Physiotherapists perceptions on informed consent and role in the healthcare system, in Europe

Introduction Physiotherapy has developed over the last century, and the physiotherapists’ professional identity is growing. The heterogeneity of physiotherapy studies in Europe, local government, and health policies have influenced the responsibilities and ethical reasoning of physiotherapists. Our study aims to explore the perceptions and differences regarding informed consent (IC) and the role of physiotherapists in healthcare in an educational, legislative, and health policy context. Material and Methods A cross-sectional survey was distributed online to physiotherapist graduates in Europe. The survey contained two open questions regarding IC and assumed role in healthcare. The data was operated to and analyzed by using a theory-based approach (open and axial coding), providing a qualitative spectrum of categories for the two items linked on IC and the role in healthcare. Results Eight categories of issues related to IC and seven categories related to the role in healthcare were identified. The physiotherapist graduates from Romania, France, Belgium, Italy, and other countries from inside and outside European Union response rate was 81.85% (n = 248 from 303) for the item related to IC and 71.62% (n = 217) to the second item related to the role in healthcare. A percent of 24.20% (n=60) are still considering IC a simple patient information process, while 23.40% (58) have linked IC with ethically and legally issues, 21.67% (n=51) of physiotherapists are minimizing their role in healthcare at restoring physical independence, while 6.91% (n=27) are aware of their multidisciplinary role. The country comparison analysis revealed that physiotherapists from UK and Italy are more aware regarding IC and that physiotherapists from Belgium and France are better oriented regarding their role in healthcare. Conclusions The study shows that heterogeneity, legislation, and healthcare system differences influence physiotherapists professional development. Future research is needed to establish the reason for the reduced perception of physiotherapists regarding their role as health promoters.


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Physiotherapy has developed over the last century, and the physiotherapists' professional identity is 29 Results

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Eight categories of issues related to IC and seven categories related to the role in healthcare were 31 identified. The physiotherapist graduates from Romania, France, Belgium, Italy, and other countries from 32 inside and outside European Union response rate was 81.85% (n = 248 from 303) for the item related to

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Throughout the evolution of the physiotherapist profession, the concept of professional identity has developed, assuming the existence/presence of a set of moral norms, abilities, and skills designed to 48 define the profession of the physiotherapist towards high standards (1)(2)(3). The occupation of the 49 physiotherapist has developed throughout Europe during the last century as a profession assimilated to 50 healthcare professionals (4)(5)(6). In most countries in Europe and around the world, the profession of 51 physiotherapy has been regulated and recognized so far, leading to the occurrence of ethical norms that 52 must be respected and compliance with high standards of practice (7)(8)(9). Romania is the only country 53 of the European Union where the physiotherapist profession was partially regulated in 2016, and the 54 professional organization has incomplete legislation (10).

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The professional identity of those performing social work, as in the case of physiotherapists, is a 56 continuous process that is determined by the context, factors, or situations that may occur at work. It is 57 linked to specific roles that are attributed more from a legal point of view than relative to the complexity 58 and potential conceptualization of each profession. Formation of the professional identity of 59 physiotherapists takes place over time. The workplace, the staff involved in everyday activities, the moral 60 principles and values of each, the accumulated experience, and the moral conflicts arising from the 61 intersection of individual values and beliefs are elements which influence the accumulation of 62 professional skills (11) (12).

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The legislation, health systems, and study programs in physiotherapy vary from one country to another,

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although competencies are mostly similar, with few exceptions. However, the differences between countries health systems are essential, especially in the context of migratory physiotherapists, especially development of professional identity in the context of educational, legislative and professional

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Previous literature often advocates the need for a concise framework for IC in physiotherapy, given the by providing treatment information. In Romania, the heterogeneity of university studies, the lack of a 234 professional association and a code of conduct for physiotherapists are elements that might influence this 235 process. Also, in France, it is likely that the influence of this legal and ethical aspect is related to the type

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The results obtained reveal that of the 248 respondents, 24.20% (Table 2) linked the IC process to simple 246 patient information, s omitting the ethical and legal issues that were created and implemented as practice 247 standards, continuing to use the IC process as a tool for detailing the treatment objectives and the 248 techniques used (38)(24).

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An important aspect to consider is professional autonomy and initial contact with the patient. Considering 250 the legislative aspect, specific to each country, the physiotherapists performing the medical activity, only 251 at the physician's indication, are having secondary contact with the patient, so the ethical and professional 252 responsibilities lie primarily with the physician and less with the physiotherapist. We cannot extrapolate 253 on this, because in Italy for example, where the situation is similar to Romania and physiotherapists work Differentiating response categories by the reason physiotherapists believe that IC is obtained has allowed 258 us to point out important aspects of physiotherapists' perception of IC. So far, this aspect has not been 259 studied from this perspective, and the responses suggest that the IC process is elaborate. In addition to 260 legal and deontological considerations, obtaining IC is a useful tool that allows physiotherapists to 261 establish a connection and a relationship with the patient. (32) (39) 262 It seems that the lack of a concrete framework for IC obtaining in physiotherapy, due to treatment specific 263 and dynamics are negatively influencing the perceptions of physiotherapists regarding IC even after a 264 century of professional development (6) (38).

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Assumed role in healthcare

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From the summary analysis of the results, it is observed that the highest percentage was attributed to the 267 role in the physical rehabilitation process (21.67%) (Table 3)

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Most of the WCPT physiotherapists attributions are found in the categories of responses differentiated by 285 the present study (Table 3), but the proportion of physiotherapists that perceive their complex role in 286 healthcare is deficient. Although it is a profession that has been developing for more than 100 years in 287 Europe, the professional identity of physiotherapists is still in a complicated process, dynamic and with 288 various influences (1)(3)(2).

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The transition from student to practitioner, as well as the many elements that can influence the

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Comparative analysis

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One of the issues investigated was the influence of factors such as age, work experience and country of 297 origin in the formation of professional identity and IC perceptions.

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As far as the professional identity of physiotherapists is concerned, they are still in development and they 299 seem to have difficulties in terms of professional strength and integration into the medical team (43)(44).

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The results of our research (Table 4) show that there are no differences in the perception of the role in the 301 health system or on the ethical aspects of IC based on age or work experience. In contrast, there was a perception of IC and professional identity, to the disadvantage of physiotherapists in Romania, France,

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and Belgium, versus physiotherapists in the UK and Italy. The differences of physiotherapy programs 307 available in many countries, mainly linked to the profile of the faculties: physical education or healthcare 308 are elements that influence the formation of physiotherapists professional identity and professional ethics,

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Also, the importance of continuing professional education has proven to be an essential factor in the 311 development of professional identity. Moreover, we want to emphasize that physiotherapists in Romania 312 do not currently have an obligation to attend continuous professional training (46) (47).

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Pair comparison with Bonferroni correction of the Kruskal Wallis test (Table 5) denotes differences of 314 perception both on IC aspects, but also on the role in the healthcare system and the formation of 315 professional identity, to the benefit of physiotherapists in the UK and Italy, to the detriment of 316 physiotherapists in Romania, France, and Belgium. In Romania, physiotherapy program studies can be 317 either in a university with a medical profile or in a sports university. Also, in France and Belgium, this 318 specialization is also earned from a university study program with a physical education background.

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Contact with the clinical component of the physiotherapist students is a factor affecting the professional 320 training process, which takes shape during the physiotherapy studies (48)(49)(50)(51).

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The development of the professional identity of physiotherapists in Europe differs according to the