Physiotherapy 100 (2014) 73–79

Relevant patient perceptions and experiences for evaluating quality of

interaction with physiotherapists during outpatient rehabilitation:
a qualitative study
M. Elena Del Baño-Aledo a , Francesc Medina-Mirapeix b,∗ , Pilar Escolar-Reina b ,
Joaquina Montilla-Herrador b , Sean M. Collins c
a Central Unit of Anatomy, Catholic University San Antonio, Murcia, Spain
b Department of Physiotherapy, Regional Campus of International Excellence ‘Campus Mare Nostrum’, University of Murcia, Murcia, Spain
c Department of Physical Therapy, University of Massachusetts, Lowell, MA, USA

Abstract
Objective To identify elements of the physiotherapist–patient interaction considered by patients when they evaluate the quality of care in
outpatient rehabilitation settings.
Design A qualitative study with nine focus groups, Two researchers conducted the focus groups, and a topic guide with predetermined questions
was used. Each group discussion was audiotaped„ transcribed verbatim and analyzed thematically according to a modified grounded theory
approach.
Setting Three postacute ambulatory centers in Barcelona, Madrid and Seville (Spain).
Participants Fifty-seven adults undergoing outpatient rehabilitation for musculoskeletal conditions/injuries.
Results Patients based their evaluations of quality of care on their assessment of physiotherapists’ willingness to provide information and
education, technical expertise and interpersonal manners (eg. respect, emotional support and sensitivity changes in the patient’s status). Both
positive and negative aspects of the physiotherapist–patient interaction emerged under all these themes, except for friendly and respectful
communication.
Conclusion This study identified which elements of the physiotherapist–patient interaction are considered by patients when evaluating
the quality of care in rehabilitation outpatient settings. Further research should work to develop self-report questionnaires about patients’
experiences of the physiotherapist–patient interaction in rehabilitation services to provide empirical and quantitative evidence.
© 2013 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Quality of health care; Qualitative research; Physiotherapy; Outpatients; Rehabilitation

Introduction been created to measure them [5–7]. Often, these ques-

In health and rehabilitation care literature, there is rela-
tively broad agreement on the need for a patient-centered
approach in service delivery [1–4]. Therefore, efforts have
been made to determine aspects of care relevant for patient-
centered care, and several self-report questionnaires have
∗ Correspondence: Departamento de Fisioterapia, Facultad de Medicina,
Universidad de Murcia, 30100, Campus de Espinardo, Murcia, Spain.
Tel.: +34 868884199; fax: +34 868884150.
E-mail address: mirapeix@um.es (F. Medina-Mirapeix).
tionnaires focus on the aspects related to interpersonal
interactions that take place during service delivery. However,
recent studies have indicated that not all aspects of deliv-
ery of care are predictive of patients’ overall evaluations of
the quality of care, such as satisfaction or perceived service
quality [8].
Capturing what matters to patients when they evaluate
their health care is increasingly recognized as essential in
quality assessment and improvement efforts [9,10]. Attempts
have been made to determine the features of patient care that
are likely to influence patient satisfaction in rehabilitation

0031-9406/$ – see front matter © 2013 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.physio.2013.05.001
74 M.E. Del Baño-Aledo et al. / Physiotherapy 100 (2014) 73–79
services [11–13], but little advance has been made regarding
what matters to patients when they evaluate their perceived
service quality.
This article explores the physiotherapist–patient interac-
tion and patients’ perceptions of service quality in outpatient
rehabilitation settings in Spain. As an outpatient rehabili-
tation setting consists of alert patients (i.e. patients are not
sedated and usually participate actively in their treatment),
and programs typically last for multiple weeks with one
session per day, and include manual therapy, exercise and
instruction, patients and therapists need to interact continu-
ally and modifications may need to be made to the program
[11]. Therefore, the physiotherapist–patient relationship is at
the heart of the overall perception of service quality, as reha-
bilitation services always require interpersonal interactions
which occur over a prolonged period of time [14,15].
Service quality has been widely conceptualized in market-
ing, yet it has not been fully studied in rehabilitation services.
In part, this conceptualization recognizes that the interaction
elements influencing service quality perceptions can be clas-
sified into three groups: attitude, behaviors and/or expertise
of the service personnel [16]. Although these elements or
their importance can vary across contexts, there is no consen-
sus regarding the content of these elements in rehabilitation
services.
The purpose of this study was to identify elements of
the physiotherapist–patient interaction that are considered by
the patient when evaluating the quality of care in outpatient
rehabilitation settings.
Methods
Design
The qualitative design involved focus groups because
group interaction can trigger responses and build insights that
may not arise during individual interviews [17]. Focus groups
have been used previously to identify experiences related to
perceptions of overall quality [16].
Setting and participants
This study included subjects who were receiving postacute
rehabilitation services from a healthcare provider network
in Spain, in a total of three centers located in Barcelona,
Madrid and Seville. They were all public interdisciplinary
outpatient rehabilitation centers with similar organizational
and professional characteristics.
The subjects were included if they were aged 18 years
or older, had musculoskeletal disorders (i.e. fractures, joint
replacements, orthopedic surgery), and had received more
than 10 sessions of physiotherapy. Subjects were excluded
if they were non-Spanish speaking or had communication
impairments.
Recruitment
The study was approved by the Committee of Ethics and
Research of the University of Murcia. The recruitment pro-
cess took place in February and March 2007. Subjects were
identified in each ambulatory center using a list of patients
referred to rehabilitation care. In total, 95 patients were eli-
gible for participation in this study.
Purposive sampling was used to include subjects with
varying ages, genders, and clinical conditions. This allowed
for the selection of participants who could best provide
insight into specific and personal experiences about the issues
being examined, rather than obtaining a representative sam-
ple as would be sought in quantitative research [18].
The size of each group was sufficiently large to create dis-
cussion but not so large as to prohibit some members from
being able to share their insights within the available time. It
is generally considered that an adequate group size is between
four and 12 participants, with the optimal size being between
six and eight individuals so that subgroups are not formed
[19]. Although the authors were aware that the final sam-
ple size was dependent on the saturation of information, 62
subjects were selected initially, which enabled creation of
between seven and 10 focus groups. In the authors’ expe-
rience, the content of group discussions becomes repetitive
and no new information is acquired when nearing the point of
“enough” about six to eight focus group encounters [20,21].
In each center, a research assistant handed an invitation
letter to selected subjects and confirmed their willingness to
participate. This letter contained an explanatory statement,
date and place of meeting. The letter was not signed by a
physiotherapist in order to limit the possibility of subjects
feeling intimidated about participating. When several patients
declined to participate, new patients with similar character-
istics were invited in order to create a group with at least four
members. Subjects were asked to confirm their attendance 2
to 3 days before the relevant focus group.
Data collection
Two researchers conducted the focus groups: one mod-
erator (MEDBA) and one assistant (FMM). A topic guide
that contained predetermined questions was used, and this
was created from a literature review (Table 1). Additional
questions were included as themes emerged from the ini-
tial focus groups.Group discussions were audiotaped for data
collection.
The focus group interviews started with a brief introduc-
tion, presenting the aim of the study, how the information
would be used and asking permission to audiotape the inter-
view.All participants gave their consent, and agreed to the
request to keep the discussion confidential. Participants were
encouraged to discuss,their opinions, rather than find con-
sensus. Focus groups were conducted until data saturation
was reached. Thematic saturation was reached when no new
 M.E. Del Baño-Aledo et al. / Physiotherapy 100 (2014) 73–79
Table 1
Thematic guide for focus group discussions.
Encouragement to speak freely about whatever they think is relevant
for the study, experiences from the onset of their disorder, etc.
How the participants were informed about/recruited to rehabilitation
care.
Description of the first day in the center.
Experienced follow-up from therapists in the first weeks until the time
of the focus group
Descriptions of ways to meet needs during therapeutic sessions.
Suggestions for ways to improve the quality of the
physiotherapist–patient interaction
Additional comments/reflections.
themes were discovered during the focus groups [18]. Ses-
sions lasted an average of 1 hour.
The sessions were transcribed verbatim. Notes taken dur-
ing the interviews and the moderator’s reflections were used
to write a report of each focus group.
Analysis
Transcribed sessions were used for independent analysis.
Participants’ names were changed using an assigned numeric
code in the transcripts and quotations. Data analysis was
undertaken using a modified grounded theory approach [22].
Two authors (MEDBA, FMM) reviewed the transcripts
independently and coded sentences that contained mean-
ingful incidents. These were labeled in categories using a
combination of predetermined and emergent codes. These
two authors reviewed and compared their findings in order
Fig. 1. Selection process for focus groups.
75
to reach agreement on codes and categories. Three rounds of
coding and discussion took place with the aim of enhanc-
ing the credibility of the coding process and to develop
clearer categories. This process was iterative with data collec-
tion from subsequent transcripts. The next level of analysis
involved identifying relationships between categories and the
grouping of categories with hierarchical conceptual unifor-
mity into themes and subthemes.
To check consistency of the final themes and subthemes,
two researchers (FMM, JMH) cross-checked their agreement
through a blind review using codes for the same passages
of 2 transcripts [18]. Any disagreements between the two
researchers were resolved by discussion. At every step, an
independent author (PER) played the role of reviewer to ver-
ify if the analysis was systematically supported by the data
with the intention of enhancing dependability [22].
Results
Data saturation occurred after nine focus groups (three
at each centre); the final two groups did not contribute any
new themes or categories. Focus group sizes varied from
six to seven participants. The stages of selection for the
focus groups are shown in Fig. 1. (see supplementary online
material). A total of 57 patients participated in these focus
groups. Characteristics of patients are shown in Table 2.Of
the 62 patients selected, only five did not attend a focus
group meeting, and there was a similar dropout rate from
the 3 centers evaluated. These subjects did not express any
76 M.E. Del Baño-Aledo et al. / Physiotherapy 100 (2014) 73–79

Table 2 supportive care from physiotherapists was essential for

Characteristics of participants. them to learn how to deal with their own disabilities and
Characteristics n (%) to build their self-confidence Consequently, supportive
Sex care was appreciated as a relevant factor that influenced
Male 33 (58) their perceptions of service. Supportive care was
Female 24 (42) perceived during dialog with therapists and by their
Age (years)
<30 12 (21)
willingness to listen to patients’ viewpoints or concerns
31 to 45 21 (37) “My physiotherapist always encourages me to reach
>45 24 (42)
Diagnosis
maximum improvement. To have a professional that
Fractures 28 (49) helps me and gives me emotional support is very impor-
Upper limb 14 (25) tant for my perception of service quality.” (Female, 51
Lower limb 14 (25) years, shoulder injury).
Soft tissue injuries 25 (44)
Shoulder 11 (19) Sensitivity to change in the patient’s status therapists’
Knee 10 (18) consideration of changes in patients’ functional or emo-
Others 4 (7) tional status and their life circumstances over time was
Amputation 4 (7) appreciated. Participants perceived high service quality
when physiotherapists made an effort to understand
the participant’s changes and were willing to develop
reason for their non-participation. Patients’ experiences and
quick responses to those changes. Participants valued
perceptions were related to one of the following themes:
responses such as an alternative treatment in response to
(1) interpersonal manners; (2) providing information and
pain or a change in emotional or functional status; and
education; and (3) technical expertise. They will be presented
changing appointments in response to unexpected life
in subthemes with example quotes.
situations.
(1) Interpersonal manners “Some days I am worse. I have more pain or I’m in
The way in which physiotherapists related to par- low spirits to exercise. When I tell my physiotherapist
ticipants and carried out their work was important in this change he always tries to use alternative techniques
the perception of service quality. The following data to avoid hurting me or he avoids demanding of me
emerged as subthemes. high efforts. They provide a good service.” (Female, 44
Friendly and respectful communication: friendly and years, upper limb fracture).
respectful behavior of physiotherapists was a predom-
inant patient experience reported in all focus groups. Participants who felt a delayed response to recovered
Negative experiences with physicians were used to functions perceived a lower quality of service While
emphasize the respectful behavior of physiotherapists. some participants reported low service quality in relation
to the effectiveness of their treatments, others reported
“The physiotherapists are very nice. They behave so problems of being bored, especially during exercise.
kindly that I feel that everything works better. In con- There was consensus the professional’s response should
trast, some doctors had a more distant attitude. For them be constantly aligned with the patient’s acquired skills
we are like a number in a list.” (Female, 48 years, lower and functions.
limb fracture).
“Three weeks ago, I could walk without any problem,
Although all participants agreed that respectful behav- but I’m just walking in the swimming pool for training
ior facilitated positive perceptions of service quality, the gait and I’m bored.” (Male, 35 years, lower limb
some participants commented that respectful behavior fracture).
was not enough in itself to ensure a positive per-
(2) Providing information and education
ception of service quality throughout the treatment
All participants reported a strong motivation to
period.
understand their situation and to be given education and
“I felt comfortable with the manner of my physiother- information, especially at the beginning of treatment.
apist, but I think that being friendly is not enough to They wanted early explanations about their problem,
provide a good service. For example, sometimes, she prognosis and treatment. They agreed that knowledge
didn’t supervise the exercise session as she should have helped them to organize their thoughts and grasp what
done.” (Male, 21 years, amputation). was happening. Thus, most participants judged service
quality by physiotherapists’ attitudes and behaviors
Emotional support: the long-term disabilities of the
when providing information and education.
participants led to continuous uncertainty and emotional
needs throughout the treatment period felt particularly “The physiotherapist spent a lot of time explaining the
in the first weeks. Most participants mentioned that usefulness of each exercise to me. It has been very
 M.E. Del Baño-Aledo et al. / Physiotherapy 100 (2014) 73–79
important for me, especially in the first sessions of
treatment.” (Male, 37 years, torn ligament).
When physiotherapists were willing to provide
patients with regular information and education about
their plan of care or health status, this had a positive
impact on patients’ perceptions of service quality.
Conversely, when physiotherapists provided no clear
or accurate information, this had a negative impact on
patients’ perceptions of service quality.
“My negative perceptions of service quality with my
physiotherapist were affected by his lack of answers to
my questions. When I asked him about my progress he
just said everything was all right, he didn’t give me any
explanation.” (Female, 48 years, torn ligament).
(3) Technical expertise
All participants acknowledged that the physiother-
apist’s technical expertise impacted their perceptions
of service quality. The impact was based on partici-
pants’ feelings about the physiotherapists’ ability to
provide good assessments and early improvement of
functioning. Many of these feelings were reported by
comparing outcomes or qualifications of knowledge
among professionals.
“Service quality is directly affected by the therapists’
expertise to get good outcomes. I lost 30◦ of flexion in
15 days with a therapist but I gained 10◦ in the same time
with another one. My opinion of service quality was
very different.” (Female, 31 years, lower limb fracture).
Discussion
The results of this study demonstrate that patients base
their evaluations of service quality on their assessment of
therapists’ interpersonal manners, willingness to provide
information and education, and technical expertise.
Providers’ interpersonal manners are elements of the
interpersonal process captured by almost all service quality
measures in health services [23]. Interpersonal manners iden-
tified by the study participants – respectful, emotional support
and sensitive to patients’ changes – appear to be three impor-
tant elements of interpersonal care. Moreover, there is strong
evidence that these particular elements of interpersonal care
are related to patients’ satisfaction with rehabilitation care
[11,14,24]. Patients in the current study mentioned nega-
tive experiences concerning delayed response to changes or
needs. This may be due to the emphasis on cost-cutting,
high patient volume and understaffing of the current Span-
ish healthcare services, which reduces the period of time
for physiotherapist–patient interactions. Hence, additional
monitoring of health status during treatment can lead to
improvements in perception of quality.
The relevance of the role of physiotherapists in pro-
viding information, teaching and education for patients’
77
satisfaction [25,26] was also supported by the findings for
patients’ perceptions of service quality. In general, phy-
siotherapists who provided information about the cause of
the patient’s problem and rationale for treatments were
perceived by the participants as active, whereas physiother-
apists who gave information about prognosis and discharge
were perceived as passive. This result is consistent with other
qualitative studies [4]. Therefore, there is room for improve-
ment in the areas related to progress and outcomes. This is
likely due to lack of knowledge on recovery patterns over time
and the dynamic nature of the disability process in which
each patient exhibits a unique trajectory of recovery that
may include periodic setbacks. In this context, physiother-
apists may need to reflect on ways to handle uncertainty of
this nature, specifically how to convey this uncertainty to the
patient and what unknown factors, if known, would reduce
uncertainty.
This study provides evidence that both physiotherapists’
communicative skills and updated technical expertise are
significant matters influencing patients’ perceptions of qual-
ity.This study is consistent with previous studies which have
found that perceptions of qualifications and technical exper-
tise during assessment and treatment are related to service
quality [27].
In spite of the relevance of technical expertise as a factor
influencing perceptions of service quality, it is a controversial
factor because some authors have concluded that patients’
assessments by questionnaires are not reliable for assess-
ment of the technical quality of care [10]. As such, there is
no consensus regarding its inclusion in instruments to mea-
sure perceptions of quality of care [28]. However, the trend
for its inclusion is growing because, as in the present study,
patients always have an opinion about their physiotherapist’s
practices and this opinion will influence their perceptions
of service quality [29]. The measurement of patient percep-
tion is thus informative in any case, regardless of whether or
not this perception conforms with professional standards of
quality. It seems that patients, use of information from past
versus current episodes of care in their assessment of tech-
nical expertise needs to be considered. If a patient assesses
technical expertise based on progression or outcomes and
compares this with a previous episode of care, the differences
may be entirely related to the underlying condition and not to
technical expertise. A goal should be an assessment of tech-
nical expertise from the patient perspective that attempts to
be either immune to differences in the underlying condition
across various episodes of care, or makes this component of
assessment very explicit such that its impact can be evaluated.
It is also possible that technical expertise and providing
information and education are related to therapists possess-
ing higher technical expertise, handling and communicating
uncertainty better than those with lower technical expertise.
This study identified many patients’ experiences with
positive and negative impacts on service quality. In all
themes and subthemes apart from friendly and respectful
communication, both positive and negative experiences were
78 M.E. Del Baño-Aledo et al. / Physiotherapy 100 (2014) 73–79
included. Some patients identified either positive or negative
experiences in all areas, but patients often mentioned positive
and negative experiences with the same physiotherapist.
This finding suggests that even though these patients could
recollect positive experiences in rehabilitation, at certain
times during the physiotherapist–patient interaction, the
patients perceived problems that in some way compromised
their perception of service quality [24].
Limitations of the study
The present study has certain limitations that need to be
taken into account. The study was crossisectional and the
participants’ recollection of events was retrospective, relying
on their memory of past events. It is possible that signifi-
cantly positive and negative aspects of care were reported
more frequently than more neutral aspects. It is possible
that other study designs would allow the subjects to provide
a more detailed and complete perspective of their experi-
ences. For example, longitudinal and prospective studies that
follow patients throughout the entire rehabilitation process
may offer additional understanding about which elements
influence quality perceptions.
Although there were limitations to this study, the method-
ology used was controlled. Methodological rigor was
enhanced by multiple and coordinate coding and cross-
checked codes developed by different researchers when
comparing results. The principal investigator’s personal and
intellectual biases were minimized by using a research assis-
tant for the interviews, by allowing open questions to develop
the interviews naturally, and by reporting on a wide range of
perspectives.
Implications for practice
This study has provided important new insights into the
specific dimensions that patients use to evaluate service qual-
ity in rehabilitation outpatient settings. Firstly, reports with
the main results and conclusions of the study were provided
to the managers of the three physiotherapy departments that
participated in the research along with suggestions and strate-
gies that could be adopted to improve perceived quality. These
strategies included: allocating time for individualized treat-
ment for each patient regarding his or her needs; giving;
patients verbal or written information of their progress and
treatment; and grouping patients with similar processes so
they can perform the same exercises under a physiotherapist’s
supervision. Since the professional and personal manners
of physiotherapists, in addition to the provision of infor-
mation, appear to influence patients’ perceptions of quality,
these issues should be taken into account in the design of the
rehabilitation setting (e.g. having individual rooms to inform
confidentially about treatment progress).
Secondly in addition to managers, clinicians should
take these issues into account to benchmark their perfor-
mance, given that individual physiotherapists have the main
responsibility to provide the best treatment for their patients
at every moment to obtain the best results.
Third, this study also has implications for the education
and ongoing training of physiotherapists. In view of the fact
that respectful and supportive care is such an important aspect
of service quality, it is important that physiotherapists receive
specific training on how to analyze the perspectives of people
receiving services and preparation in the “art” of care.
Moreover, the findings also imply a need to develop
self-report questionnaires about patients’ experiences of the
physiotherapist–patient interaction to provide empirical and
quantitative research on several issues: the association of
patients’ perceptions of service quality and compliance with
physiotherapy; the in-depth study of the characteristics of
professionalism in each sector; and the relations between
interaction experiences and outcomes, such as patient sat-
isfaction and health status.
Conclusion
These findings indicate that therapists’ interpersonal
manners, their willingness to provide information and
technical expertise influence patients’ perceptions of the
quality of care in rehabilitation settings. Results from this
study contribute important information to the literature
relating physiotherapist–patient interaction factors to service
quality, and highlight the need for physiotherapists and
managers to review their performance from the point of view
of patients.
Ethical approval: Committee of Ethics and Research of the
University of Murcia (Ref. no. 238/2006).
Funding: This study was supported by a research
grant from the Ministry of Health and Consumers Affairs
(PI060836) Spain.
Conflict of interest: None declared.
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