Physiotherapist and Patient Experiences of Team-Based Interprofessional Collaboration During the COVID-19 Pandemic in Canada

Abstract

Purpose: To examine the perspectives of physiotherapists and physiotherapy patients regarding team-based interprofessional collaboration during the COVID-19 pandemic in Canada. Method: This mixed methods study combined online surveys (physiotherapists, patients) and qualitative semi-structured interviews (patients). Descriptive statistics and thematic analysis summarized the quantitative and qualitative data before final data integration. Results: Physiotherapists (n = 334) and patients (n = 784) participated in the surveys, while 19 patients were interviewed. Less than half (48%) of physiotherapists reported delivering care as part of multidisciplinary teams and 38% of these individuals reported that the pandemic decreased their ability to deliver team-based, interprofessional care. Physiotherapists found that team-based care was negatively impacted by communication challenges, poor care coordination, and patients lacking access to other health professionals. While over one-third (38%) of patients reported poor care coordination between health professionals, qualitatively many patients reported that these challenges were similar pre-pandemic. They also experienced increased communication challenges and emphasized poor access to general practitioners and specialists. Both groups saw future opportunities for increased use of virtual care to improve team-based health care delivery. Conclusions: Physiotherapists and patients had varied experiences with aspects of team-based care during the pandemic that included challenges with communication, care coordination, and ability to access health professionals. Improved training and implementation of virtual care may enhance interprofessional collaboration and improve patient care in the future.

The COVID-19 pandemic began in December 2019,¹ with its spread having devastating and far-reaching consequences worldwide. In Canada, public health measures were put in place including social distancing protocols, public school closures, and restricted access to most in-person health care, all aiming to curb the spread of the infection.² These measures caused massive disruptions to daily life, including to usual health care organization and delivery across all services, such as preventative care services and chronic disease management.^2,3

The pandemic exacerbated many current health care challenges in Canada resulting from an antiquated fee-for-service system, an aging population, and the increasing burden of chronic disease.⁴ The pandemic also aggravated problems related to the lack of health care providers working in a team-based approach to deliver care to these complex populations.⁵ However, interprofessional collaboration has become even more critical with the rise of complex and chronic diseases.^6–8 Defined by the World Health Organization as when “multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care,” interprofessional collaboration involves health care professionals working together to apply their unique knowledge and skills to patient management.⁹

Interprofessional collaboration between health professionals, also known as team-based care or multidisciplinary team care,¹⁰ can improve both clinician well-being and patient outcomes.^11–13 Physiotherapists are trained as experts in exercise prescription and promotion of self-management strategies for people with musculoskeletal, cardiorespiratory, and nervous system conditions. Therefore, it is unsurprising that family physicians and nurse practitioners see physiotherapists as making important contributions to these collaborations, particularly in the management of chronic diseases.¹⁴ However, the integration of physiotherapists in team-based care in community settings has been slow in Canada. A previous study reported that only 18% of community health centres in Ontario have physiotherapists as part of their health care teams.¹⁵ Little is known about the role of physiotherapists as part of interprofessional collaborations in other Canadian health care settings.

The pandemic highlighted potential opportunities for physiotherapists to increase their participation in team-based interprofessional collaboration to improve patient health outcomes. For example, physiotherapists in teams could have provided supervised exercise-therapy and education for patients with osteoarthritis who experienced lengthy delays for total joint replacement during the pandemic.^16,17 These opportunities remain in the context of COVID-19 recovery, where physiotherapists could have a key role as part of a team helping patients to recover from COVID-19 by providing safe rehabilitation and exercise to help address fatigue and the sequelae of other complex symptoms.^18,19

Physiotherapists have the potential to be included as important team members in interprofessional collaborative care models well beyond the pandemic. Yet, the perspectives of the physiotherapy profession on team-based interprofessional collaboration during the pandemic are largely unknown. Furthermore, the lived experience and perspectives of patients in receiving team-based interprofessional care during the pandemic, which could inform future strategies in expanding this model of care, has not been explored. The purpose of this work was to examine the perspectives of Canadian physiotherapists and physiotherapy patients towards team-based interprofessional collaborations during the COVID-19 pandemic.

Methods

Research design

This study used a mixed methods explanatory sequential design²⁰ to examine the perspectives of physiotherapists and physiotherapy patients towards team-based interprofessional collaboration during the COVID-19 pandemic across three phases. Phases 1 and 2 involved pan-Canadian cross-sectional surveys, while phase 3 involved in-depth qualitative interviews with a subset of physiotherapy patients who had completed the survey in phase 2 (Figure 1). We felt the open-ended responses from physiotherapists in phase 1 already provided rich responses that enhanced the quantitative survey data; thus we choose to focus our qualitative phase on generating further in-depth understanding of patient experiences of team-based care. The sequential design allowed the preliminary results from the earlier phases (phase 1 and 2) to inform the future research questions (phase 2 and 3) and interview guide (phase 3).²¹ This novel mixed methods design incorporates perspectives of multiple stakeholder groups where the one-on-one, semi-structured qualitative interviews facilitate a richer, deeper understanding of the quantitative data obtained in the surveys.²⁰ In data collection across study phases we used the term ‘team-based care’ as a synonym for interprofessional collaboration.²² Reporting of this study has been guided by the Good Reporting of A Mixed Methods Study (GRAMMS) Checklist.²³ All study procedures were approved by the University of British Columbia Behavioral Research Ethics Board (H20-02878).

Figure 1.

Mixed methods study design flow chart.

Figure 1 Extended Description

Recruitment

Phase 1: All registered Canadian physiotherapists who had internet access were eligible to participate in the COVID-19 Quick Canadian Physiotherapist survey.²⁴ The survey aimed to understand physiotherapists’ experiences adapting their delivery of patient care during the first and second waves of the COVID-19 pandemic. The British Columbia Primary Health Care Network²⁵ supported the data-collection process. The online survey consisted of eight brief cross-sectional cycles, available in English and French, with each cycle open for responses for 4 days. The anonymous survey link was distributed to participants through e-newsletters (Canadian Physiotherapy Association [CPA], Physiotherapy Association of British Columbia, and the CPA Orthopaedic Division), as well as on X (Twitter at the time of distribution), and via researchers and collaborators from researchers’ personal networks. Detailed methodology on the overall survey development and distribution strategy has previously been published.²⁴ The cycles were launched between May 15, 2020, and October 19, 2020. The current study reports on data collected in cycle seven, which was open for responses from September 18 to 21, 2020, where the survey questions focused on team-based care. We have previously published the findings from other cycles related to physiotherapists implementation of virtual care.²⁴

Phase 2: Patients aged 16 years and older who had received physiotherapy in Canada in the previous 12 months were invited to participate in an 8-minute electronic survey. The survey was launched on November 11, 2020 and remained open for 1 month. It was distributed to patients by 11 physiotherapy clinic partners located in 6 provinces (Alberta, British Columbia, Newfoundland, Nova Scotia, Ontario, and Saskatchewan) via clinic newsletters or using study posters, through the CPA E-newsletter, and on social media platforms and channels (e.g., Twitter and Facebook) of the research team investigators and collaborators.

Phase 3: Patients who completed the cross-sectional survey in phase 2 had the option to leave their email address if they agreed to be contacted to participate in a semi-structured one-on-one interview. This study phase was informed by an interpretative descriptive paradigm²⁶ that aimed to generate further understanding of patient health care experiences during the pandemic. Interview participants were selected and contacted based on diversity across location (province), age, gender, and mode of physiotherapy delivery (in-person or virtual physiotherapy) among participants who left contact details.

Data collection

Part 1: A full description of all questions across the eight survey cycles has previously been published.²⁴ The study information page was embedded at the beginning of the online survey and participation in the survey implied the provision of consent. The current study reports on data generated in cycle seven where there were both closed-ended and open-ended questions. Closed-ended questions included sociodemographic characteristics (e.g., gender, practice location, practice details) and questions related to physiotherapists’ experience with team-based care provision during the COVID-19 pandemic. Specifically, physiotherapists were asked whether they provided care as part of a multidisciplinary team (e.g., working closely with other health professionals including primary care providers, specialists, nurse practitioners, dieticians, etc.), with response options of “yes” or “no”. For those who answered “yes,” they were further asked about their beliefs regarding any change in their ability to provide team-based care during the COVID-19 pandemic (“Since the start of COVID-19 in Canada, do you feel there has been any change in your ability to provide team-based care?”). Participants chose one of the three provided options: no change in ability, increased ability, or decreased ability to provide team-based care. Following this was an open-ended question to explain why or how they believed their ability to provide team-based care had changed. The University of British Columbia's Survey Tool was used to manage survey data.²⁷

Part 2: The patient survey included a set of sociodemographic questions (e.g., age, gender, province) and closed-ended questions related to patients’ experiences with interprofessional care during the COVID-19 pandemic. These questions included: (1) “What other health services (in addition to physiotherapy) have you received since the start of the pandemic in Canada (March 2020)?”, (2) “How much did your family physician or nurse practitioner help you get access to other needed healthcare services from place to place in the last 6 months?”, (3) “How much have the health care professionals (specialist, physiotherapist, and family doctor) helped to ensure smooth transitions from one healthcare professional to another?”, (4) “Overall, do you feel the appointments with healthcare professionals (specialist, physiotherapist, and family doctor) are coordinated to offer you the best possible care?” Participants provided responses on a Likert scale from 1 = no help/not coordinated at all; to 5 = a lot of help/very coordinated.

Phase 3: Semi-structured one-on-one interviews were conducted via videoconference using a topic guide that was developed by the research team (online Appendix 1). The development of the interview guide was informed by previous research expertise from two authors as well as the preliminary results from phases 1 and 2. One author (SW) has extensive background in studying team-based care,^28,29 while another author (AE) previously led qualitative research, which involved understanding physiotherapist and physiotherapy patient experiences with virtual care.³⁰ The interview was broadly focused on the experiences of physiotherapy patients during the pandemic, including virtual care and team-based care. Interviews were conducted in English between July 27, 2021 and January 12, 2022 by a physiotherapist (SG) with 6 years of clinical experience. She did not have any pre-existing relationships with any participants. Interviews were recorded, de-identified, and transcribed by a professional transcription service (Transcription Australia) before analysis. Reflective field notes were made after each interview.

Data analysis

Responses from participants who opened the survey but did not answer any questions were deleted. All other participants were included and missing responses for each question documented. Survey data were summarized using frequencies and percentages with the Statistical Package for Social Sciences version 27 (SPSS, Armonk, NY).

Qualitative open-ended survey questions and interview data were initially analyzed separately using a thematic analysis approach.³¹ First, one researcher (AE) comprehensively read and re-read the physiotherapist data, created unique codes, and generated preliminary categories. These were reviewed, discussed, and modified based on discussions with two other team members (IN, SW). Subsequently, qualitative interviews with patients were read and re-read by one researcher (AG), with a focus on obtaining insight related to team-based care. She generated initial codes and had numerous reflective meetings with a second researcher (AE) to discuss interpretations and emerging themes for patient data. Lastly, these researchers (AE, AG) concurrently integrated and discussed the data from both phases of physiotherapists and patients together. The remaining authors (JFE, SG, AH) read and provided input to finalize the overarching themes that aligned between groups. Throughout this iterative process, Microsoft Excel was used to manage and organize the qualitative data. Physiotherapist and patient perspectives were presented in parallel in a joint display²⁰ to facilitate an understanding of congruences and differences in their experiences towards team-based interprofessional collaboration. Interpretation and discussions of the quantitative and qualitative results were integrated in the discussion for overall comprehensive understanding of physiotherapist and patient perspectives.

Results

Quantitative: physiotherapists and patients

A total of 334 physiotherapists responded to the cycle seven survey. The majority were women (80%, 261), with most participants from British Columbia (45%, 146), Ontario (23%, 76), and Quebec (15%, 48). Additional demographic details are found in Table 1. Nearly half (48%, 160) of participants reported delivering care as part of a multidisciplinary team, and of these participants, 24% reported working in a hospital while the majority worked in a community setting. Two-thirds (64%) reported working in private practice, compared with 32% working in public practice. Online Appendix 2 displays the demographic details of the subset of participants working as part of a multidisciplinary team alongside the full sample. Nearly 2 in 5 (39%, 61) of these participants reported that the pandemic decreased their ability to deliver team-based care, whereas 7% (11) reported that the pandemic increased their ability to deliver team-based care. Just over half, 54% (85), reported that their ability to deliver team-based care remained the same. We quantitatively explored the data for different perspectives in how the pandemic impacted team-based care (negatively or positively) between physiotherapists working in private practice compared with public practice or between physiotherapists who reported working in a hospital compared with community settings, but no differences were found (online Appendix 3). Thus, our results reflect the perspectives of participants across diverse practice settings and contexts.

Table 1.

Physiotherapist and Patient Sociodemographic Characteristics

	Group, no. (%)
Variable	Physiotherapists; n = 334	Patients; n = 784
Age	N/A
16–18		11 (2)
18–29		44 (7)
30–44		163 (26)
45–59		209 (33)
60–75		187 (30)
>76		17 (3)
Prefer not to say		1 (0)
Gender
Woman	261 (80)	414 (66)
Man	60 (19)	195 (31)
Prefer to self-describe	1 (0)	3 (1)
Prefer not to answer	3 (1)	13 (2)
Province
British Columbia	146 (45)	230 (36)
Alberta	21 (7)	47 (7)
Saskatchewan	7 (2)	98 (16)
Manitoba	8 (3)	0 (0)
Ontario	76 (23)	18 (3)
Quebec	48 (15)	21 (3)
Nova Scotia	11 (3)	212 (34)
Prince Edward Island	1 (0)	0 (0)
New Brunswick	3 (1)	0 (0)
Newfoundland and Labrador	3 (1)	4 (1)
Northwest Territories	1 (0)	0 (0)
Location
Urban	242 (75)	529 (85)
Rural	82 (25)	95 (15)
Remote	N/A	1 (0)
Primary type of practice setting		N/A
Private	262 (78)
Public practice	61 (18)
University (research/teaching)	2 (1)
Other	9 (3)
Owner of physiotherapy clinic	129 (40)	N/A

Missing data for physiotherapists: gender (9, 2.7%); province (9, 2.7%); ownership of clinic (13, 3.9%); and location (10, 3%). Missing data for patients: age (152, 19.4%); patient's province (158, 20.2%); location (159, 20.3%); and gender (159, 20.3%).

There were 784 physiotherapy patients who participated in the survey, of whom 66% (414) were women. The greatest proportion of participants were from British Columbia (36%, 230) and Nova Scotia (34%, 212). Additional demographic information is provided in Table 1.

The majority of patients (84%, 662) accessed additional health care services beyond physiotherapy since the start of the COVID-19 pandemic in Canada (March 2020). Nearly half (47%, 369) reported receiving primary care services, whereas 31% (239) received care from other allied professionals, such as dieticians and psychologists. Fewer participants reported seeing medical specialists (28%, 220), while 11% (86) visited the emergency department, and only 3% (24) had overnight hospital stays (Figure 2). A total of 524 out of 662 (79%) patients who interacted with other health professionals answered the questions related to patient experience with team-based care. Since the start of the pandemic, 38% (194) reported that their appointments with other health professionals were only a little bit or not at all coordinated, with similar proportions (40%, 203) receiving a little bit or no help from a family physician or nurse practitioner in accessing other needed healthcare services. In addition, 39% (201) did not at all receive help or only a little bit of help from health professionals to ensure a smooth care transition between health professionals (Figure 3).

Figure 2.

Additional health services accessed by physiotherapy patients between March 2020 and November 2020 (N = 784).

*Included dietician, psychologist or counselor, nurse practitioner, chiropractor, and family physicians. Figure 2 Extended Description

Figure 3.

Patients’ experience with team-based care during the COVID-19 pandemic (March–November 2020) (N = 524).

*Included specialist, physiotherapist, and family doctor; missing data: n = 11. Figure 3 Extended Description

Qualitative: physiotherapists and patients

Open-ended qualitative responses on the impact of the pandemic on team-based care were received from 38% (61) of physiotherapists who reported as working as part of a multidisciplinary team. Semi-structured interviews were conducted with 19 patients (9 [47%] female, age ranged from 18 to 75 y). There were four common overarching themes that emerged from both physiotherapist and patient data related to team-based interprofessional collaboration. The themes are described below, followed by Table 2, which contains the full qualitative matrices with additional key quotes related to each theme. Further qualitative data is also provided in online Appendix 2.

Table 2.

Qualitative Themes and Subthemes Related to Team-Based Care During the COVID-19 Pandemic From Physiotherapists and Patients

Physiotherapists; n = 61	Patients; n = 19
Theme 1: Communication and relationship-building challenges: both physiotherapists and patients expressed communication challenges among health care team members and between patients and clinicians affecting team-based care
“More challenging to communicate with other team members since when we worked from home, we didn't see each other daily … we would discuss cases informally in addition to our more formal weekly meetings” PT 213 “Patients requiring interdisciplinary rehab approach are now scattered around several hospital wards rather than in one cohort, missing most especially the nursing culture that maximizes patient participation in rehab efforts” PT 109 “[The team has] less getting together and more effort required to confer together.” PT 128	“… when I access healthcare – it's been really hard … over the phone seems to be the most commonly used method of communication, and I have been dealing with stuff with mental health and then being tired … it's hard to see the difference if you are not able actually physically talk to them.” P 13 “Missing that in-person connection without communication, some stuff does get lost, or it does get harder to translate some of their opinions or thoughts via email or even via video call” P 17 “I also – we saw a fertility doctor in the pandemic and that was also all by phone, and I did not like that. I would have preferred to be in- person for that, just to have a bit more personal – we felt impersonal for some big questions that I have.” P 4
Theme 2: Different perspectives on coordination of health care: Physiotherapists indicated negative consequences of the pandemic to team-based care coordination, while patients had mixed views with health care coordination, reporting generally that it was the same as before the pandemic, yet some expressed ongoing frustration that coordination has always been a challenge.
“Limits on building capacity.” PT 45 “No longer in a shared office, more difficult to collaborate, no longer performing as many multidisciplinary appointments.” PT 201 “Harder to coordinate scheduling of [patient] appointments due to limited availability.” PT 60	“They were pretty good in keeping in touch with each other but, again, I think missing that in-person connection without communication, some stuff does get lost, or it does get harder to translate some of their opinions or thoughts via email or even via video call.” P 17 “The one doctor could tell that I had had a procedure done even though he didn't order it sort of thing … they can all see the results. That was existing prior to the pandemic, so that didn't change.” P 4 “I mean, the new doctor, the one you're going to, always asks for clarification and asks all the questions … the specialist has told me, “Well, here's what your doctor has said.” So, I know that there is good information passed at least amongst the ones I deal with.” P 11
Theme 3: Lack of access and delays for health services: Both physiotherapists and patients were concerned about patient access to general practitioners and specialist care disrupting team-based care.
“Decreased ability for patients to access clinicians as many are still telehealth only with limited appointments.” PT 133 “More difficult for patients to access imaging and specialists.” PT 209 “Having difficulty having continuity of care with family doctors.” PT 324 “Physicians are far less accessible to their patients where I live.” PT 76 “We typically refer patients on to community-based programs for ongoing maintenance exercise – these programs are stopped, virtual, and/or not taking on new patients. Our seniors are struggling to maintain fitness and safety in the absence of these programs.” PT 193 “Backlog of referrals leading to increased load with decreased ability to meet the load.” PT 45 “Slowed/delayed referrals from GP, and extremely long and impossible wait times for specialist appts for clients.” PT 284	“I am currently in Canada, went in and out of restricted COVID protocols, and at those times, we typically didn't have access to physios, so that had been as short as 2 weeks to up to, I think, 6 [weeks] was the longest time we didn't have access to anyone.” P 17 “Well, they're like, “Okay, well, in the future, I should probably see you in the office.” And it's like, “Okay, well, when should I do that?” And there's a lot of delay of physical care because they're trying to push off having people in their office and it's really hard to get appointments right now. Very hard …. And I feel like potentially that the doctors’ offices are overwhelmed with lab work associated with COVID 19. They've been kind of burdened.” P 13 “As a result of the pandemic, first of all, everything was shut down so everything got backlogged and then when it opened up, there were a capacity of restrictions in place. … I'm just saying that I think it slowed the process down so much. So, getting the specialist is always an issue, anyway, so that makes it that much more difficult.” P 15 “I think the amount of time that was available to see the physio was way down because he could only see one client at a time. So booking an appointment. I actually tried to get in the GLA:D program at five different stores, physio shops.” P 1 “Yeah, I needed to see an asthma allergy specialist and it took me quite a few months to get in and it's been almost 2 years since they have not done one of the tests they're supposed to, because they're so backed up. It took me 2 years to get my – finally get an appointment with a dermatologist. It'll be in March so that'll be over 2 years. I needed to see an intensivist. It took quite a few months to get in to him …. The only big problem was the wait times. They're horrendous and they're worse with COVID.” P 9
Theme 4: Potential opportunities for virtual care: Physiotherapists were mixed about whether virtual care increased or decreased team-based care, but many saw potential for ongoing use. Patients spoke favourably about virtual care as convenient for simple appointments with certain health professionals (i.e. general practitioners), whereas they preferred in-person for more complex health care concerns.
“For my job in ambulatory care, our team has been seeing people together (i.e., telehealth session). We're in a conference room so we can all hear each team members’ questions and interactions to prevent repeat questions for the patient.” PT 67 “Family docs are more likely to refer [to physio] and they are doing so by telehealth after I fax a report to them.” PT 20 “Practitioners are becoming more adept at using online tools to communicate.” PT 122 “Virtual team meetings not as conducive to discussion as in person.” PT 244 “I typically work in a multidisciplinary format with OT, medical, and SW. We continue to work in this format virtually but it has been more difficult.” PT 255	“The family doctor things were more of a general check-in … it was a lot more convenient doing it over the phone.” P 18 “Well, my doctor, we actually did do phone calls for a while … It didn't require that she actually needed to physically check me out kind of thing.” P 11 “My elderly parents, on the other hand, their doctor hasn't been seeing anyone and my mom is suffering from edema … he would only talk to her on the phone. And I said, that's not good enough, we're coming in.” P 1 “People who are travelling up to 45 minutes to an hour just for their own physio session and back, and it'd be quite demanding and just stressful for them to. So I think having that access remotely or just in your own home would be a big benefit for a lot of people.” P 17

In theme 1, Communication and Relationship-Building Challenges, physiotherapists expressed that they found it overall “harder to communicate with team members” (PT 310), both formally and informally saying there was “less hallway conversation” (PT 58) since the pandemic started, which disrupted interprofessional care. Similarly, patients also expressed communication challenges with different health professionals, especially in building a “connection with your health care provider” (P 10). Patients generally preferred video communication over phone regardless of with which health professional they were interacting. P 4 expressed: “anything [medical appointments] was all by phone, which I actually didn't like it as much. I would have preferred a video option. I found that not as personal, which is why I like the physio. It was nice that it was video.”

Theme 2 was Perspectives on Coordination of Health Care. Physiotherapists indicated negative consequences of the pandemic to team-based interprofessional coordination, “Harder to coordinate scheduling of [patient] appointments due to limited availability” (PT 60). They discussed the challenges of coordinating different health professionals’ schedules, saying its “Just more difficult to meet as a team” (PT 270). Most patients perceived that health care coordination was the same as before the pandemic: “It was what I would have normally expected from a doctor–physio relationship seemed to occur …. No, I don't remember any big glitches that were any different than I would have experienced in normal times” (P 5). However, patients expressed ongoing frustration at challenges in care coordination that existed before the pandemic: “Very disjointed [transition from one service to another], ’cause I consider physio as one thing in one avenue and then medical healthcare is another avenue that I'm responsible for if something were to arise in the future. But it's always been that way before the pandemic” (P 13).

The third theme was Delays and Lack of Access to many Health Services, where both physiotherapists and patients were concerned about patients’ reduced ability to see different interprofessional team members. PT 193 suggested that “Patients have very limited access to see physicians.” Some patients who needed to see multiple different specialists also felt that wait times had increased, as P 9 explained: “I needed to see an asthma allergy specialist and it took me quite a few months to get in … it took me two years to get an appointment with a dermatologist … I needed to see an intensivist …. The only big problem was the wait times. They're horrendous and they're worse with COVID” (P 9).

In theme 4, Potential Opportunities for Virtual Care, physiotherapists and patients had mixed feelings about the role of virtual care to improve interprofessional collaboration. Many physiotherapists saw positive aspects such as “Our team has been seeing people together (i.e., by telehealth) … we can all hear each team member questions and interactions to prevent repeat questions for the patients” (PT 67). They mentioned that virtual care could facilitate more interaction with other health professionals: “Much more interaction and dialogue especially with GPs many of whom are not seeing patients in person. They are reading assessment reports and acting on recommendations” (PT 119). Yet a few physiotherapists also mentioned disadvantages: “Virtual team meetings are not as conducive to discussion as in-person [meetings]” (PT 244). Patients viewed virtual care more favourably with some types of health professionals and in dealing with less complex medical situations. For example, P 18 said: “With the family doctor things were more of a general check-in, just to have a report of how my recovery was going. So, in that regard, it was a lot more convenient doing it over the phone.” Whereas other patients valued in-person care when dealing with specialists: “I have rheumatoid arthritis as well, and I don't as much enjoy meeting with my rheumatologist virtually because it's harder to show – it's harder to explain something when I could just show him, right?” (P 8).

Mixed methods integration

While quantitative data revealed that many physiotherapists believed they had decreased ability to deliver team-based care during the pandemic, this result is enriched and further explained by our qualitative findings that found challenges related to communications, care coordination, and a lack of access to health services. Quantitatively, patients also reported challenges with care coordination, yet qualitative analysis further illuminated this result by highlighting that patients perceived these frustrations were not worse than pre-pandemic times. Both physiotherapists and patients had a mix of positive and negative experiences related to how virtual care could improve team-based care, yet both groups saw potential future opportunities for virtual care.

Discussion

This mixed methods study investigated physiotherapist and patient perspectives towards team-based interprofessional collaboration during the COVID-19 pandemic. Integration of the quantitative and qualitative findings suggests that physiotherapists generally feel they have limited opportunities to participate in team-based care across health care settings. Less than half felt part of a multidisciplinary team, and they often perceived challenges in communication and care coordination. As for patients, over one-third reported having issues with health care coordination and transitions. However, many of them expressed that these challenges were already present pre-pandemic. Conversely, lack of help and difficulty accessing various health professionals increased during the pandemic. Among both physiotherapists and patients, many respondents saw virtual care as a potential opportunity to improve team-based interprofessional health care in the future.

Our results suggest that physiotherapists found it more challenging to build and deepen interprofessional relationships during this time, which can be considered critical for keeping health care teams together.^32,33 Standard in-person pre-pandemic team meetings were often replaced by virtual communication. Team-based care relies on regular communication to build and strengthen interprofessional relationships. Yet, both physiotherapists and patients reported communication challenges between team members and between health professionals and patients. This was particularly expressed by patients with complex health issues that needed to see multiple health professionals on a regular basis. Results from other studies indicate that many health care settings were not equipped to provide virtual patient-centred care that could have improved communication.^24,34

Our quantitative results found that more than one in three patients felt their health care was only a little bit or not at all coordinated, which was echoed in the qualitative findings, where patients felt care was “very disjointed” and that they had to take their own responsibility for accessing health care services and/or transitioning between primary care and other places. The qualitative data further expands on the quantitative result to highlight that patients did not necessarily perceive that care coordination was worse during the pandemic compared with pre-pandemic times. This echoes previous research that found poor communication between hospital-based and community-based health providers before the pandemic.³⁵ However, this is counter to other studies indicating the negative impact of the COVID-19 pandemic on care transitions and integration of health care services.^36,37

The physiotherapists in our study also qualitatively reported that care coordination became more challenging since the onset of the pandemic. This may be due to a disruption in established ways of working together in the same office or the lack of in-person working environments, which has been echoed by others as facilitators of team-based interprofessional collaboration.^38,39 Co-location creates opportunities for frequent informal and formal communication.^38,40 This, in turn, facilitates the informal exchange of patient information,^38,41 shared care plans,^42,43 and effective patient care coordination.⁴⁴

Both physiotherapists and patients viewed virtual care as an opportunity that could be integrated into team-based interprofessional care delivery in the future. Virtual care can increase access to specialists for patients, particularly those living in more rural communities. Different team members and the patient may be able to more easily coordinate interprofessional meetings to provide better aligned patient-centred care. Individual virtual appointments with health team members could happen more quickly and conveniently, saving patients travel costs and time. Previous work examining Canadian physiotherapists’ integration of virtual care during the pandemic found that physiotherapists adopted virtual care to provide continuity of care for patients, yet further resources and support are likely needed to facilitate this integration in the future.²⁴

Both physiotherapists and patients were concerned with delays in accessing primary and specialist care. This may have been due to some primary care providers feeling overwhelmed, or reducing or ceasing services during that phase of the pandemic.^45–47 Staffing levels were also reduced due to temporary redeployment from some primary care teams to support hospitals in managing the COVID-19 crisis.^34,48 Our results are aligned with previous work in Canada, which showed that patients experienced delays in accessing specialist care, such as access to total joint replacement during the COVID-19 pandemic.⁴⁹ Since our study occurred early in the pandemic, it is unknown if physiotherapist and patient perspectives on access to these services improved later in the pandemic. Future research is needed to understand the implications of this reduced access to care at patient and health systems levels.

Our results should be considered in the context of study limitations. Survey data are cross-sectional, indicating valid perspectives from only a “snapshot in time”. However, given the unique and complex nature of the pandemic, physiotherapist and patient perspectives from this early time point should be considered to provide unique and valuable insight. There were multiple survey distribution methods across study phases that were intended capture a broad, comprehensive sample of physiotherapists and patients; however, due to this strategy we are unable to determine a precise response rate to our surveys or ensure that there was not an over-representation of patient responses from an individual clinic. Survey cycles were designed to be brief to minimize response burden for physiotherapists, yet this also limited the extent of our quantitative data collection and complexity of data analysis. Therefore, we enriched the interpretation of the quantitative data with insights from qualitative responses, allowing for a deeper understanding of the survey results. Although during data collection we provided physiotherapy participants with a broad definition of multidisciplinary teams (working closely with other health professionals), their interpretations may be conceptualized differently than intended (e.g. referral to other health disciplines rather than working as part of interprofessional collaborations). The patients and physiotherapists in our study were recruited from different provinces and territories within Canada. Differences in health care system funding and structure across provinces and territories may have also impacted their responses. Despite these limitations, this study is novel in providing an insight into the impact of the COVID-19 pandemic on team-based interprofessional collaboration in Canada from both physiotherapist and patient perspectives.

Conclusion

This novel mixed method study investigated and synthesized the perspectives of physiotherapists and patients towards team-based interprofessional collaboration during the COVID-19 pandemic in Canada. Overall, only half of physiotherapists in our study felt they contributed to team-based health care. Communication, care coordination, and access to health services were found to be challenging, especially from the physiotherapists’ perspectives. Patients also expressed reduced access to health professionals, yet reinforced that many of these challenges regarding care coordination existed prior to the pandemic. As we move into the post-pandemic phase, our findings suggest that improved training and implementation of virtual care may facilitate better team-based interprofessional collaboration and improve the delivery of patient care in the event of a future highly disruptive event like COVID-19.

Key Messages

What is already known on this topic

Integration of physiotherapists as part of team-based interprofessional collaborations is associated with better management of chronic diseases and improved patient outcomes. However, little is known about how COVID-19 impacted these collaborations from physiotherapist and patient perspectives.

What this study adds

Physiotherapists had variable experiences related to communication, care coordination, and patients’ ability to access other health professionals during COVID-19. Patients also expressed similar communication and accessibility challenges during this time. Both groups also saw positive aspects related to the increased use of virtual care as a tool to improve team-based interprofessional collaboration in the future.

Figure Descriptions

Figure 1 Extended Description

Phase 1

• 1.Quantitative and qualitative collection data
  • a.Cross-sectional physiotherapist survey
  • b.Closed and open-ended questions
  • c.(334)
• 2.Quantitative data analysis

Phase 2

• 3.Quantitative data collection
  • a.Cross-sectional physiotherapist patient survey
  • b.Closed-ended questions
  • c.(784)
• 4.Quantitative data analysis

Phase 3

• 5.
  Quantitative data collection

  • a.
    Semi-structured interviews with subgroup from phase 2 (19)
• 6.Quantitative data analysis
• 7.Final integration of quantitative and qualitative

Back to Figure 1.

Figure 2 Extended Description

Data:

Other health services	Percentage of physiotherapy patients
Primary care	47%
Medical specialist	28%
Emergency department	11%
Hospital for overnight stay	3%
Other health professionals*	31%
None	16%

Back to Figure 2.

Figure 3 Extended Description

Data:

Questions	Very coordinated/a lot of help	Moderately coordinated/moderately helpful	A little bit coordinated/a little bit of help	Not at all coordinated/no help at all
Has your family physician or nurse practitioner helped you access other needed health care services in the last six months?	38%	23%	19%	21%
How much have the health care professionals helped to ensure a smooth transition from one health facility?	26%	35%	22%	17%
Are appointments with health care professionals* coordinated to offer you the best possible care?	29%	33%	22%	16%

Back to Figure 3.

Funding Statement

Dr. AM Ezzat was funded through a CIHR post-doctoral fellowship.

Authors' Contributions:

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:

The authors have no conflicts of interest to declare.

Funding:

Dr. AM Ezzat was funded through a CIHR post-doctoral fellowship.