatively low and FEO2 = fractional concentration of oxygen. will likely introduce a measurement error of only a small Table 4 Backward Stepwise Regression Model, with V˙O2max as the Out- magnitude in predicted V˙ O2max using the regression come Variable equation presented earlier. For example, a boy who is Variable Parameter 95% CI aged 7–10 years, has a BMI of 20, and has a step test estimate p-value average of 130 BPM will have a predicted V˙ O2max of 31.16 mL·kgÀ1·minÀ1 (95% CI: 23.82, 38.5). Intercept 63.54 – 56.30, 70.79 Sex (male vs. female) 1.72 0.04* 0.06, 3.40 The overall correlation for this model (R = 0.71) is sim- BMI –0.73 < 0.001* –0.98, –0.48 Step test (average heart rate) –0.15 < 0.001* –0.21, –0.10 ilar to the PACER prediction models (Rs = 0.74 and 0.75) Note: R 2 = 0.52; adjusted R 2 = 0.51. Dash indicates that p-value cannot be and One-Mile Run Test model (R = 0.71) used in the Fit- computed.*p < 0.05. nessGram.17,18 This similarity is important to note (p > 0.05) and were therefore excluded from the final because it lends credibility to our study. The PACER has model. The adjusted R2 for the final model was 51%. been validated against V˙ O2max and is the recommended assessment of aerobic fitness in children.1,19 Multiple On the basis of the analyses, we created separate regression equations for boys and girls aged 7–10 years, predictive models have been published to estimate aero- accounting for the variables retained in the final model. bic fitness from PACER data.17,20,21 The PACER is consid- The equation is shown with the relevant regression coef- ficients and their standard error estimates: ered reliable, with a systematic review reporting ICCs varying from 0.78 to 0.93.22 PACER predictive models V˙ O2max = 63.54 + (S × 1.72 [± 0.84] + [–0.73 (± 0.13) × BMI] + [–0.15 (± 0.03) have high concurrent validity, with correlation coeffi- × step test average heart rate]), cients between the models and V˙ O2max varying from 0.65 to 0.87.9,23 Some of the developed PACER prediction where S is 0 for female and 1 for male. models were adjusted for variables such as BMI, sex, speed, and age of the participants to improve the predic- tion of V˙ O2max from PACER performance.17,20,21 The ICC values reported for the One-Mile Run Test range from 0.39 to 0.90 in children, and validity coefficients range from –0.60 to –0.90.1,9,22 The data for the One-Mile Walk Test are more limited, with one study reporting an ICC of 0.91 in a small group of adolescents and another report- ing a correlation of 0.84 with V˙ O2max.1 Step tests are a method of estimating V˙ O2max, and they have the benefit of requiring minimal space and re- sources.10 Step test protocols are available for adults,24,25 and a recent systematic review of studies of the use of step tests in adults showed correlations varying from 0.47 to 0.95 when comparing predicted values with measured

192 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 V˙ O2max.26 These step tests tended to be highly valid in the scope was chosen as a practical method of heart rate population used to formulate the prediction equation determination. Polar heart rate monitors and an electro- but less valid when applied to different groups. Addi- cardiogram (ECG) may have provided more accurate tional research is needed to discern which step protocols data, but monitors do not work well on young children, are best to predict V˙ O2max in the adult population. and ECG is not practical for a clinical setting. We found fewer validated step tests to estimate aero- In addition, the sample size for this study was not cal- bic fitness in children. A systematic review in 2014 sought culated a priori. Nonetheless, post hoc analyses revealed to investigate all submaximal exercise equations devel- that we would have needed 23 children to obtain 90% oped to predict V˙ O2max in individuals aged younger power for testing the associations among five predictors than18 years.27 A total of 16 tests were included, and the (age, sex, BMI, step test average heart rate, and comor- majority involved running, walking, or cycling; only two bidity count) and V˙ O2max for the R2 of 0.51 obtained from studies used step tests. Francis and Feinstein studied 93 the analyses.33 Our sample size clearly exceeded the req- children aged 6–18 years who performed step tests and uisite sample size. Last, the resultant adjusted R2 of 0.51 found the correlation of a 15-second recovery heart rate for our prediction model for V˙ O2max shows sufficient and V˙ O2max to be 0.79 to 0.81, depending on the pace of promise for the ability to use the STEP to predict V˙ O2max steps per minute.28 Garcia and Zakrajsek evaluated the in children aged 7–10 years. Nonetheless, clinicians usefulness of the Canadian Aerobic Fitness Test in chil- should be cautioned that a single study does not provide dren aged 10–15 years;11 this protocol used a three-stage sufficient defining evidence to alter clinical practice. step test, and the total sample correlation with V˙ O2max was 0.79. One study developed a reference system of We anticipate that our work will prompt further mean post-exercise heart rate after a 3-minute step test research and efforts to build stronger evidence to deter- in children aged 6–12 years; however, this was not vali- mine the utility of the STEP among children. Further dated against actual V˙ O2max.10 research can also examine the relationships between other covariates, such as a child’s physical activity level The development of a validated step test for children or hydration level, and V˙ O2max to improve the precision of aged 7–10 years has great potential for use in a clinical the model. setting to monitor the fitness of individual patients over time, and in the schools, and to provide information on CONCLUSIONS the health status of students. The STEP protocol is sim- In summary, step tests can be used to estimate aerobic ple, is effort independent, and uses low-cost equipment (steps, metronome, stop watch, and stethoscope). It also fitness individually and for large samples of participants. requires a small amount of space and time and a minimal The newly developed STEP for children aged 7–10 years amount of training to administer. gives health care providers and educators the ability to measure and follow aerobic fitness in children over time. The argument for monitoring aerobic fitness regularly Although the STEP is a feasible option to assess aerobic and including it as a fifth vital sign in addition to the four fitness in children, the results of this study should be con- established vital signs (heart rate, blood pressure, tem- sidered preliminary, encouraging efforts to validate the perature, and respiratory rate) is gaining popularity in results in subsequent research studies. adults.29,30 It may be beneficial to also begin monitoring these in the paediatric population because the literature KEY MESSAGES shows that aerobic fitness is a marker of cardiovascular health in children and adolescents.4 Cardiovascular fit- What is already known on this topic ness is important for participation in sports as well as for Aerobic fitness is a marker of cardiovascular health in basic activities of daily life for children.31 Unfortunately, the fitness of young people is declining worldwide.32 paediatrics. Tests to estimate aerobic fitness in children Therefore, it may benefit physicians and health care pro- require substantial space and maximum effort, which is viders to monitor aerobic fitness over time to provide often difficult for children. effective feedback and interventions for patients. Because of its high test–retest reliability and low SEM, the newly What this study adds developed STEP allows aerobic fitness to be tracked. This study introduces a new, effort-independent step We acknowledge some limitations with our study. test to reliably estimate the aerobic fitness of children First, it was conducted at a single institution, which may ages 7–10 years. The protocol is simple and requires a limit the generalizability to other populations. The STEP small amount of space to administer. The step test allows was validated for children aged 7–10 years; however, we for aerobic fitness to be monitored over time by health were unable to validate it for a younger population (chil- care professionals and schools. dren aged 5–6 years) because of lower recruitment and a submaximal effort level. Second, auscultation by stetho- REFERENCES 1. Plowman SA, Meredith, MD. Fitnessgram/activity reference guide. 4th ed. Dallas, TX: The Cooper Institute; 2013.

Hayes et al. Developing and Validating a Step Test of Aerobic Fitness among Elementary School Children 193 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 2. Cureton KJ, Mahar MT. Critical measurement issues/challenges in 18. Cureton KJ, Sloniger MA, O’Bannon JP, et al. A generalized equation assessing aerobic capacity in youth. Res Q Exerc Sport. 2014;85 for prediction of VO2peak from 1-mile run/walk performance. Med (2):136–43. https://doi.org/10.1080/02701367.2014.898979. Sci Sports Exerc. 1995;27(3):445–51. https://doi.org/10.1249/ Medline:25098009 00005768-199503000-00023. Medline:7752874 3. Eisenmann JC, Welk GJ, Ihmels M, et al. Fatness, fitness, and 19. Wek GJ, Going SB, Morrow JR, et al. Development of new criterion- cardiovascular disease risk factors in children and adolescents. 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194 Physiotherapy Canada, Volume 71, Number 2 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 APPENDIX: STEP TEST OF ENDURANCE FOR PEDIATRICS 2 minutes at each step height, progressing from the 0.1- (STEP) PROTOCOL metre (4-in.) step to the 0.3-metre (12-in.) step. The sub- ject was instructed to stand in front of the step after each The step test protocol consisted of three step heights: 2-minute segment. Heart rate was auscultated by stetho- 0.1, 0.2, and 0.3 metres (4, 8, and 12 in.). Wooden steps scope for 10 seconds between each step height. This was were used and placed 0.3 metres (1 ft) apart in a linear the only break between steps. The test administrator pro- fashion. Subjects bench-stepped to a 22-step-per-minute vided verbal encouragement to keep the subjects on metronome cadence. Subjects were introduced to the cadence, if needed. The three heart rates auscultated cadence just before the test, and research staff demon- were averaged, and this result is the step test average strated the stepping cadence. Subjects followed a heart rate used in the final model to predict V˙ O2max. cadence of up, up, down, down. Subjects stepped for

Clinician’s Commentary on Hayes et al.1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 Cardiorespiratory endurance is an important component of auscultation to measure heart rate at the end of each stage was health-related fitness.2 Physiotherapists may, therefore, want to also curious. Even in very young children, and despite the relia- evaluate cardiorespiratory endurance in their clients who have, bility issues, it is usually measured using a heart rate monitor, or who are at risk for, impairment in this area. Maximum, or and it is usually measured during the exercise4 to avoid the pos- peak, oxygen uptake during a graded exercise test typically quan- sibility that heart rate recovery might influence the results. tifies cardiorespiratory endurance. This type of direct measure- ment of cardiorespiratory endurance, however, requires Information about the test–retest between-session reliability specialized equipment to analyze the expired gases. Because and about the minimal detectable change would also help clini- such equipment may not be available in a physiotherapy clinic, cians who want to use the test to make decisions about the ef- tests that estimate cardiorespiratory endurance without expired fects of an intervention or about change over time. Also, more gas analysis, referred to as clinical tests or field tests, may be information about the error associated with the maximum oxy- more feasible for physiotherapists to use. gen uptake prediction and an independent validation of the algorithm would help test users interpret the maximum oxygen Hayes and colleagues1 were interested in clinical cardiore- uptake predictions. Finally, future studies may want to evaluate spiratory endurance tests appropriate for younger school-aged the measurement properties of the STEP with the various clinical children aged 5–10 years. They developed and evaluated some of populations appropriate for the test, because this information the measurement properties of a new submaximal step test, the would also help physiotherapists interpret test results. Step Test of Endurance for Pediatrics (STEP). This test uses a set of three wooden steps, 0.1, 0.2, and 0.3 metres high. Beginning In conclusion, Hayes and colleagues1 have provided some pre- with the lowest step, children step up and down at 22 steps per liminary evidence about the reliability and validity of the STEP. minute (following a metronome) for 2 minutes, with a 10-second Physiotherapists interested in knowing more about available pae- break between steps (stages), during which time their heart rate is diatric cardiorespiratory endurance tests may want to follow the measured by means of auscultation. The test score is the heart guidelines in the COnsensus-based Standards for the selection of rate, in beats per minute, during the 10 seconds after each 2- health Measurement INstruments.5 These guidelines recommend minute stage and the average of these three end-stage heart rates. that clinicians consult systematic reviews of the measurement properties of tests, which evaluate, for the population of interest, The researchers recruited 170 children aged 5–10 years who the construct of interest (in this case, cardiorespiratory endur- had no contraindications to exercise testing, although some of ance). Another recommended strategy, if systematic reviews are them had comorbidities (attention deficit disorder, asthma, heart not available, is to refer to individual articles that have evaluated murmur, environmental allergies). The children performed the the measurement properties of the test with the population of STEP twice, followed by a graded exercise test to exhaustion on a interest. treadmill, during which time their expired gases were analysed. There was a 15-minute break between each test. The authors Désirée B. Maltais, PhD, PT report high test–retest within-session reliability of the various Associate Professor, Department of Rehabilitation, heart rate results (intra-class correlation coefficients < 0.90). How- ever, in their opinion, many of the children aged 5 and 6 years did Université Laval, and Researcher, Centre for not appear to be able to reach an adequate level of exertion dur- Interdisciplinary Research in Rehabilitation and Social ing the STEP; as a result, they were not able to validate the test for Integration, Quebec City; [email protected]. this age group. For the group aged 7–10 years, who had an ade- quate result for the graded exercise test on the treadmill (111 of REFERENCES 125 children of both sexes), the average STEP heart rate and BMI accounted for about half the variance in maximal oxygen uptake. 1. Hayes RM, Maldonado D, Gossett T, et al. Developing and validating a step test of aerobic fitness in elementary school children. Physiother The study illustrates some of the challenges in developing a Can. 2018;71(2):xxx–xx. https://doi.org/10.3138/ptc.2017-44. new paediatric cardiorespiratory endurance test for clinical prac- tice. The test may not be feasible for some clinicians to use 2. Pate RR. The evolving definition of physical fitness. Quest. 1988;40 because it requires steps of three specific heights. Given that the (3):174–9. https://doi.org/10.1080/00336297.1988.10483898. test may not be feasible for children aged 5–6 years, a test requir- ing less motor control, or a smaller difference in the level of exer- 3. Eiberg S, Hasselstrom H, Gronfeldt V, et al. Maximum oxygen uptake tion between the stages, may be needed for them and perhaps and objectively measured physical activity in Danish children 6–7 for some clients with motor impairment. Performing all tests in a years of age: the Copenhagen school child intervention study. Br J single session may also have been fatiguing for the children in Sports Med. 2005;39(10):725–30. https://doi.org/10.1136/ the study, even if their heart rate recovered between the tests. bjsm.2004.015230. Medline:16183768 The maximum oxygen uptake values in the study, for example, are on the lower end of what is typically seen for children with- 4. Nguyen T, Obeid J, Timmons BW. Reliability of fitness measures in 3- out motor impairment.3 to 5-year-old children. Pediatr Exerc Sci. 2011;23(2):250–60. https:// doi.org/10.1123/pes.23.2.250. Medline:21633137 The study protocol cannot rule out the fact that fatigue might have influenced test performance, especially on the graded exer- 5. COSMIN. Find the right tool [Internet]. Amsterdam: COSMIN; n.d. cise test on the treadmill, the third test performed. The use of [cited 2018 Oct 16]. https://www.cosmin.nl/finding-right-tool/. DOI:10.3138/ptc.2017-44-cc 195

https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Monday, February 22, 2021 9:48:24 PM - IP Address:43.246.243.82 COCHRANE COLLABORATION What does Cochrane Say about . . . the Use of Acupuncture in Rehabilitation? Deare JC, Zheng Z, Xue CCL, et al. Acupuncture for treating Database Syst Rev. 2013;3:CD007700. https://doi.org/10.1002/ fibromyalgia. Cochrane Database Syst Rev. 2013;5:CD007070. 14651858.cd007700.pub3. Medline:23543554 https://doi.org/10.1002/14651858.cd007070.pub2. Med- line:23728665 Xu M, Li D, Zhang S. Acupuncture for acute stroke. Cochrane Database Syst Rev. 2018;3:CD003317. https://doi.org/10.1002/ Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the preven- 14651858.cd003317.pub3. Medline:29607495 tion of tension‐type headache. Cochrane Database Syst Rev. 2016;4:CD007587. https://doi.org/10.1002/14651858.CD007587. Yang A, Wu HM, Tang JL, et al. Acupuncture for stroke rehabilita- pub2. tion. Cochrane Database Syst Rev. 2016;8:CD004131. https://doi. org/10.1002/14651858.cd004131.pub3. Medline:27562656 Manheimer E, Cheng K, Linde K, et al. Acupuncture for periph- eral joint osteoarthritis. Cochrane Database Syst Rev. 2010;1: The Cochrane Collaboration is an international not-for-profit CD001977. https://doi.org/10.1002/14651858.cd001977.pub2. and independent organization dedicated to making up-to-date, Medline:20091527 accurate information about the effects of health care readily available worldwide. It produces and disseminates systematic re- Manheimer E, Cheng K, Wieland LS, et al. Acupuncture for hip views of health care interventions and promotes the search for osteoarthritis. Cochrane Database Syst Rev. 2018;5: CD013010. evidence in the form of clinical trials and other studies of inter- https://doi.org/10.1002/14651858.cd013010. Medline:29729027 ventions. For more information, visit http://www.cochrane.org. Wong V, Cheuk DKL, Lee S, et al. Acupuncture for acute manage- DOI:10.3138/ptc.71.2.cochrane ment and rehabilitation of traumatic brain injury. Cochrane 196