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Implementation of MeasurementInstruments in Physical TherapistPractice: Development of aTailored StrategyJ.G. Anita Stevens, Anna J.M.H. Beurskens

Background and Purpose. The use of measurement instruments has becomea major issue in physical therapy, but their use in daily practice is infrequent. Theaims of this case report were to develop and evaluate a plan for the systematicimplementation of 2 measurement instruments frequently recommended in Dutchphysical therapy clinical guidelines: the Patient-Specific Complaints instrument andthe Six-Minute Walk Test.

Case Description. A systematic implementation plan was used, starting with aproblem analysis of aspects of physical therapist practice. A literary search, structuredinterviews, and sounding board meetings were used to identify barriers and facilita-tors. Based on these factors, various strategies were developed through the use of aplanning model for the process of change.

Outcomes. Barriers and facilitators were revealed in various domains: physicaltherapists competence and attitude (knowledge and resistance to change), organi-zation (policy), patients (different expectations), and measurement instruments (fea-sibility). The strategies developed were adjustment of the measurement instruments,a self-analysis list, and an education module. Pilot testing and evaluation of theimplementation plan were undertaken. The strategies developed were applicable tophysical therapist practice. Self-analysis, education, and attention to the practiceorganization made the physical therapists aware of their actual behavior, increasedtheir knowledge, and improved their attitudes toward and their use of measurementinstruments.

Discussion. The use of a planning model made it possible to tailor multifacetedstrategies toward various domains and phases of behavioral change. The strategieswill be further developed in programs of the Royal Dutch Society for PhysicalTherapy. Future studies should examine the use of measurement instruments as anintegrated part of the process of clinical reasoning. The focus of future studies shouldbe directed not only toward physical therapists but also toward the practice organi-zation and professional associations.

J.G.A. Stevens, PT, MSc, is Re-searcher and Teacher, Center ofResearch Autonomy and Participa-tion of People With Chronic Ill-nesses, Department of Physiother-apy, Zuyd University, NieuwEyckholt 300, PO Box 550, 6400AN Heerlen, the Netherlands. Ad-dress all correspondence to MsStevens at: [email protected].

A.J.M.H. Beurskens, PT, PhD, is As-sociate Professor, Center of Re-search Autonomy and Participa-tion of People With ChronicIllnesses, Department of Physio-therapy, Zuyd University.

[Stevens JGA, Beurskens AJMH.Implementation of measurementinstruments in physical therapistpractice: development of a tai-lored strategy. Phys Ther. 2010;90:953961.]

2010 American Physical TherapyAssociation

Case Report

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M onitoring the health statusof patients through the useof outcome measures is con-sidered to be an aspect of good clin-ical practice in physical therapy.13

The clinical guidelines of the RoyalDutch Society for Physical Therapyrecommend the use of measurementinstruments. Until now, this recom-mendation has been implemented ina passive way by mailing the clinicalpractice guidelines containing themeasurement instruments. Despitethe overall positive attitude of phys-ical therapists, the daily use of out-come measures in physical therapistpractice is remarkably low.2,48

In Europe and Australia, implemen-tation is a common term for what inthe United States is called knowl-edge translation or exchange. In thisarticle, the term implementation,which means a systematic processin which innovations or changes ofproven value become structurallyembedded in professional practice,was used. It is well known that pas-sive implementation strategies arenot effective.9,10 Systematic reviewsof the effectiveness of implementa-tion interventions have shown thatstrategies should be targeted towardspecific barriers to and facilitators ofchange that have been assessed in athorough problem analysis of the tar-get group and setting.9,1118 Althougheducation is an important strategy,implementation should not be re-stricted to educational interventionsfor individual health professionalsonly. Factors concerning practicepolicy and organization, patients,

and the measurement instrumentsthemselves also are important.4,12

The Dutch Scientific College of Phys-iotherapy of the Royal Dutch Societyfor Physical Therapy has made a sys-tematic approach to the implemen-tation of outcome measures in dailypractice a focal point of its policy.The aims of this case report were todevelop and evaluate a systematic im-plementation plan for the use of 2measurement instruments frequentlyrecommended in Dutch physicaltherapy clinical guidelines: the Patient-Specific Complaints (PSC) instru-ment,19 which is comparable to thePain-Specific Functional Scale,20 andthe Six-Minute Walk Test (6MWT).21

To meet our aims, we sought answersto 2 questions:

1. Which barriers and facilitatorscontribute to the use of the PSCand 6MWT in physical therapistpractice?

2. Which implementation strategiescan be tailored to these barriersand facilitators and applied tophysical therapist practice?

Target SettingThe implementation plan was aimedat physical therapists in private prac-tice in the community. This group isthe largest group of physical thera-pists in the Netherlands; they are eas-ily accessible and are not restrictedby complicated and formal institu-tional rules. It also appears that thesephysical therapists use fewer mea-surement instruments than their col-leagues in hospitals and otherinstitutions.7

Development andApplication of the ProcessAs a guideline for a systematic ap-proach, the implementation modelof Grol et al10 was used. The 5 stepsin this model and the methods usedin this case report are shown in theFigure.

Step 1: Proposal forImprovementWe focused on the implementationof 2 easily applicable measurementinstruments that are frequently rec-ommended in Dutch physical ther-apy guidelines. The first instrumentwas the PSC, a Dutch instrument thatis comparable to the Pain-SpecificFunctional Scale.19,20 In both instru-ments, patients must list 3 activitiesand score them. Differences are thescoring method (visual analog scaleversus numerical rating scale), thetime frame on which the score isbased (1 week versus 1 day), and theavailability of a sample activity list inthe PSC to help patients identifytheir main complaint. The second in-strument was the 6MWT, which isused to assess the aerobic exercisecapacity of a patient by measuringthe walking track length in 6minutes.21

Step 2: Problem AnalysisTo obtain a complete and valid over-view of relevant barriers and facilita-tors, we used various methods to col-lect information. First, a literaturesearch of the PubMed and Cochranedatabases was carried out to identifystudies about barriers and facilitatorsin the use of measurement instru-ments and clinical guidelines. Fromthis information a topic list was for-mulated (the list is available on re-quest from the authors). Second,physical therapists in several privatepractices were interviewed. Wesearched for a wide variety in termsof expertise and number of employ-ees and considered the use of clini-metrics (purposive sampling).

The semistructured interviews(4560 minutes) were digitally au-diotaped, summarized, and memberchecked by the physical therapists.The interviews started with generalinquiries on the following themes:information about the practice, pa-tient categories, and measurementinstruments used. Thereafter, open

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questions were asked about per-ceived barriers and facilitators in theuse of measurement instruments indaily practice. At the end of eachinterview, the topic list was pre-sented to the interviewees, and addi-tional relevant items could be indi-cated. The barriers and facilitatorsidentified were ordered in variousdomains: the physical therapist, theorganization, patients, and the mea-surement instruments themselves.The number of interviews was esti-mated at between 15 and 20, and theinterviews were stopped when a sat-uration of data was reached.22

Step 3: Development ofImplementation StrategiesThe information from step 2 guidedthe selection of both the type and

the specific content of the imple-mentation strategies developed; aplanning model for the process ofchange was used.10,16 In addition, aliterature survey on how to selectand tailor strategies to the informa-tion from the problem analysis wasperformed. Until now, not many im-plementation studies have beenbased on a problem analysis. There-fore, studies about the effect of im-plementation on general health wereused. The results from both the liter-ature search and the interviews werediscussed with the project group(experts in the field of guideline im-plementation) and a sounding board(the interviewed physical therapists).Subsequently, implementation strate-gies were selected and developed.

Steps 4 and 5: Testing andEvaluation of theImplementation PlanIn the literature, recommendationswere made about testing interven-tions initially in small groups, inwhich active education and profes-sional support seemed to be effec-tive in improving physical therapistsattitudes and adherence.4,23,24 There-fore, pilot testing of the implemen-tation plan was undertaken with 2groups of physical therapists from 4physical therapist practices. Theevaluation focused on feasibility andreadjustment of the strategies devel-oped. The results of the first pilotprogram were used to make adjust-ments in the second pilot program. Itwas not our intention to evaluate theeffectiveness of the strategies, but the

Figure.Implementation model of Grol et al10 and the methods used in this case report. KNGFKoninklijk Nederland Genootschap voorFysiotherapie (Royal Dutch Society for Physical Therapy).



therapists were asked whether theirknowledge, attitudes, and use of mea-surement instruments had changed.

OutcomeStep 2: Problem AnalysisAll of the physical therapists whowere invited for the interviews at-tended the interviews. After 11 inter-views with 13 physical therapists, asaturation of data was reached, andthe interviewing was stopped. Thephysical therapists, whose agesranged from 22 to 54 years (medi-an43), were interviewed in thesouthern region of the Netherlands.Their working experience variedfrom 2 to 30 years (median21), and

the number of colleagues in the prac-tice varied from 1 to 11 (median6).The interviewed physical therapistsspecialized in different areas. The re-port of the interview was sent toeach therapist for member check-ing, and the reports were all inagreement.

The 13 therapists indicated that theywere familiar with the PSC and6MWT, but less than half of themindicated that they used these mea-sures. Almost all interviewed physi-cal therapists were motivated to usethe instruments and were convincedof the additional value. Barriers and

facilitators reported in the inter-views are summarized in Table 1.

In the sounding board, discussionsabout the identified barriers and fa-cilitators took place. During thesediscussions, some physical therapistswere very honest and admitted thatthey did not use the measurementinstruments as often as they claimed.Because of the gap between claimingto use and actually using the instru-ments, the physical therapists madea commitment to use the PSC and6MWT for 1 month and then discusstheir experiences in a subsequentmeeting. In the second meeting,they indicated that the instruments

Table 1.Summary of Barriers to and Facilitators of the Use of Measurement Instruments Reported in the Interviews

Domain Barriers Facilitators

Physical therapist

Competence Lack of knowledge, education, routine, andexperience

Sufficient knowledge and education

Diagnosis focused on ICFa domain: bodyfunctions

Measurement instruments are already used indaily routine

Attitude Resistance to change Readiness to change

No conviction of additional value on the planof care

Positive attitude toward the use ofmeasurement instruments

Being overloaded with information Conviction of contribution to quality of physicaltherapy care

Headstrong in own working method

Defining therapy outcome otherwise

Lack of confidence in own skills

Organization

Practice Takes too much time Patient computer system

No financial compensation

Absence of practice policy Presence of practice policy

Colleagues Lack of discussions, meetings, and feedbackfrom colleagues

Regular meetings and feedback from colleagues

No adherence to the agreements made Innovative team and cooperative colleagues

Patient Different expectations and preferences: needsno measurement instruments, wants onlytherapy, and puts pressure on therapist

Patient wants objectives to evaluate outcome oftherapy

Linguistic problems and lack of understanding

Measurement instrument Poor availability Good availability

Difficult choice

Feasibility: extensive, difficult interpretation,and unclear instructions

a ICFInternational Classification of Functioning, Disability and Health.



were useful in daily practice. Forexample, 1 therapist previouslythought that he could not use theinstruments because his patientsonly wanted therapy and no mea-surements; however, the patients ap-preciated the use of the measure-ment instruments and asked him touse them regularly to monitor theirprogress. These experiences led tothe identification of new barriers andfacilitators, which made the imple-mentation a cyclic process.

Step 3: Development ofImplementation StrategiesThere is no consensus about thebest general implementation strate-gy.9,17,25,26 It is clear, however, thatactive, multifaceted strategies tai-lored to a problem analysis are themost effective.13,16,18,24 In addition,different models of behavioralchange are recommended, but thereis no agreement about which modelshould be used.10,12,1416 Grol andcolleagues10,16 described a planningmodel for the process of change in

which different theories of behav-ioral change are integrated to inducechanges in professional behavior. Ta-ble 2 shows various domains, phasesof behavioral change (orientation, in-sight, acceptance, change, and pres-ervation of change), and specific im-plementation goals. On the basis ofthis information, we tailored the out-come of the problem analysis to theappropriate implementation strate-gies. The definitive strategies, result-ing from the project group andsounding board discussions, were

Table 2.Planning Model for the Process of Changea

DomainPhase of Behavioral Change and

Implementation Goals Implementation Strategies

Physical therapist

Competence Orientation:Awareness, interest, and involvement

Insight:Increasing knowledge and understanding

KNGF:Dissemination by publicationsOffering education possibilities

Education:Homework tasksPractical training and role playing

Attitude Insight:Insight into own working method

Acceptance:Positive attitude and motivationIntention and decision to change

Change:Confirmation of the benefit

Self-analysis list:Increasing awareness, self-reflection, and insight

into own working method

Education:Discussions about resistance, advantage, and

added value of clinimetricsCoaching style, own responsibility, individual

learning goals, and interactions with colleagues

Organization Insight:Insight into own working method

Acceptance:Positive attitude and motivationIntention and decision to change

Change:Implementation in daily practice

Preservation of change:Integration in daily routinesAnchoring in the organization

Self-analysis list:Insight into practice policy

Education:Discussions and agreements with colleagues,

development of practice policy, and formulationof learning and practice goals

KNGF:Embedding in future electronic patient dossier

Measurement instrument Insight:Increasing knowledge and understanding

Acceptance:Positive attitude and motivation

Change:Implementation in daily practice

Preservation of change:Integration in daily routinesAnchoring in the organization

Adjustments in PSC and 6MWT:Increasing feasibility and simplifying instructionsExtending PSC activity lists

Education:Practical training and homework tasksFormulation of practice policy

a The developed implementation strategies are based on various domains and phases of behavioral change, each with specific implementation goals.10,16KNGFKoninklijk Nederland Genootschap voor Fysiotherapie (Royal Dutch Society for Physical Therapy), PSCPatient-Specific Complaints instrument,6MWTSix-Minute Walk Test.



critically evaluated and readjustedseveral times. An overview of thesestrategies is shown in Table 2.

To improve the feasibility of usingthe PSC and 6MWT, we made severaladjustments:

The instructions were slightly ad-justed to improve interpretation.

The original PSC was developed forpatients with low back pain, andthe sample activity list containedactivities with which only those pa-tients would have difficulties. A listof sample activities was made forpatients with other disorders.

The visual analog scale of the orig-inal PSC was replaced with an 11-point numerical rating scale. Prac-tical use by the physical therapistsand information from the literaturerevealed that this scoring methodwas more feasible for some (older)patients.27 Changing the visual ana-log scale to a numerical rating scaledid not change the principle of thetest; the scoring methods are highlycorrelated.28 A numerical ratingscale also is used in the Pain-Specific Functional Scale.20

A self-analysis list was developed toprovide insight into and self-awareness of barriers and phases ofbehavioral change. This list wasbased on a questionnaire on the self-reported use of outcome measures inphysical therapy and was obtained,along with other items, from theproblem analysis.7 It contained 3 sec-tions with questions concerning thephases of change for the physicaltherapist, the organization and itspolicy, and an inventory of the actualuse of measurement instruments indaily practice. A few examples ofquestions from sections 1 and 2,rated on a Likert scale, are shown inthe Appendix. The self-analysis listwas pretested by the physical thera-pists of the sounding board and wasused as a guide for the educationmodule.

An education module focusing onthe physical therapist and the prac-tice organization was developed.The aims of the education modulewere to provide insight into the useof measurement instruments andphases of behavioral change, to op-timize the use of the PSC and 6MWTin the process of clinical reasoning,and to fit the use of the PSC and6MWT to practice policy. The edu-cation module consisted of 3 ses-sions of 2.5 hours. The first 2 ses-sions were planned to take placewithin 1 month, and the last sessionwas planned to take place after 2months. The program was not com-pletely determined in advance butwas tailored to the professionals. Ac-tive teaching methods, such as dis-cussion and role playing, were usedin a coaching style instead of a teach-ing style. We expected the attendeesto show an active learning attitude,initiative, and responsibility.

Steps 4 and 5: Testing andEvaluation of theImplementation PlanPilot testing and evaluation of theimplementation plan were under-taken. The adjusted instruments, theself-analysis list, and the educationprogram were tested with 2 groupsof physical therapists from 4 privatepractices in the community. The firstgroup consisted of colleagues fromthe same practice (n11); the sec-ond group consisted of colleaguesfrom 3 different practices (n10).After each session, the process andthe program were evaluated orally;after the third session, an evaluationform was filled out.

The strategies developed could beapplied to physical therapist prac-tice. The evaluation of the adjustedmeasurement instruments was posi-tive. The adjusted instructions wereeasier to interpret, and the additionalactivity lists were useful for deter-mining treatment goals. The self-analysis list appeared to be valuable

because physical therapists becameaware of their own barriers in dailypractice. The link with their phasesof behavioral change was revealingand stimulated them to use the in-struments in daily practice. Workingwith heterogeneous groups made itdifficult to accommodate the individ-ual barriers of the physical therapistsbut, on the other hand, they couldlearn from one another.

After the evaluation of the first piloteducation program, the second pro-gram was adjusted at several points.The program became more fixed inadvance. In the first session, attend-ees began to devise a practice policy.Individual learning goals were dis-cussed, and homework tasks werechecked. More time was allocatedfor practical rehearsal of the tests.The outline of the final educationprogram is shown in Table 3.

All of the physical therapists appre-ciated the active teaching methods,discussions, and role playing duringtraining. Developing a practice pol-icy was an issue of major impor-tance, especially for the preservationof change. During busy daily prac-tice, the therapists never took thetime to discuss these matters.

The physical therapists indicatedthat they were interested in practic-ing with other instruments besidesthe PSC and 6MWT and would ap-preciate sets of short, feasible, andmethodologically sound instru-ments. At the last meeting, mostphysical therapists indicated thatthey actually used both instruments.

DiscussionIn this report, we have shown that itis possible to develop and evaluate asystematic implementation plan forthe use of 2 measurement instru-ments. A thorough analysis was usedto identify practical barriers and fa-cilitators. In the interviews and dis-cussions, we could continue asking



about underlying thoughts and pos-sible solutions and strategies. In thisway, the problem analysis produceda larger amount of information thanearlier reports, in which only writteninquiries were used.48,2931 The re-vealed factors matched the barriersand facilitators described in theliterature.4,68,29,30,32

Many studies2,48,14,2932 have fo-cused on identifying the extent ofuse of measurement instruments aswell as factors that affect that use.

We took the additional steps of de-veloping various strategies based onthese factors and evaluating their ap-plicability in a pilot program in sev-eral physical therapist practices. Theinvolvement of a sounding boardduring the development phase guar-anteed interest in and acceptance ofthe implementation strategies by thetarget group.12,14,15

Starting education with self-analysisprovides therapists with the oppor-tunity to formulate their own learn-

ing goals, and trainers can tailor strat-egies to the professionals as well asthe organization. This approachhas been recommended in otherstudies.13,18

Using the planning model of Groland colleagues10,16 for the process ofchange, we were able to tailor mul-tifaceted strategies to various barri-ers and phases of behavioral change.In this way, a change in behavior wasinitiated. The physical therapists in-dicated that they used the measure-

Table 3.Outline of the Education Programa

Day Main Issues Goals Working Methods

1 Introduction Explicating expectations of therapists:active learning attitude, responsibility,initiative, active teaching methods, andcoaching style

Plenary

Self-analysis list Insight into own working method andphase of behavior

Individual

Individual learning goals and practicepolicy

Responsibility for own learning process inprofessional and practice organizationdomains

Working group of 3 or 4 people

Advantages and disadvantages ofPSC and 6MWT

Insight and acceptance Plenary

Training on PSC: clarification of thepatients main complaint

Increasing knowledge and practical skills Working group of 3 or 4 people

Homework on PSC Using PSC in practice for the next month Plenary

Evaluation of the session Reflection Plenary

2 Results of self-analysis list Insight on working method and phase ofbehavior

Presentation

Evaluation of homework task Insight and acceptance Plenary

Training on 6MWT: standardizationand interpretation

Knowledge and practical skills Working group of 3 or 4 people

Use of measurement instruments inpractice policy

Integration in the practice organization toobtain (or preserve) change

Working group of 3 of 4 people

Homework on 6MWT Using 6MWT in practice for the next 2 mo Plenary

Evaluation of the session Reflection Plenary

3 Evaluation of homework task Insight and acceptance Plenary

Theory of clinimetrics Insight and knowledge Lecture

Step-by-step plan to search for othermeasurement instruments

Transfer to the use of other instruments Lecture

Evaluation of practice policy Integration in the practice organization toobtain (preserve) change

Working group of 3 or 4 people

Integration of instruments in clinicalreasoning and daily practice

Preservation of behavioral change Plenary

Written and oral evaluations of totaleducation module

Reflection Plenary and individual

a PSCPatient-Specific Complaints instrument, 6MWTSix-Minute Walk Test.



ment instruments more often, andthey were convinced that doing socontributed to the process of clini-cal reasoning. For the preservationof change, more time is needed.

It is evident that quality improve-ments should start with small, simpleprojects.23 This case report involveda small group of selected physicaltherapists in the southern region ofthe Netherlands; therefore, generali-zation of the results is unjustifiable.Further studies and additional de-signs with other measurement in-struments are needed to evaluate theeffects of implementation strategies.

Our recommendations for the policyof the Royal Dutch Society for Phys-ical Therapy are as follows. First, in-formation about measurement in-struments should be disseminatedthrough publication in professionaljournals, newsletters, and guidelines.This strategy represents the orienta-tion phase, in which awareness ofthe existence and use of measure-ment instruments is an important is-sue. The information should not berestricted to the measurement instru-ments alone but also should focus onhow to use and interpret the resultsof the instruments in daily practice.Second, educational opportunitiesshould be offered for physical thera-pists to increase their knowledgeand skills regarding the use of theseand other measurement instrumentsin the process of clinical reasoning,with attention to behavioral change.This education should be includedin mainstream physical therapistschools. Third, the measurement in-struments should be embedded inthe future electronic patient dossier.

The actual use of measurement in-struments should not be the only ob-jective in implementation programs.The integration of the instruments inthe process of clinical reasoning is ofmajor importance. Therefore, futureprograms should focus not only on

the physical therapist but also on thepractice organization and profes-sional associations.

Both authors provided concept/idea/projectdesign, writing, and project management.Ms Stevens provided data collection andanalysis. Dr Beurskens provided fund pro-curement and facilities/equipment.

The authors are grateful to members ofthe project group (Dr Rob de Bie, Dr ErikHendriks, Mr Pieter Wolters, Dr RaymondSwinkels, Mrs Anja van den Donk, and MrJohn Meijers) and the sounding board (thephysical therapists interviewed).

This work was funded by the Dutch ScientificCollege Physiotherapy of the Royal DutchSociety for Physical Therapy (TD/2008/01).

This work, in part, was presented at the An-nual Congress of the Royal Dutch Society forPhysical Therapy; November 9, 2007; Am-sterdam, the Netherlands.

This article was received March 30, 2009, andwas accepted February 24, 2010.

DOI: 10.2522/ptj.20090105

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Appendix.Examples of Questions in the Self-Analysis Lista

QuestionsFully

Disagree Disagree

NeitherAgree norDisagree Agree

FullyAgree

Section 1: questions about yourself

I am able to interpret the outcome of measurementinstruments in the right way

I think it is important to document patient data inan objective way

I think that the use of measurement instrumentsdoes not take too much of my time

The use of measurement instruments is a fixed partof my methodical approach

Section 2: questions about policy in your practice

In my practice, enough measurement instrumentsare available

My supervisor supports employees in usingmeasurement instruments

The colleagues in my practice use measurementinstruments

a The complete list is available on request from the authors.



Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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