Discussion
This study explored the impact of an SDT-based course module on physiotherapy students’ (de)motivating interaction styles (primary outcome), and SDT-based beliefs and self-management support (secondary outcomes). Current findings offer valuable insights into enhancing healthcare education towards improving care recipients’ self-management. This quasi-experiment showed positive Group*Time effects for self-perceived interaction styles, effectiveness beliefs of SDT-based strategies, and self-efficacy in self-management support.
More specifically, physiotherapy students who received an SDT-based course module reported increases in autonomy-support, while students who did not receive the module reported no change in autonomy-support. This means that after completing the module, students in the intervention group reported offering more meaningful choices and using more inviting language [9, 16]. For care recipients, these improved autonomy-support may lead to more positive treatment motivation, better rehabilitation adherence, and less negative emotions [9, 12, 16]. It should be acknowledged that, at baseline, the intervention group reported slightly lower levels of autonomy-support compared to the control group, potentially leaving more room for improvement. However, at post-intervention, the intervention group level of autonomy-support increased more over time (even above the levels of those who did not receive the module), indicating a meaningful impact of the intervention beyond baseline differences. Similar results appeared for the structuring interaction style (increase in intervention group, no change in control group), however, this Group*Time effect was only marginally significant after applying the Benjamini-Hochberg correction. The lack of Group*Time effect for the structuring interaction style is surprising and contrasts with a previous SDT-based study involving HCPs in practice, where both motivating styles were higher and both demotivating styles were lower in the intervention group compared to the control group [27]. However, an important distinction is that the earlier study only reported post-measurement group differences, whereas the present study’s inclusion of baseline measurements provides a more robust picture of the intervention’s effectiveness. Several factors may help explain the lack of Group*Time effect for structure. First, students may find autonomy-support more intuitive, easier to implement, or more recognizable to reflect on than structure. Second, the intervention may not have emphasized all interaction styles equally, as students were free to choose which motivating style to focus on (see Appendix C). Unfortunately, the researchers had no access to the reflections, making it impossible to clarify which student focused on which motivating style. In the future, it might be good to provide students with more guidance during their reflection and ask them to pay attention to both motivating interaction styles. Lastly, implementing a more structuring interaction style during internships may be more challenging due to, for example, contextual barriers such as time constraints or lack of role models [45].
Regarding demotivating interaction styles, the interaction-effects followed the expected direction, with the intervention group showing greater decreases over time in control and chaos compared to the control group. A remarkable finding of the present study is the increase in both demotivating styles in the control group over time, showing more controlling and chaotic interactions from baseline to post-measurement. Several explanations may account for this. One possibility for the unexpected increase in self-reported demotivating interaction styles in the control group is that these students may have completed the questionnaire more thoughtfully or became more self-critical over time, particularly as they gained more internship experience. Alternatively, in the absence of training in motivating interaction styles, it may lead students by default to less supportive and even need-thwarting styles. Contextual factors during internships (such as limited supervision, time pressure, or a lack of role models) may also have contributed to the increase in demotivating styles in the control group [35, 45]. Moreover, it is possible that students did not perceive their need-thwarting behaviors as detrimental to care recipients, and thus did not consciously avoid them. Nevertheless, research showed that these behaviors do thwart care recipients’ basic psychological needs and result in negative emotional experiences [9, 13, 16]. This detrimental evolution in the control group highlights the need to educate future HCPs with practical tools and guidance to avoid demotivating interaction styles and to develop and maintain motivating interaction styles throughout their internships.
Regarding the secondary outcomes, as expected, significant Group*Time effects were found for effectiveness beliefs of SDT-based strategies, all six subscales of self-efficacy in self-management support, and the subscales “assess” and “overall competence” of performance in self-management support. However, in contrast to the hypothesis, there was a lack of Group*Time effects for feasibility beliefs and some subscales of performance in self-management support. Several factors may explain these findings. First, the group that did not receive the SDT-based course module also improved over time in feasibility beliefs, self-efficacy in “advise” and performance in “assess”, “advise”, “agree”, “assist”, and “overall competence”. These improvements align with most of the outcomes that did not show significant Group*Time effects. This might suggest that also without an SDT-based course module, physiotherapy education has a positive impact on feasibility beliefs of SDT-based strategies. Second, the course module’s primary focus on the SDT-framework – without explicitly targeting the 5As model of behavior change for self-management support competencies – may also have contributed to the lack of additional Group*Time effects. Additionally, the higher self-efficacy scores compared to performance (in both groups) suggest that students may face challenges in translating self-efficacy or knowledge into practice – a common issue during education and in the field [42, 46, 47].
Strengths and limitations
A first strength of this study is the fact that the intervention was grounded in theory, here SDT, an empirically based framework, suited for investigating and promoting (de)motivational interaction styles in healthcare settings [9, 15]. SDT’s emphasis on the universal importance of basic psychological needs offers a strong foundation for designing interventions aimed at enhancing self-management, behavior change and therapy adherence [9, 15]. However, at the same time, we acknowledge the fact that other theories or frameworks can be useful to support self-management [48, 49] or behavior change [50], and SDT is not free of limitations or criticism [51, 52]. For example, the experiences of care recipients’ needs and interaction styles may be personal and context-related (versus universal), leading to variability across situations. This may highlight the importance of other individual circumstances and factors that shape care recipients’ self-management and therapy adherence, such as family support and the reason for therapy [53, 54], next to the role of the HCP [55]. Secondly, the course module was strengthened by practical components that required future physiotherapists to engage in both self- and peer-feedback, in which they received information on how to use it. This approach encourages developing feedback skills and fosters self-awareness, and reflection on both personal and peer behavior. Thirdly, addressing an important gap in the literature [30], methodological strengths include that this study’s design was controlled, and that reliable and valid measurements were used [11, 40].
However, some limitations need to be mentioned too. First, the reliance on self-reports may have caused socially desirable answers, particularly because the post-measurement of the SIS-HCP was part of the intervention group’s curriculum and incorporated into the course’s grade for a small part. To address these considerations, future research could use care recipient reports or external rating of the interaction styles. Accordingly, future studies could explore changes in care recipients’ experiences such as the satisfaction and frustration of their basic psychological needs, their motivation, therapy adherence, behavior change, and self-management. A second limitation is the short-term post-measurement period. Future longitudinal studies are important to measure long-term behavior change of HCPs, which could enrich the sustainability of the education process. Such studies can examine whether the observed improvements in physiotherapy students’ outcomes extend beyond internships and are transferred to real clinical practice. Third, interaction styles were measured as separate dimensions. It is important to consider that HCPs do not adhere to a single interaction style exclusively but exhibit a combination of styles [14, 33]. Fourth, although including a control group at the same stage of their master’s program (i.e. second semester of the first master year) was a strength, random allocation was not feasible for practical reasons. This may have contributed to some baseline differences between the groups. However, these baseline measurements were taken into account in the analyses to minimize their potential impact on the results. Further, it is important to acknowledge that students’ usual education continued alongside the intervention, with different accents in the universities’ programs and curricula. Nevertheless, both programs align with the same national graduation outcomes, ensuring comparable educational standards and similar academic trajectories, including a master’s thesis, internships (including self-reflection and mentor feedback) and standard physiotherapy courses. Still, minor differences in content may have occurred due to variations in scheduling, instructors, or elective choices. Fifth, more dropouts occurred in the control group than the intervention group, likely due to the non-optimal timing of the post-measurement and the initially high response rate in the control group at baseline. However, sensitivity analyses (only including participants with complete baseline and post-intervention measures) revealed similar results as the intention-to-treat analyses (maximum use of data including all participants who completed baseline measures). Sixth, since only two universities of the same educational stage and profession were included in this study, at this stage, the findings cannot be generalized to other health professions (such as occupational therapy, speech language therapists, dietitian, nursing), different educational stages, or other universities or colleges. However, future research can address these limitations.
Practical implications
This study has several implications for healthcare education. First, the results indicate that focusing on improving physiotherapy students’ interaction skills and self-management support is welcome, as students scored higher on control and lower on autonomy-support, self-efficacy (except for subscales “agree” and “assist”) and performance (except for “agree” “assist”, and “arrange”) in self-management support on the reported outcomes at baseline, compared to nurses, as reported in previous studies [14, 41]. Second, the results of this study support the integration of an SDT-based course module into physiotherapy education. This SDT-based course module holds considerable potential to enhance future HCPs’ ability to support people with chronic diseases by strengthening their interaction skills essential for supporting care recipients’ basic psychological needs [9, 10] and motivation [12], which can have a positive impact on therapy adherence and clinical practice [12].
The module was embedded in a course programmed in the first masters’ year and focused on developing students’ knowledge, skills and competencies, using methods such as in-class lectures, online learning, self-assessment, self-reflection, and peer-observation. The findings suggest that applying this SDT-based course module during healthcare education has added value for educating those competences [8, 30]. The module could also be effective when integrated and linked to the clinical internship component of the educational program, which starts in the bachelor’s years. Given the structured format of the module and the online delivery mode in wave 2, the intervention is adaptable to online platforms and requires minimal training for educators, increasing its applicability across programs. Although this study did not focus on between-wave comparison (i.e. in-class versus online delivery mode of aspects of the theoretical part), the similar Group*Time effects (data not shown) suggest that both teaching methods are effective. This finding aligns with recent studies reporting comparable outcomes between in-person and online courses [56,57,58]. Still, to gain deeper insight into how students engage with and respond to specific delivery methods or particular components of the SDT-based course module, future research could incorporate student engagement as an additional variable or compare the effects of different (delivery) methods and teaching activities.
It should be acknowledged that recording a treatment session posed challenges as ensuring care recipients’ privacy is essential under all circumstances. Hence, the implementation of that part of the module can be experienced as a barrier. Solutions should be found so that peer-observation can still be facilitated. Another way to address privacy concerns related to video recordings could be to ask the care recipient to provide feedback after the therapy session regarding physiotherapy students’ interaction styles and self-management support. A short anonymous or identified online survey – depending on wishes of care recipients – can be developed on which the HCP (student) can reflect on. This can be developed and tested in the future.
Although beyond the scope of this study, there are possibilities to broaden this SDT-based module to, for example, other educational programs and HCPs in practice. To make the module more suitable for them, content adaptations could be recommended. The SDT-component needs to be adapted to situations relevant for their profession (written and video cases). When targeting HCPs in practice, high workload might pose a barrier to participate in a training program [59]. However, this should not hinder opportunities in lifelong learning and efforts to improve the quality of care. To increase feasibility, it might be valuable to develop a less intensive version of a program tailored to working HCPs. Given their practical experience, the applied components of the training could be integrated into their job.
Conclusion
This study enriches the SDT-based literature on optimizing healthcare education by evaluating the effectiveness of an SDT-based course module in physiotherapists’ curriculum. The findings suggest that integrating an SDT-based module can improve graduating physiotherapists’ (de)motivating interaction skills. Positive Group*Time effects were found for self-perceived autonomy-support, control and chaos, as well as for effectiveness beliefs of SDT-based strategies, self-efficacy in self-management support, and the subscales “assess” and “overall competence” of performance in self-management support. While these results are promising, conclusions regarding effectiveness and generalizability should be drawn with caution due to the specific and controlled educational setting.
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