Patient-Perceived Barriers & Facilitators towards Aligning Expectations in SDM
Patients often felt very comfortable with rural providers with longer relationships, sense of community and greater privacy. This facilitated SDM. Physical distance and lack of choice were geography-related barriers.
“That’s one real advantage of [Town 3] is that he is it. And there’s next to nothing else going on. There’s no other distractions. He’s focusing entirely on you. … He takes his time.” [Rural Patient 4, Male]
Patients prefer consistency in provider approaches and language at repeated appointments. Patients appreciated evidence of multidisciplinary collaboration and where follow-up specific to, and built upon, similar previous discussions.
“With the massage therapist, I feel confident, it’s an in-depth, specific conversation. It’s not ‘how are you today?’ He says to me every time, I read your notes of what you did with [the physiotherapist] last, have you seen the concussion specialist? What’s happening with that? … And then he says okay what’s the worst thing that’s a challenge to you this week, or today, and then he says, what would you like me to work on?” [Metropolitan-Urban Patient 3, Female]
Organizational facilitators included feelings of privacy, family interactions, and availability of multiple, collaborative professionals. Barriers related to finances, waitlists, professional relationships, and service convenience.
Especially if I’m just put on a machine and it’s like here you go just pay $85. It’s like would it be cheaper if I just buy the darn machine and do it at home?” [Metropolitan-Urban Patient 3, Female]
Patients’ influential traits included level of assertiveness, lifestyle, positive perception, perceived responsibility, perseverance, self-deprecation, memory, emotions, and vulnerability. Facilitators included active lifestyles, positive attitudes, and taking personal responsibility.
“I am pretty coy about [my goals] you know. I think he recognizes [sic] that different people have different goals and motivation. Like I’m sure there’s lots of couch potatoes out there. In fact another fella that I know went to [the physiotherapist], he’s kind of accepted where he is and I’m not that kind of person.” [Rural Patient 4, Male]
Patients felt most comfortable with consistently-available and previously-known providers. Patients positively contrasted rehabilitation providers to other professions (physicians, dentists).
“[The previous physiotherapist] just kept insisting that we have to go through with it. And I’m like no … and he just never let up on it and finally I just wouldn’t go back anymore.” [Rural Patient 3, Female]
Time impeded SDM when patients perceived appointments as abrupt; issues as novel; experiences as unremarkable and unsustainable; and physical progress as too slow. Time-related facilitators afforded dynamism and apt appointment frequency.
“She talks very fast, she moves very fast, and it’s like, I feel like ‘oh we’ve got to get you out of here because there’s 500 other people waiting and I don’t have time for that.’ … And I don’t want to upset anybody. But [sic] this whole thing has made me a little insecure to voice my opinion.” [Metropolitan-Urban Patient 3, Female]
The availability of choice was important, but not absolute. Convenience, accessibility and geography influenced this availability. Rarely, patients sought second opinions.
“We’re equal distance between [Town 1], [Town 2] and [Town 3] and so I could go any of those places. … So [Town 3] is convenient, but if it wasn’t the quality then I probably would be going elsewhere. So it’s convenient but I also have good rapport, trust and think I’m getting high quality care when I go to [Town 3].” [Rural Patient 4, Male]
Power & Deference
Patients expressed great deference to providers, which led to difficulties in expressing goals or complaints. Patients often went without care or without fully expressing their preferences.
“Shared decision-making [is that] they’ll help me out. I don’t know, you’re talking to an old old lady.” [Rural Patient 1, Female]