Professional practice, competence, and education related to COVID-19: A mixed-methods light study of physiotherapists’ experiences

ABSTRACT Background Coronavirus Disease 2019 (COVID-19) became a significant challenge for the work and personal experience of physiotherapists (PTs) Objective To investigate how the work activities of PTs in a region in Italy have changed, describe the reasons for change, perceived competence, and effectiveness of professional education, and explore their personal experience Methods We adopted a monocentric convergent mixed-methods light–questionnaire variant study. The questionnaire contains both closed-ended and open-ended questions. Quantitative and qualitative data were combined to interpret the results Results Among 78 respondents (response rate 24.4%), 87.2% worked during the pandemic, 52.9% treated patients with COVID-19, and 45.6% changed their working activities. Professional competence was perceived as low in intensive and sub-intensive care settings. The major critical aspect of professional education was respiratory rehabilitation. Life-learning education was judged as effective, even if mainly focused on safety. Nine themes emerged from the analysis of the PTs’ experiences: 1) Physiotherapy during COVID-19; 2) Fear and negative feelings; 3) Positive aspects; 4) Organization and management; 5) Prevention measures; 6) Patients; 7) Change; 8) Information; and 9) Professional education Conclusions PTs who have direct experience with patients with COVID-19 showed great resilience. They overcame the first phase of disorientation and fear, despite a specific lack of competence in the respiratory field.


Introduction
In March 2020, the World Health Organization (WHO) declared the Coronavirus Disease 2019 (COVID-19) as a pandemic.As of October 2022, the World Health Organization (2022) reported over 256 million cases of COVID-19 and over 2.1 million COVID-19-related deaths across the WHO European Region.The pandemic has had a huge impact on the healthcare system and healthcare professionals even in the field of rehabilitation (Bettger et al., 2020;Boldrini et al., 2020b).Accordingly, several guidelines and professional statements at both international and national levels were published to help health professionals in their practice (Lazzeri et al., 2020;National Institute for Health and Care Excellence, 2021;Thomas et al., 2020;Vitacca et al., 2020aVitacca et al., , 2020b;;Wang et al., 2020;World Health Organization, 2021).
The pandemic prompted the need for a sudden reorganization of the rehabilitation services (Amatya and Khan, 2020;Boldrini, Bernetti, and Fiore, 2020a) and changes in the activities of all professionals including physiotherapists (PTs) (Iannaccone et al., 2020;Simonelli et al., 2020;Wade, 2020).Several quantitative and qualitative studies have highlighted several issues related to PTs' professional experiences during the pandemic.The level of care of patients with COVID-19 was found to be highly variable across different settings, and interventions were mainly focused on improving respiratory functions and preventing deconditioning (Tiwari et al., 2021).It was a stressful situation with pressing physical and emotional demands on the frontline workers combined with an unprepared healthcare system for managing a pandemic situation (Palacios-Ceña et al., 2021).The investigation of the emotional experiences of PTs revealed the risk of burnout and the need to provide early support (Jácome et al., 2021).
PTs taking care of patients without COVID-19 often had to interrupt their practice or adopted digital tools to provide assessment and treatment with changes in session structure and nature (MacDonald et al., 2020;Minghelli et al., 2020).Concerning Italian PTs a national cross-sectional survey in 2020 found that 3.6% of participating PTs had tested positive for COVID-19 and that the main work-related risk factors were working in a healthcare facility, being reassigned to a different unit, and changing job tasks (Gianola et al., 2021).No comprehensive national data pertaining to PTs were available; in fact, they were limited to specific contexts or regions.In a survey conducted in Lombardy (Privitera et al., 2021) more than half of the respondents had to face organizational changes, 10.9% had to support nurses in assisting patients, and 6.6% were involved in the treatment of patients in intensive care units.Furthermore, to our knowledge, professional and lifelong education after the onset of the pandemic was investigated only in a small study of manual therapy practice and education (MacDonald et al., 2020).Finally, we found no studies examining and integrating, both quantitatively and qualitatively, aspects such as professional practice, self-perceived competence, professional and lifelong education, and personal experience of (Italian) PTs during the pandemic.
For these reasons, we performed a mixed-methods study.The quantitative (QUANT) part will investigate the following: aspects of PTs' professional practice (i.e.type, structure, and working modalities); type of users during the pandemic and any changes relative to the pre-pandemic period; evaluation and intervention strategies and their rationale and outcomes considered in the management of people with COVID-19 or its consequences; self-perceived professional competence in the management of patients with COVID-19 or its consequences; professional consultation received or given; and aspects related to professional education (i.e.selfperceived proficiency, emerging needs, and courses attended) during the pandemic.The qualitative (Qual) part explored the reasons for the given quantitative judgment and the pandemic experience of PTs.The mixed-methods part explained the data emerging from the quantitative and qualitative aspects and identify any new emerging issue/topic.

Study Design
This is a monocentric nonprofit-convergent mixedmethods light-questionnaire variant (QUANT + Qual) study (Creswell and Clark, 2017).It was based on the administration of a questionnaire (survey) to a single sample/population that includes closed-ended (QUANT) and open-ended (Qual) questions.In the "light-questionnaire variant," the quantitative part predominates the qualitative part, the open-ended questions of the questionnaire were mainly included to confirm, validate, or explain the results derived from closed-ended questions.Quantitative and qualitative data were merged and then interpreted in the discussion part.The intent of this study was mainly descriptive, as the phenomenon examined was a new one in the context and population under study.A phenomenological approach was applied only for the last open-ended question of the questionnaire.

Rationale
A mixed-methods approach (Hong et al., 2018;Levitt et al., 2018) is useful in overcoming the limitations of using a single methodological approach, as it provides a broader understanding of the phenomenon being studied.The "light" model, even in the absence of a rigorous qualitative dataset, might allow for deriving labels or emerging themes useful for validating, explaining, and deepening the results of the quantitative part.The protocol of this study was prospectively registered on Open Science Framework (OSF) (Identifier: DOI DOI 10.17605/OSF.IO/QGDCS) on July 14, 2021.

Inclusion and exclusion criteria
PTs registered in the professional register of Physiotherapists of Ferrara, Italy TSRM-PSTRP Order (320 subjects) were invited to participate in the study and those who gave their consent were included.Individuals belonging to a special certification list (i.e.masseurs) were excluded as they have different professional education.

Setting
The study was performed in a territory covered by the professional register of Ferrara, Italy.The region is a rural area in the northern part of Italy, expanding over 2.635 km 2 with about 341,000 inhabitants.

Researchers
Eight researchers, who were also PTs, were involved in the study.One physiotherapist was involved in professional education (MB), five physiotherapists in different fields (respiratory and COVID-19 (AO), musculoskeletal (GS and MDR), neurological (SM and MDR)), and one was a physiotherapy student (EB); one of them is a freelance physiotherapist (GS), two of them were representatives of the professional order (GS and SM), and three of them (MB, MDR, and GS) had experience in quantitative and mixed-methods research.Furthermore, one expert in qualitative research (SB) and one statistician (GV) were members of the research team.

Recruitment of Participants
The study was approved by the local Ethics Committee (Comitato Etico Area Vasta Emilia Centro) on May 20, 2021.Further, while formulating the questionnaire and analyzing its results, the research group considered and respected the potential different sensitivities and diversities of the study population.The Professional Order of Ferrara sent the participants an e-mail invitation to fill in the questionnaire.No benefits were offered for study participation.The researchers were not aware of the mailing list.Upon voluntary access to the online questionnaire, the participant could access the study protocols and was requested to sign an informed consent; at the end of the questionnaire, consent for the use of the data provided was requested from the respondents.

Data Collection
The data were collected through an anonymous electronic questionnaire that consisted of closed and openended questions.

Preparation and pretest of the questionnaire
No validated questionnaires were found in the literature.Based on the relevant literature, the questionnaire was developed using an inductive-deductive recursive process by four researchers.MB, AO, and EB developed the first draft of the questionnaire, which MDR revised to prepare a new draft.The questionnaire (version 1) was imported into an electronic form in order to make it suitable for online administration.The form does collect neither the computer ID of the respondents nor their e-mail address, thereby guaranteeing data anonymity from an IT perspective.
The questionnaire was structured based on the macro areas of investigation, with closed-ended questions that depending on the positive/negative answer can direct the respondent to specific sections with more closed/ open question(s) for explaining or expanding on the previous answer.In this way the respondent would be able to navigate across different sections of the questionnaire without encountering any irrelevant questions.For quantitative questions a 5-point Likert scale was adopted (Artino, Rochelle, Dezee, and Gehlbach, 2014;Boynton and Greenhalgh, 2004).
The questionnaire (version 1) was tested using a short pilot study.GS and SM conducted separate trials of the questionnaire of all the possible branched variants and filled in a reporting form.The form requested an opinion on clarity of the wording, overall usability of the online questionnaire form, acceptability of time required, respect for privacy, relevance and completeness of the questionnaire with respect to the stated objectives, and a qualitative description of any problem and suggestions for improvement.Version 1 was revised by MB, MDR, AO, and EB on this basis to obtain the definitive version.

Administration
To promote participation, a notification was sent via e-mail and published on social media (Facebook) 15 days prior to the administration of the questionnaire.The questionnaire was administered in an electronic form on computer support ("Computer Assisted Web Interview") sent via e-mail on July 15, 2021.The respondents had 25 days to complete the questionnaire.Two reminders were sent to them via e-mail before the deadline.

Privacy
The confidentiality of the data was ensured in the collection phase, as the questionnaire did not collect personal identification data.Further, suitable procedures according to the current Italian laws were established during the processing and storing phases.

Data Management and Analysis
The data from the questionnaire were collected automatically in a .csvformat.Since the respondents were anonymous from the initial stage, each participant was assigned a unique alphanumeric identification code.

Quantitative data
The normality of the distribution of continuous variables was evaluated with the Shapiro-Wilk test.In the case of distribution symmetry, the variables were represented as mean and standard deviation, while the median value and interquartile range were used in the case of distributional non-normality.The categorical variables were expressed in absolute and percentage values.Likert scales were expressed as median and interquartile ranges.Comparisons between groups were made using the χ2 test or Fisher's exact test for categorical variables.For the comparison between two groups (e.g.stratified analysis by sex) the continuous covariates were used and the Student's t-test for normally distributed variables and the Mann-Whitney test for asymmetric variables.All analyses were performed using STATA® 15.1/MP (Stata Corporation, College Station, Texas, USA).P < .05 was defined as statistically significant.Two researchers (MDR and GV) were involved in the analysis.

Qualitative data
The answers to the open-ended questions were imported into a software (Atlas.ti9 Scientific Software Development GmbH, Berlin) for qualitative research.The text was independently analyzed and coded by two researchers (MB and EB).The different encodings were compared to obtain consensus and unique encoding.
Codes that emerged from the simple explanatory open-ended questions were computed to extract a quantitative description.The codes that emerged in the wide exploratory open-ended questions were grouped by different emerging themes.Subsequently, two researchers (MDR and SB) validated the results (i.e.triangulation of the researchers).After data merging, coding and groups were revised again.

Merging of data
The qualitative and quantitative data were crosstabulated to create a matrix and, subsequently, a joint integrated display table (Creswell and Clark, 2017).Interpretations were conducted at the discussion level to obtain a better description and understanding of the problem (Creswell and Clark, 2017).The different methodological steps are depicted in Figure 1.Validity, reliability, and methodological integrity "Trustworthiness" (i.e. the trust that can be placed on the results) (Korstjens and Moser, 2018) was supported by promoting credibility through: triangulation of quantitative and qualitative methods and the triangulation of researchers in the analysis, integration, and interpretation of data; transferability through a detailed description of the characteristics of the context being examined; dependability through the detailed description of the methods used to allow replication to others; confirmability through a detailed description of the ways in which conclusions were drawn and discussed; and reflexivity through notes where researchers left traces of their reflection on implicit and explicit assumptions, values, and preconceptions and on the conceptual lens being used (Korstjens and Moser, 2018).An "audit trail" was used to further promote dependability and confirmability.

Results
A total of 80 PTs answered and completed the questionnaire, but the data for 78 PTs were included, yielding a response rate of 24.4%.The two respondents who did not give their consent were excluded.The respondents' flow diagram is available in Supplemental Material Among the participants, 53 (68.0%) were females and 25 (32.0%) were males.Respondents had a mean age of 45 (SD 12), and the median was 46 years (IQR 21.8).No statistically significant difference was found in age and sex distributions between the survey respondents and the entire population of eligible, registered PTs (p = .30and p = .59,respectively).
The respondents had different types of the first qualification: 35 (44.9%) had a title prior to the assignment to the university of health professionals' education (Lex n.341/ 1990); 7 (9.0%) a bachelor's title (between 1992 and 2002); and 36 (46.2%) a bachelor's degree (post-2002).A mean of 19.4 (SD 12.2) and a median of 19.5 years (IQR 31.8)have passed since the first qualification.
Regarding PTs' working activities during the pandemic (Table 1-Part A), working in a private professional clinic was associated with a possible activity interruption (p = .0001).By contrast, working in a National Health System (NHS)-related setting was associated with a change in type of patient and ward or setting (p = .05and p = .004,respectively).No other statistically significant association was found.

Discussion
Our survey had a low response rate, despite being consistent with previous/other online surveys (Fincham, 2008) conducted in the same context (Matarazzo et al., 2021) involving the same professionals (Privitera et al., 2021;Tiwari et al., 2021) or other Italian professionals (Albano et al., 2020;Attanasi et al., 2020;Bontà, Campus, and Cagetti, 2020;Cagetti, Cairoli, Senna, and Campus, 2020).Despite our efforts to promote participation (i.e.social media and reminders) the time requested to fill out the questionnaire and sending the questionnaire in the summer might have discouraged more participation.Therefore, we cannot consider our results to be representative of the population owing to the number of respondents and a possible self-selection bias (Draugalis and Plaza, 2009).However, our sample is similar to the population in terms of age and gender; moreover, a wide range of professional experience, working settings, and type and time passed since the entry-level education were represented.As described in the method section our study adopted a mixed-methods light -questionnaire variant (QUANT + Qual) design, and quantitative and qualitative data were merged and then interpreted in the discussion phase.
The pandemic had a big impact on PTs' working activities, as 44% of respondents, not dissimilar from the percentage reported by Privitera et al. (2021) had to stop their work.In our study working as a freelancer was a significant factor affecting the interruption.Minghelli et al. (2020) emphasized this aspect.Government provisions were one of the main reasons, but in some cases, professionals or patients chose to stop.Freelancers complained about the shortage of PPE, and some of them preferred to postpone the treatment of patients with chronic deferrable conditions.A respondent who chose to close the practice as a precaution expressed admiration for their colleagues who continued working in the frontline: " . . .I feel . . .professional admiration and gratitude for all the colleagues who were, and still are today, [working] on the frontline." Table 1.Joint display of quantitative and qualitative results.Setting of respiratory condition treatment.Hospital outpatient clinic 9 (11.6), hospital unit/division (other than the above) 12 (15.5),outpatient clinic 2 (2.6), home care 7 (9.0),intensive care unit 2 (2.6), medicine unit 3 (3.9),other 3 (3.9).More than one setting 10 (13.0).
Variations in working activity.Yes 31 (45.6), no 37 (54.4)How it changed.Most of the respondents (n = 14) indicated the adoption and use of PPE and other prevention measures (disinfection of environments, environmental and organizational changes for distancing).The time for filling in the forms, as required by COVID-19 regulations, and the lengthening of the time required for each patient were also cited (especially by freelancers), which resulted in a reduction in the number of patients treated daily and an increase in waiting time.Regarding physiotherapy treatment, some (n = 2) used a "remote" approach, while in other cases, the physiotherapy was described as less intense (elderly) or more difficult due to the lack of non-verbal language and body contact (children).In another case, it was integrated with the constant monitoring of saturation and heart rate; group activities were abandoned.Those who changed their work settings described changes in users (patients with COVID-19 or hospitalized) or transition to non-physiotherapy activities.
Change in ward or work setting.Yes 10 (14.7); no 58 (85.3)How it changed.Regarding work settings, the respondents mainly highlighted the change in the type of patients-transition from outpatients to inpatients (mainly due to COVID-19).One respondent stated having transitioned from patients with sub-acute neurological to musculoskeletal conditions.

Max
Reasons.The reason cited by respondents for the problem of low competence in assessment was the lack of knowledge of the COVID-19 pathology or the respiratory aspects.Those who have expressed intermediate competence ascribed a positive contribution to internships (n = 1) and previous knowledge (n = 1) or to knowledge acquired through specific guidelines (n = 1) or to have applied usual strategies (n = 2), while a negative contribution is associated with lack of training, especially in the respiratory field (n = 6) or to lack of experience in treating similar conditions (n = 4) or the pandemic situation (n = 1).On the other hand, those who declared high competence ascribed it to the utilization of already used and validated scales and tools (e.g., oximeter) (n = 8), learning through past (n = 1) or present education (n = 1), and/or consulting with colleagues (n = 2).
Need to seek advice from healthcare professionals.Yes and asked 17 (54.8),yes but not asked 2 (6.5), no 12 (38.7)Reasons for seeking advice.The respondents revealed seeking advice from professionals with more experience in respiratory problems and/or COVID-19, or for problems of specific medical competence (n = 6), in order to obtain information or confirm a suspect.Some PTs (n = 3) justified their action by highlighting their lack of specific education, while others stated a lack of expertise (n = 5).Those who did not ask for advice, even though they wished to do so, declared that it was not objectively feasible (n = 1) or because the interlocutor (territorial medicine) was not very cooperative (n = 1).
Note: advice was sought from PTs with varying levels of self-declared competence.

Max
Reasons.Those who declared insufficient or poor professional education ascribed the problem to the lack of specific education on COVID-19 and/or respiratory conditions.In the case of intermediate adequacy, the positive aspects concerned self-education, having specific education, previous experience, or the ability to work for goals; the negative ones were obsolescence or superficiality of knowledge, and lack of specific education.In the case of good/excellent education, experience (n = 7) and/or university studies (4) or positive results obtained (n = 2) were the supporting reasons.

Table 1 part E -WORKING IN AN INTENSIVE OR SUB-INTENSIVE CARE SETTING (CRITICAL PHASE) (36 respondents)
Taking charge of patients with COVID-19 in intensive or sub-intensive care (critical phase).Yes 5 (13.9), no 31 (86.

Table 1. (Continued).
Need to seek advice from healthcare professionals for treating patients with COVID-19 in intensive or sub-intensive care.Yes 5 (100.0),no 0 (0.0) Reasons.Those who asked for advice sought to confirm their treatment activities or seek help in managing monitoring devices or NIV.

Max
Reasons.There was an imperfect alignment between competence and adequacy of education.Having a specific respiratory training was mentioned as a positive (n = 1), whereas its absence was a negative (n = 3).Education was rated as adequate because the treated patients were similar to usual patients (n = 1) or PT experience (n = 1) or the patient had reached clinical stability.One respondent evaluated the adequacy of education based on feedback of patients.
Need to seek advice from healthcare professionals for treating patients with COVID-19 in non-intensive care settings Yes 7 (58.3),no 5 (41.7)Reasons.Those who had previously declared poor competence or professional education (n = 2) sought advice for receiving help or exchanging views.Others either wanted to get advice from a specialist (pulmonologist or a physiatrist) (n = 2) or define goals as a team (n = 3).In this section, there was one missing data.Reasons.Some respondents did not provide a reason (n = 3).A respondent with a perception of low competence cited an outdated education as the reason, while those who reported an intermediate competence (n = 2) said they used the usual rationale or the experience gained in the field; those with good self-reported competence mentioned teamwork (n = 1), experience (n = 1), university education (n = 1), previous knowledge of evaluation and monitoring tools (n = 1), results achieved by patients (n = 1), similarity with previous cases (n = 1), less critically ill patients (n = 1).Those who reported high competence (n = 2) stated that they were in charge of stable patients or collaborated with respiratory PTs.

Max
Reasons.Not all respondents provided a real reason.Those who rated poor training cited the lack of updating or the novelty of the problem as reasons.Among these, one respondent referred to university education, which was also cited as a reason for good competence.Aerobic exercises (cycling, treadmill, free walking) 6 (85.7), strengthening of the peripheral muscles 7 (100.0),monitoring of parameters 5 (71.4), balance exercises 4 (57.1),training for functional activities (ADL) 6 (85.7), monitoring of dyspnoea and fatigue 5 (71.4), patient education on oxygen therapy 1 (14.3),lung recruitment exercises (to enhance lung volume recruitment) 1 (14.3),education about self-management strategies for dyspnoea and fatigue (i.e.adoption of postures, breathing techniques, Energy Conservation Techniques) 3 (42.9),respiratory muscle training in case of inspiratory muscle weakness 1 (14.3),support for management of tracheostomy tube 0 (0.0), bronchial clearance techniques 0 (0.0), neuromuscular electrical stimulation 0 (0.0), other 0 (0.0) More than one type of intervention: "2 to < 5" 2 (28.6), "≥ 5 to <7" 2 (28.6), "7 to 8" 3 (42.Reasons.All respondents except one stated that teamwork was generally successful.General positive aspects of teamwork were the integration of specific skills (n = 4), exchanging views and collaboration (n = 9), harmony (n = 2), source of support (n = 4), shared decision on objectives (n = 9) and facilitation of their achievement (n = 5), taking a comprehensive charge of the person (n = 3).Lack of knowledge and uncertainty related to COVID-19 further enhanced teamwork (n = 1).Negative aspects, on the other hand, were a hierarchical (medical) team and that physiotherapist was not considered a member of the team (in the pre-COVID-19 stage) in some departments.

Table 1 part M -PROVIDING ADVICE FOR MANAGEMENT OF PATIENTS WITH COVID-19 OR POST-COVID-19 (36 respondents)
Being asked for advice.Yes 5 (13.9), no 31(86.1)Only for the 5 respondents who answered "Yes" 2.6.1.1From whom and why.One respondent mentioned generically exchanging views, while two respondents received a request for advice from colleagues due to their experience with patients with COVID-19 and treatment of respiratory problems; one respondent reported having been consulted by a patient and caregivers about motor recovery; one respondent reported having consulted with a specialist doctor for information (however, there is doubt that the respondent might have misunderstood the question). (Continued)

Table 1. (Continued)
. Respondents highlighted some aspects: the human and formative value of lived experience (n = 1), the initial feeling of inadequacy, discouragement and anxiety (n = 4), stories of loneliness (n = 1), and the improvement with time owing to good management (n = 1).The multidisciplinary team was important to knowledge sharing (n =1).Patients with COVID-19 needed serious consideration due to their deconditioning (n = 1) and psychological difficulties (n = 1).Gratitude to colleagues remained at work (n = 1).One reported having contracted COVID twice (n = 1).Only for the 44 respondents who answered "Yes" Types of new learning goals.Two participants would have liked to deepen their knowledge in the field of reconditioning and endurance training; 16 respondents said they needed training in the respiratory field and one stated to treat severe post-COVID-19 respiratory insufficiency; 14 reported that they wanted to deepen their knowledge on the virus, its characteristic consequences, and management of both physical and psychological aspects.Others mentioned information on infection prevention and the use of PPE (n = 4), information on regulations, emergency management (n = 4), and information on how to perform telerehabilitation (n = 1).A participant would have liked to learn more about the devices used in the ICU; another participant stressed the importance of knowing how to take care of the carers.Attended professional continuing lifelong educational courses on COVID-19 during the pandemic.Yes 52 (66.7), no 26 (33.3) Only for the 52 respondents who answered "Yes" Educational learning goals.Use of protective devices 46 (88.2), prevention of infection 47 (90.1), management of patients with COVID-19 25 (47.9),ventilation modalities in patients with respiratory insufficiency due to , use of telerehabilitation 7 (13.4),how to practice smart-working 3 (5.7),other 2 (3.8).

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Reasons.Those who complained of poor or intermediate effectiveness negatively report the presence of discordant information (n = 2), a very theoretical (n=2) or general approach (n=4)), an almost exclusive link to safety at work (n = 2), the limit of distance learning (n = 5), the time length (n=1) or the poor applicability (n=1), the lack of attention to "care of the carers" (n=1).Those who attributed good effectiveness (n = 21) referred negatively to the lack of interactivity (n = 2), the lack of attention to the acute (n=1) or post-COVID-19 (n = 2) condition or the excess of specificity (n = 1) or repetitiveness (n = 1).On the other hand, the efficacy with respect to the objectives (n = 8) and the transferability to the clinic (n = 1) were positively mentioned.Those who attributed excellent adequacy (n = 9), mentioned the preparation of teachers (n = 1), the good structure and clarity (n = 4) and the possibility of having useful information for prevention purposes (n = 2) and for work (n = 1) Reasons.Respondents who considered their entry-level education ineffective stated that a long time has passed since its completion and lack of specific course content linked to pandemics, PPE, and respiratory physiotherapy.Those who judged poor efficacy cited either the total absence of training (n = 4) or poor training on PPE and prevention (n = 4); some referred specifically to the lack of training for pandemics (n = 6) or lack of training in the respiratory field (n = 1).Those who rated intermediate efficacy, although reporting the presence of basic elements for managing the transmission of infections (n = 9), underlined the difficulty of applying training to pandemic situations (n = 2); a respondent stated that no one would ever have thought of such a situation to emerge.Once again, insufficient training in respiratory physiotherapy was highlighted (n = 6), especially in acute situations (n = 1).Those who judged good or excellent efficacy spoke of basic elements relating to prevention and respiratory physiotherapy or management of the person.Someone highlighted that the judgment was calibrated for one's own specific non-COVID-19 clinical setting and that, as a result, in other contexts, the evaluation of efficacy could be different.Personal professional experience during the pandemic.Of the 78 respondents, nine did not give an informative answer.
The "physiotherapist during COVID-19" played an important role in supporting patients, even psychologically.Communicating and performing one's educational role with young patients was difficult due to the use of PPE.Some rehabilitation services were suspended; treatment times were extended, and part of the physiotherapy was delivered remotely.Someone felt inadequate and lacked enough knowledge, but teamwork was of great help.The constant level of attention to be paid made the work tiring, but it was gratifying to have the gratitude of patients.Feelings of fear emerged from the risk of infecting themselves, their family, and patients.Being "on the frontline" was associated with exhaustion and emotional fatigue.The confusion, sense of inadequacy, the unpredictability of the situation, and concern for one's family were a source of great stress.
However, there were also positive aspects such as the progressive acquisition of tools for managing the pandemic, a "new routine", team working, a "calm yet prudent" attitude, gratitude of patients, and pride in the work done.
Services and working modalities were reorganized, but initially, indications from the professional order or the management were not clear.Some PTs felt like "meat to be slaughtered".Some freelance PTs had to or chose to stop their work.It was difficult and expensive to find personal protective equipment.Working conditions were often precarious and no psychological support was provided.The support of colleagues and teamwork was very valuable.The adoption of preventive measures has had a great impact from many perspectives.It took time, and the physiotherapy session was made longer.It was difficult to use verbal and non-verbal communication, and wearing PPE for many hours was really tiring.Someone who was already equipped with the devices experienced less difficulty; however, over time, even the non-experienced ones become habituated to the routine.
It was reported that some patients stopped their treatment due to fear of contagion.Those infected with COVID-19 showed great physical and psychological fatigue.
The respondents looked for information, although it was not always reliable; furthermore, the fake media spread was misleading and made it difficult to educate patients.Change and resilience have emerged as important themes: adapting to a new situation, learning, and having a positive attitude led to continuing work as a physiotherapist.
The problem of lack of initial preparation was partly overcome due to professional training/education (e-learning), self-learning, and the support of the few colleagues who had had training in the respiratory field.
A NHSemployee instead expressed the frustration of not being able to choose: " . . .we were assigned to different sites without any chance of choice . . ." Approximately half of those who continued working had to modify their work activities.The need to adopt a variety of prevention measures and fill-out forms/ documents increased the time between patients and reduced their number, with possible economic harm to freelancers.These results are coherent with the findings of other studies (Campo, Hyland, and Hansen, 2022;Ditwiler, Swisher, and Hardwick, 2021;Palacios-Ceña et al., 2021;Tiwari et al., 2021).Physiotherapy became less intense but more demanding due to difficulties in communication (Tiwari et al., 2021).In contrast there was little change in the type of users (i.e. increase in patients with respiratory problems) and setting.Just over half of respondents were involved in treating patients with COVID-19 or its consequences; especially from October 2020 onwards, the increase in the number of cases and the progressive onset of long COVID-19 syndrome may have played a role.Among the PTs working in professional studies, only a small percentage treated symptomatic patients.From the cross-tabulation of answers, it emerged that 17 respondents worked at the same time or sequentially in multiple settings.It should be noted that a small percentage of respondents (13.9%) worked in an intensive or subintensive setting lower than the 34% reported by Privitera et al. (2021) in Lombardy a region affected first and most intensely by COVID-19.
The majority of respondents who treated patients with COVID-19 or with COVID-19 sequelae directly performed multidimensional assessments including: monitoring of dyspnea; clinical monitoring of oxygen saturation at rest and during exercise; and the exercise tolerance tests as noted by the survey by Privitera et al. (2021).These tests are important for patients post-COVID-19 but not commonly used.In fact, some respondents felt a low level of competence and needed to seek advice from experienced respiratory specialist colleagues or medical specialists.
The different treatment options for a variety of settings in our questionnaire were created based on the main literature published until March 2021 (Thomas et al., 2020;Vitacca et al., 2020aVitacca et al., , 2020b;;World Health Organization, 2021).Monitoring of clinical conditions (i.e.parameters and signs) and monitoring of dyspnea were the types of intervention that seem to have been widely adopted in all settings, albeit in varying proportions.Strengthening and active exercises of the limbs were also frequently proposed.In acute settings passive mobilization and generally less active interventions with respect to those proposed by Tiwari et al. (2021) were performed.In the other settings, active exercises, balance training, and ADL were proposed frequently.This approach is also compatible with the clinical stability of patients in different settings.Similar interventions were reported by Privitera et al. (2021) and Tiwari et al. (2021).
With regard to the perception of competence the greatest criticalities emerged in the acute settings where the clinical conditions of patients were more unstable, treatment was multidisciplinary and involved specialized, and respiratory components were not previously employed by PTs who had worked there.In the gradual transition to non-acute and outpatient settings, where treatments were more similar to "usual" physiotherapy, PTs were more confident and did not feel the need to seek advice from colleagues.Contrary to other studies (Bettger et al., 2020;Minghelli et al., 2020), only a few respondents mentioned that telerehabilitation was a strategy used during the pandemic.
In summary, observing the different settings, a differentiated pattern of resilience following the acuity/gravity gradient of the patient seems to emerge.From the acute-post-acute phase to non-acute settings we see a shift from a physiotherapist (PT) "absorbed in the rehabilitation role" requested to apply respiratory specialist skills for treating patients with COVID-19 that they do not usually possess and work in a team for the management of prevention measures and PPE, to a PT who had to autonomously take charge of important organizational changes and manage prevention measures applying usually well-known treatment procedures.The treatment of patients during the pandemic, beyond the technical aspect, was an intense and challenging experience.In fact a rich range of coexisting feelings emerges from the answers to the final open-ended question from the fear of contagion and insecurity (i.e."fatigue and a lot of heat," "emotionally demanding" or "very human and touching" or "very intense personal" experience) to "satisfaction of having been . . .helpful to people who were struggling physically and psychologically" and " . . .people . . .isolated in a room, often elderly, who were waiting for us, grateful for the time we gave them." Most respondents who treated patients with COVID-19 or COVID-19 sequelae worked in a multidisciplinary team.Working in a team is mainly an organizational aspect typical of hospital wards, rarely possible in private clinics.Sharing objectives, mutual help/support, and synergy with other members in patient global care were successful elements of teamwork for treating patients with COVID-19, as reported by Palacios-Ceña et al. ( 2021).
The rationale for management of patient derived from various sources in the majority of respondents, coherently with the rapidly changing and increasing knowledge of COVID-19.The prominent use of previous experience and exchanges with colleagues may derive from PTs' low competence and restricted time to perform EBP steps in clinical practice, which is consistent with a recent Italian study (Castellini, Corbetta, Cecchetto, and Gianola, 2020).
We found evidence of inadequate education in the respiratory field, both in the qualitative and quantitative parts of the respondents' answers.In fact, few PTs attended post-graduate courses in this field before the pandemic, and entry-level education was not sufficient to face this specific aspect of the new disease.New educational needs emerged during the pandemic for our respondents, but not all were able to find suitable educational education or training.Most of the respondents attended online courses offered by the Istituto Superiore Sanità, which was a valuable source of obtaining background information and prevention/protection strategies for COVID-19.We could not make comparisons with other studies as to our knowledge this is the first study to investigate PTs' educational needs and educational activities during COVID-19.
All the respondents whether having carried out clinical or other activities had the chance to freely talk about their experiences during COVID-19.Some recurring themes having multifaceted aspects emerged.Fear for oneself and their loved ones "Will I bring you food for dinner or illness this evening?"and for patients, stress, physical and emotional fatigue were often mentioned which is consistent with other published literature (Bennett et al., 2020;Campo, Hyland, and Hansen, 2022;Ditwiler, Swisher, and Hardwick, 2021;Xiong and Peng, 2020).The high level of attention needed constantly for such a new and unpredictable situation and the simultaneous managing of multiple fronts (i.e.organization, family, and learning new things) seemed to require an enormous amount of energy consumption.PPE made it difficult to communicate via nonverbal cues."The quality of interaction has suffered, because of difficult non-verbal communication through \the body and facial expressions . . .' as reported in another study (Tiwari et al., 2021) and prompted to need to find out new strategies, especially with children.
However, some positive aspects also emerged.There was a progressive improvement due to: teamwork (Campo, Hyland, and Hansen, 2022); acquisition of new knowledge; enhanced experience and establishment of a new routine; and satisfaction in seeing success of their efforts and receiving the gratitude of patients and caregivers (Palacios-Ceña et al., 2020).It seems that change and resilience occurred by facing fear and performing a process of awareness, adaptation, learning, and redefinition of priorities.
The pandemic emphasized the educational and informative role of PTs, forced the remodeling of communication skills to adapt to the use of PPE and distancing, and valued psychological support for patients and teamwork.Nevertheless, some PTs complained that organizations rarely recognized physiotherapy as "essential."Another aspect to face was the distorted information spread by the media to professionals and patients.
Professionals had to undergo a reorganization of their work activities.After the first moment of "confusion" in which "no one knew what to do," someone felt forced to move ("The employees cannot choose") while others mentioned an effective adaptation of organization, although little attention was paid to the "caring of those who take care." Initially, a number of respondents perceived a lack of competence and professional education, and many PTs proactively studied or followed educational courses and shared experiences and knowledge with colleagues.The few PTs who had specific training in the respiratory field played an important professional advisory role for those working with patients with COVID-19.
While psychoneuroimmunity prevention measures reduced the risk of psychiatric symptoms in a population of Chinese non-health workers (Tan et al., 2020) in our study physiotherapists highlighted difficulties in obtaining and fatigue using PPE and problems in communicating with patients.However, other psychoneuroimmunity prevention measures (e.g.scheduled rest periods, regular exercise, nutritional meals, flexible staffing resources, and COVID-19 pandemic rehearsal) (Tan et al., 2020) could also be considered in health workers.
Our study has some limitations.Only a specific population was examined, and the study had a low response rate.Moreover, it was not possible to investigate non-response motivations recommended for detecting/controlling response bias (Davern, 2013;Halbesleben and Whitman, 2013) and verify with respondents the correctness of our interpretation, due to the anonymity of the questionnaire.However, a strength of the study was the use of a mixed-methods design for investigating and exploring simultaneously working activities, perceived competence, professional education, and individual beliefs and experiences during more than one-year span time of COVID-19.

Conclusion
In conclusion, the assessment and intervention strategies employed by the PTs who answered our questionnaire seem to be consistent with the ones found in the Italian and international literature.The great emotional involvement and importance of keeping the person at the center of the caring process are also consistent.
Not all respondents were affected in the same way by the pandemic.However, those who dealt with patients with COVID-19 directly showed greater resilience.They overcame the first phase of disorientation and fear, despite a specific lack of competence in the respiratory field, and tried to build competence by studying, sharing ideas with colleagues, and working as a team.Hopefully, the strict respect for the prevention of infection measures should be a rule for the future to prevent new pandemics.Since the local context does not seem to be a relevant determinant, experimentation with successful approaches in other regions or countries should be considered to help professionals to tackle such challenging events in the future.

Figure 1 .
Figure 1.Methodological flow diagram of the mixed-methods study.For each phase, the specific procedures and their products are presented.
1) Only for the five respondents who answered "Yes" Types of intervention performed (multiple selectable options).Passive/active mobilization 5 (100.0),frequent posture changes 2 (40.0), monitoring of clinical conditions (parameters and signs) 3 (60.0),therapeutic postures (early sitting/pronation 1 (20.0),monitoring of dyspnoea 1 (20.0),ventilation support/adjustment of oxygen therapy 0 (0.0), bronchial clearance techniques in patients with co-existing respiratory or neuromuscular comorbidity 0 (0.0), neuromuscular electrical stimulation 0 (0.0), other 0 (0.0).More than one type of intervention: two 4 (80.0),four 1 (20.0)Perceived competence in treating patients with COVID-19 in an intensive or sub-Respondents expressing low (n = 1) or medium (n = 4) competence attributed it to the lack of operators capable of providing support in complex maneuvers (1) or to the novelty of the situation and valued previous experience (n = 1), while one respondent doubted their ability to self-assess.Adequacy of professional education in treating patients with COVID-19 in an intensive or sub-Responders complained of the lack of knowledge and management of specific devices for oxygen monitoring (e.g., venous catheters (n = 1) or lack of training (n = 1), or novelty of the situation (n = 1) (Continued) Treatments and characteristics of patients post-COVID are very similar to usual practice.Effective professional (n = 1) or university education (n = 2) Adequacy of professional education for treating patients post-COVID-19 in home care setting.Not all respondents provided explicit reasons.The novelty of the problem (n = 1) or working in a setting rarely included in university courses (n = 1) were mentioned as reasons.Need to seek advice from healthcare professionals for treating patients post-COVID-19 in a home care setting.Yes 0 (0), no 7 (100) Reasons for seeking advice.NA (no one sought advice)

Reasons.
In outpatient settings, both competence and training were perceived as intermediate to excellent, and there was a perfect overlap between competence and education.Lack of familiarity with the consequences of COVID-19 infection was perceived as negative, whereas previous experience and training, effective achievement of objectives or non-critical conditions, or similarity with usual patients were positive factors.Adequacy of professional education for treating patients post-COVID-19 in an outpatient setting.Respondents reported similar reasons to those reported for the adequacy of competence, adding (n = 1) university education as positive.Need to seek advice from healthcare professionals for treating patients post-COVID-19 in an outpatient setting.Yes 2 (22.2), no 7 (77.8)Reasonsfor seeking advice.The only two people who requested advice mentioned the lack of experience in treating a specific problem or the value of sharing with the general practitioner.Table1 partJ -Working in a NURSING HOME setting (36 respondents) Taking charge of patients post-COVID-19 in a nursing home setting Yes 4 (11.1),no 32 (88.9)Only for the 4 respondents who answered "Yes" Types of intervention carried out (multiple selectable options) Aerobic exercises (cycling, treadmill, and free walking) 4 (100.0),strengthening the peripheral muscles 4 (100.0),respiratory muscle training in case of inspiratory muscle weakness 1 (25.0),monitoring of parameters 2 (50.0), monitoring of dyspnoea and fatigue 3 (75.0),balance exercises 3 (75.0),training for functional activities (ADL) 2 (50.0), support for management of tracheostomy tube 0 (0.0), patient education about oxygen therapy 0 (0.0), bronchial clearance techniques 0 (0.0), lung recruitment exercises (to enhance lung volume recruitment) 0 (0.0), neuromuscular electrical stimulation 0 (0.0), education about self-management strategies for dyspnoea and fatigue (i.e., adoption of postures, breathing techniques, and energy conservation techniques) 0 (0.0), other 1 (25.0).More than one type of intervention: ">2 to < 6" 2 (50.0), "=6" 2 (50.0)Perceived competence in treating patients post-COVID-19 in a nursing home settingThe activities were similar to the usual ones or the patients had only mild consequences from COVID, or only monitoring was needed, or the skills had been acquired during university education.Adequacy of professional education for treating patients post-COVID-19 in a nursing home settingThe reasons were similar to those provided for competence, except in the case of one respondent who specified the contribution of lifelong learning.Need to seek advice from healthcare professionals for treating patients post-COVID-19 in a nursing home setting.Yes 0 (0.0), no 4 (100.0)Reasons for seeking advice.NA (no one sought advice) Free 22 (88.0),paid 0 (0.0), both 12 (12.0)Onlyfor the 52 respondents who attended professional continuing lifelong educational courses on COVID-19 during the pandemicSatisfaction of own learning needs

Table 1 part D -ASSESSMENT OF PATIENTS WITH COVID-19 OR COVID-19 SEQUELAE (36 respondents) Assessment of patients with COVID-19 or COVID-19 sequelae. Yes
31 (86.1),no 5 (13.9)Reasons for no assessment.Some of the cited reasons are evaluation already carried out in hospital (n = 1) or by the medical doctor (n = 2), negativized patients treated for other pathologies (n = 1), and symptomatic patients treated for another problem (n = 1)Types of assessment (multiple selectable options).Monitoring of dyspnoea and fatigue perceived 23 (73.9), measurement of joint range of motion

Table 1 part F -WORKING IN NON-INTENSIVE CARE SETTINGS (36 respondents) Taking charge of patients with COVID-19 in non-intensive care settings
(e.g., internal medicine, infectious diseases department, other departments) (post-critical patients needing internal clinical monitoring for infection or fever) Yes 12 (33.3),no 24 (66.7)

of perceived competence in treating patients with COVID-19 in non-intensive care settings.*
One respondent who declared low competence cited the lack of training in the respiratory field; those who declared an intermediate competence reported having referred to the application of previous rationale or knowledge; those who declared good/excellent competence (n = 7) referred to having achieved the objectives or having performed treatment that was already established, with the possible constraint of limited knowledge of respiratory physiotherapy (n = 1).Adequacy

to seek advice from healthcare professionals for treating patients post-COVID-19 in rehabilitation, pneumology, and sub-acute care departments
Those who reported intermediate competence complained about the lack of specific education on COVID or the absence of physiotherapy courses related to COVID or training in the respiratory field.Those who reported having received a good or very good level of education positively valued the presence of training in the respiratory field (n = 2) or the type of patients treated (n = 1) or previous experience.Respondents mentioned the worsening of clinical conditions, lack of experience in cardio-respiratory or aerobic training in patients on oxygen therapy, or that psychiatric consultation was a usual practice.
Table 1 part H -WORKING IN A HOME CARE setting (36 respondents) Taking charge of patients post-COVID-19 in a home care setting.Yes 7 (19.4),no 29 (80.6)Only for the 7 respondents who answered "Yes" Types of intervention carried out (multiple selectable options).

Yes" Types of intervention carried out (multiple selectable options)
Table 1 part I -WORKING IN AN OUTPATIENT SETTING (26 respondents)Taking charge of patients post-COVID-19 in an outpatient setting.Yes 9 (25.0),no27 (75.0)Onlyfor the 9 respondents who answered "

Table 1 part N -PARTICIPANTS QUALITATIVE INTEGRATION TO PREVIOUS QUESTIONS
(36 respondents)

Table 1 part O -PROFESSIONAL AND LIFE LEARNING EDUCATION DURING COVID-19 PANDEMIC
(78 respondents)

Perceived effectiveness of post-entry level university education in offering knowledge and skills for the management of a pandemic*
Upon reading some of the responses, doubt arises that someone did not really understand what post-basic university education means.Respondents claim to have drawn useful elements from this.The education was useful for those who have completed post-graduation in respiratory rehabilitation.Musculoskeletal post-graduate degrees did not offer specific knowledge but only methodological elements.Someone underlined the usefulness of the ability to independently find evidence and information.