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Table 3 Provider-Perceived Barriers and Facilitators in SDM in Community Rehabilitation as well as Exemplar Quotes

From: Experiences of shared decision-making in community rehabilitation: a focused ethnography

Provider-Perceived Barriers & Facilitators towards Aligning Expectations in SDM
GeographyPlace and distance accentuated other factors. Rural providers felt more control, independence and sense of community. Catchment areas affected long-term relations and goal realization.
“Then the other thing I would say that is different is that often times you have a relationship already with patients in rural setting. … It might be good. It might be bad. But for the most part it’s a lot of work is already kind of done before the person even walks in the door.” [Rural Provider 5, Female]
MessagingProviders felt SDM went better when using visuals; clear language; specific and simplified strategies tied to the patient’s circumstances and preferences.
“[H]ow strong and powerful words can be with certain again different genders or different cultures…. Just knowing that maybe somebody doesn’t have strong anatomy knowledge or medical knowledge, if you say certain words it can be very scary to them and that can exacerbate their pain.” [Metropolitan-Urban Provider 1, Female]
OrganizationSDM was promoted by available patient and organizational financial resources; more privacy during appointments; facilitative intake and eligibility processes; standardized resources; and, the strong, collaborative and available multidisciplinary relations and environments.
“It doesn’t happen as much in this clinic, but there’s also obviously financial limitations. Physio, chiro all of that stuff, it’s not cheap. People have benefits but usually doesn’t cover a full treatment course.” [Metropolitan-Urban Provider 2, Male]
Patient CharacteristicsProviders attached the SDM experience to patients’ modifiable and non-modifiable attributes, including age, lifestyle, capacity, emotionality, memory, realism, and perceived desire for control. Exemplar barriers manifest as older age, less-active lifestyle, and diminished capacity.
“I think different cultures can kind of play into that so if it’s maybe someone from a cultural background or they just didn’t really have an experience with exercise. I think with different sets of cultures, you see that they’re very much like you’re the healthcare practitioner you’re supposed to fix me, I don’t need to do the homework.” [Metropolitan-Urban Provider 1, Female]
Provider CharacteristicsPrevious personal and professional experience promoted collaborative SDM and patient communication. Providers’ training, previous employment, disposition, confidence, and approach to culture were particularly influential. These factors populated underlying tensions.
“I think the turning point was when my dad had a stroke…. The physical deficits doesn’t affect me as much as the personality and the cognitive deficits I saw happening in him…. It’s not just about physical deficit, it’s the overall person, where they’re coming from, what is important to them. … [Female, Provider 6, Regional-Urban]
TimePerceptions of more time together facilitated SDM by promoting provider experience, rapport-building, and perceived patient acceptance. Externally, or self-imposed, time limits impeded communication and SDM.
“Because we get in habits a lot of the time when we’re a little bit short on time or we consider ourselves short on time. … The patients thinking about an answer, [and] sometimes we tend to jump in and try to help them answer it instead of just letting them have the time to do it.” [Regional-Urban Provider 4, Male]
Appointment TypesAppointments vary by reason, group-vs-individual, and patient population. Collaboration felt limited in hand and equipment-approval appointments with physician-imposed plans and standardized processes. SDM was impacted by how providers navigated group camaraderie.
“I would say the things that often don’t go well is when a person has a sense of that they’re coming in for some sort of specific thing and that’s not what we’re able to provide. Let’s say a referral from a physician, and they have some expectation of what we’re able to do that’s not actually within our scope of practice.” [Regional-Urban Provider 1, Female]
TrainingProviders who participated in communication training (e.g. HealthChange®) spoke in the language of ask and listen, empowered patients via education and practiced respect to promote better SDM.
“HealthChange … I find the assessment a little more focused and a lot faster if I spend a lot more time on the introduction and the question and ask them what are they here for and explain what we can do.” [Regional-Urban Provider 2, Female]