Table 4 Patient-Perceived Barriers and Facilitators in SDM in Community Rehabilitation
From: Experiences of shared decision-making in community rehabilitation: a focused ethnography
Patient-Perceived Barriers & Facilitators towards Aligning Expectations in SDM | |
|---|---|
Geography | 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] |
Messaging | 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] |
Organization | 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] |
Patient Characteristics | 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] |
Provider Characteristics | 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 | 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] |
Choices | 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] |