“This is not negotiable. You need to do this…”: A directed content analysis of decision making in rehabilitation after knee arthroplasty

Abstract

Purpose:

To understand patients’ and physical therapists’ perspectives related to decision making during outpatient rehabilitation after total knee arthroplasty (TKA), and to describe potential barriers and opportunities for shared decision making (SDM) in this setting.

Methods:

A qualitative study examined the beliefs, thoughts, and experiences of patients and physical therapists regarding decision making in outpatient rehabilitation after TKA. Semi-structured interviews were conducted and analysed using directed content analysis.

Results:

Thirty-five participants were interviewed (20 patients, 15 physical therapists). Three main themes emerged from the data: (1) there is variability among physical therapists in how patients are involved in care decisions, (2) several features of the outpatient care paradigm are not supportive of SDM, and (3) preoperative patient-clinician interactions may facilitate SDM in postoperative rehabilitation, but these interactions are not typically utilized.

Conclusion:

Physical therapists described using decision-making strategies with varying levels of patient involvement. Both patients and physical therapists described barriers to routine use of SDM in the outpatient setting. Several actionable strategies for overcoming these barriers were identified for providers and organizations seeking to consistently use SDM in outpatient TKA rehabilitation.

1 |. INTRODUCTION

Patient-centered healthcare stipulates that all clinical decisions should be guided by patient preferences and values.¹ Practicing shared decision making (SDM) is integral for clinicians seeking to provide patient-centered care.² SDM has been defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences”.³ Recently, the field of orthopaedic surgery has prioritized implementing and researching SDM^4–6 with preliminary evidence suggesting it may improve patient satisfaction,⁷ healthcare decision quality,^7,8 and quality of life.⁷ There has been a particular emphasis on the evaluation of SDM in elective orthopaedic procedures like total knee arthroplasty (TKA).^8,9 Researchers have examined how patients make the decision to undergo TKA^10–13 and investigated how best to support patients in these decisions with tools and decision aids.^14–20 These efforts have created momentum for the standard use of patient-centered care in elective joint surgery.⁶

Previous work has focused narrowly on the decision to undertake elective TKA and neglected decision making in other areas of TKA-related care. Specifically, decision making practices in postoperative rehabilitation are understudied.²¹ This is important as SDM has the potential to improve the patient experience during TKA rehabilitation—especially the anxiety and uncertainty associated with postoperative recovery.^22,23 SDM may also improve the quality of postoperative rehabilitation and associated patient outcomes. Therefore, the main objective of this study was to understand beliefs, thoughts and experiences related to decision making during outpatient post-TKA rehabilitation, from the patients’ and physical therapists’ perspectives. The overall goal was to describe barriers and opportunities for SDM in postoperative rehabilitation.

2 |. METHODS

2.1 |. Population

Patients between the ages of 40 and 90 who had undergone unilateral TKA for osteoarthritis were eligible for inclusion. Patients were recruited from local surgical centers in the Denver, Colorado, area through established research partnerships. We attempted to purposefully sample patients who had recently completed postoperative rehabilitation. We sought these patients to ensure a full experience with rehabilitation while also attempting to limit recall bias. Physical therapists were eligible for participation if they had worked in their current position for at least 3 months and had at least 1 year of experience. Physical therapists were purposefully sampled to include clinicians with varying levels of work experience and to ensure representation from several outpatient clinics in the greater Denver area. No special efforts were made to recruit physical therapists who had treated patient participants; thus, it is likely that patients received therapy with different physical therapists than those recruited for our study.

2.2 |. Recruitment

Potentially eligible patients were identified and contacted no more than three times via phone and email to confirm eligibility. Eligible physical therapists were invited to participate via email and contacted no more than three times. Recruitment for both patient and physical therapist interviews occurred between May and November, 2018.

2.3 |. Data collection

In-depth, semi-structured interviews were used to explore patients’ and physical therapists’ beliefs, thoughts, and experiences with decision making throughout rehabilitation following TKA. Interview guides used a combination of broad, open-ended questions and follow-up prompts (see Boxes 1 and 2). The interview guides were developed with recommendations from content and methodologist experts; the guides were pilot tested and refined before study interviews began. Interviews were conducted over the phone by a trained male qualitative researcher (SL). The interviewer had no previous relationship with study participants and no personal experience directly related to TKA rehabilitation. All interviewees were provided with a verbal summary of findings at the end of the interview and given the opportunity to voice concerns or make additional comments. All interviews were digitally recorded and transcribed verbatim. Field notes were recorded during and immediately after each interview to include in data analysis. Study participants were compensated for their time.

BOX 1. Interview guide items for patients.

Introduction

We are conducting interviews with patients who have had a total knee replacement surgery. These interviews will help us understand how decisions are made regarding surgery and rehabilitation. I’ll be asking you open-ended interview questions. There are no right or wrong answers.

Topics

• What were the major factors behind your decision to have knee replacement?

• What were you told to expect in terms of recovery from knee replacement?

• In general, did you feel you had enough information about your knee replacement care?

  Why or why not?

• Tell me a little bit about your experience in physical therapy after knee replacement surgery.

  • Probes

    • How were decisions made about your physical therapy program?
    • Who was involved in making decision in your physical therapy program?
• Overall, what did you think of your knee replacement care?

  • Probes

    • How do you think it could be improved?
    • What information is important for patients to understand what is involved in knee replacement care?

BOX 2. Interview guide items for physical therapists.

Introduction

We are conducting interviews with providers who have experience with total knee replacement. These interviews will help us to understand how clinical decisions are made in knee replacement care. I’ll be asking you open-ended interview questions. There are no right or wrong answers.

Topics

• Tell me about your experience caring for patients with total knee replacement.

  • Probes

    • Positive and negative experiences
• Tell me about the typical plan of care for patients with total knee replacement.

  • Probes

    • Tell me about the last time you treated a patient with knee replacement.
    • When you first see a patient, how is prognosis typically determined?
    • Do you think any aspect of care for patients after knee replacement should be standardized? Why or why not?
• What does optimal care look like for patients with knee replacement?

  • Probes

    • In your experience, what do you see as the real challenges to decision making in knee replacement care?
    • What aspect of knee replacement care do you find yourself needing to explain to patients most often?
    • What information is important for patients to have in order to understand what is involved with knee replacement to have a good outcome?

2.4 |. Data analysis

A team-based process guided by directed content analysis was used to examine the interview data.^24–27 SDM was operationally defined prior to coding as: “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”³ The analysis attempted to uncover aspects of care experiences that touched on SDM. The interviewer (SL) and the principal investigator (AK) both inductively and deductively developed a code book using transcripts and audio recordings. Briefly, transcripts and audio recordings were reviewed independently and multiple times by the analyst and principal investigator to achieve immersion. Initial codes were derived from the semi-structured interview guides themselves, and the code book was expanded using an open coding approach. Coded interview transcripts were then iteratively reviewed until no new codes were identified and there was strong code assignment agreement. The analytic team debriefed until consensus was reached with code assignment and met regularly with a qualitative methodologist (DM) to check new findings, discuss emergent new codes and themes, and assess the results. ATLAS.ti version 8 was used for data organization and management.

3 |. RESULTS

3.1 |. Participants’ characteristics

Eighty-seven individuals (49 patients, 38 physical therapists) met the inclusion criteria after screening, and 35 participants ultimately enrolled (20 patients, 15 physical therapists). There was no dropout during the study. For patients, the time since TKA ranged from 4 to 38 months (median = 5 months). Physical therapist experience treating patients with TKA ranged from 1 to 27 years (median = 7 years). Interviews ranged in duration from 32 to 62 min for a combined total of 29 h of interview data.

Three main themes emerged from the interviews: (1) variability in patients’ decision-making involvement, (2) SDM barriers, and (3) preoperative opportunities. The main themes were represented in both physical therapist and patient interviews, but differences arose within some of the subthemes (Table 1). Subthemes for (1) variability in patients’ decision-making involvement included (a) the use of both prescriptive and collaborative approaches, (b) patient responsibility driving recovery success or failure, and (c) difficulty engaging patients in care. Subthemes for (2) SDM barriers included (a) an emphasis on generic (rather than personalized) recovery benchmarks, (b) the use of TKA rehabilitation protocols, (c) certain features of the outpatient setting being clinician- rather than patient-focused, (d) discontinuity of care across settings, and (e) scheduling and insurance restrictions. Finally, subthemes for (3) preoperative opportunities included (a) expectation setting, (b) postoperative anxiety, and (c) information overload.

TABLE 1.

Themes identified from semi-structured interviews with patients and physical therapists

Major themes • Subthemes	Patients	Physical therapists
Variability in patients’ decision-making involvement
• Prescriptive and collaborative approaches	Yes	Yes
• Patient responsibility drives recovery	Yes	Yes
• Difficulty engaging patients	No	Yes
SDMa barriers
• Generic recovery benchmarks	Yes	Yes
• TKAb rehabilitation protocols	Yes	Yes
• Features of the outpatient setting	No	Yes
• Discontinuity of care	Yes	Yes
• Scheduling and insurance restrictions	Yes	Yes
Preoperative opportunities
• Expectation setting	Yes	Yes
• Postoperative anxiety	Yes	Yes
• Information overload	Yes	Yes

^aSDM = Shared decision making.

^bTKA = Total knee arthroplasty.

3.2 |. Theme 1: variability in patients’ decision-making involvement

The first major theme that emerged from the interviews was a lack of standardized approach for involving patients in rehabilitation decisions. Physical therapists described several decision-making strategies which incorporated patient input quite differently. Concordantly, patients’ perceptions of their own involvement in decision making varied between individuals. Both patients and physical therapists believed patient motivation is a key component of rehabilitation success and a key ingredient in promoting patient engagement.

3.2.1 |. Subtheme: prescriptive and collaborative approaches

Therapists described two primary decision-making strategies—prescriptive and collaborative. Prescriptive approaches were utilized early in rehabilitation to set expectations and foster adherence to the rehabilitation regimen. Some of these expectations included the time-frame of therapy, the outcomes and goals most relevant to recovery, and how much time patients should devote to exercises each day.

Just setting the expectation that you are going to need to spend—if they are tight in both flexion and extension—you need thirty minutes a day on flexion, thirty minutes a day on extension. This is not negotiable. You need to do this…Some people just aren’t really ready for that.

(Physical Therapist 12).

Therapists described using collaborative approaches to develop individualized goals and treatments. The rehabilitation process was often described as a partnership between patients and providers, where patients’ priorities directly informed the plan of care and patients were encouraged to deliberate on their goals and reasons for undertaking TKA.

Optimal care as a physical therapist is taking their goals into account and forming goals with them. Being a resource for them along the way of guiding them to help themselves, teaching them to help themselves to recover [more quickly]. We have a role in the hands-on, but I like more empowering patients in their own recovery…

(Physical Therapist 13).

Then the last thing…is making sure the individuals do a little soul-searching, and really focus on what’s important to them, and why they did the surgery… the whole point of this is to get them doing what they want to do…

(Physical Therapist 11).

There did not seem to be consistency regarding how involved patients felt in their own plan of care. Patients who were satisfied with their experience felt like they had good communication with their physical therapist and their care was personalized. Some patients expressed frustrations with the lack of personalization in their treatment and felt it did not work well for them.

Actually, I was very involved because my physical therapist would tell me that this is what we are going to do today. Yet, if I had had a day where I came in and I was in significant pain and said I cannot, then they would not force me to do it.

(Patient 20).

I would just go to the same machines, and we did not really talk about much as far as like, “What more do you think you can do?” or “Tell me what you’ve been doing at home. Have you added anything?” None of that… It was the same plan over and over again.

(Patient 15).

3.2.2 |. Subthemes: patients responsibility drives recovery; Difficulty engaging patients

Both patients and physical therapists believed that patients are ultimately responsible for their own success in recovery. Several patients mentioned their surgeons made this clear to them at their first postoperative appointment. Physical therapists stated that a lack of patient engagement and motivation creates major challenges in post-TKA rehabilitation. These therapists felt much of the onus for patient engagement should rely on the patient.

He said [Surgeon], “My job is done. It’s up to you, entirely, on how you progress.”

(Patient 8).

…I’ll also explain that it’s dependent on the person, and it’s really dependent on how much they do on their own at home… Most of it’s patient motivation and participation more than anything else.

(Physical Therapist 13).

3.3 |. Theme 2: SDM barriers

Several features of outpatient rehabilitation, at both the provider and systems levels, appeared to work against rather than facilitate SDM in post-TKA rehabilitation. Provider-level barriers included (1) the emphasis on achieving predetermined generic benchmarks of recovery and (2) the reliance on rehabilitation protocols to guide treatment decisions. Systems-level barriers included (1) the outpatient environment which promotes provider-centric perspectives on care, perhaps at the cost of patient-centered approaches, (2) discontinuity during care transitions, and (3) insurance and scheduling restrictions which impact the rehabilitation plan of care.

3.3.1 |. Subtheme: generic recovery benchmarks

The most prominently identified provider-level barrier to SDM in our analysis was the reliance on generic benchmarks to inform rehabilitation decisions. Therapists frequently referenced the importance of regaining range of motion (ROM), especially knee flexion, to a predetermined threshold as the primary indicator of recovery. Many patients also mentioned their rehabilitation focused heavily on restoring ROM to meet expectations set by their surgeons and physical therapists.

…the surgeon had an expectation at my first pre-op of where my bend should be. He sent that to—he relayed that to physical therapy.

(Patient 9).

If they are coming around that three-week time period, I think it’s, can they get to 90° of flexion? Do they have full extension?… Are they still using a walker? Are they using crutches or a cane? Are they walking independently? How are their transfers? Are they sleeping?… Are there financial issues? All these things play a part in this, but a lot of it is range of motion.

(Physical Therapist 12).

3.3.2 |. Subtheme: TKA rehabilitation protocols

Many participants also believed that rehabilitation protocols are important for clinical decision making in TKA. Physical therapists thought that using protocols can help to improve care continuity and set patient expectations. Some therapists stated they create patient goals based upon progression through these protocols, but they modify these goals to accommodate differences between patients. Some patients expressed frustration with protocols used in rehabilitation as they believed the protocol did not align with their individual needs.

…I try to go over protocols, day one; expectations, day one; goals, day one, so we are all on the same page. I think it, again, creates a continuity of care I think could be lacking in some cases, and it just makes for a better outcome. I also think patients show up to PT more when they feel there’s value produced in their sessions. I think that’s a way to show that.

(Physical Therapist 3).

I’m sure it’s [Decisions about physical therapy] probably I will not say, “Generic,” but they probably have a protocol…All the places have some kind of protocol for every type of just ailment that people have.

(Patient 13).

3.3.3 |. Subtheme: features of the outpatient setting

The outpatient setting was identified as a systems-level barrier to patient engagement as it does not facilitate insights into the patients’ life or goals outside the clinic. Some therapists felt the tools available in the clinic were convenient but may not adequately address the challenges patients face in their home every day. Therapists with experience in the home health setting remarked upon the advantage of treating people in their own homes.

In the outpatient physical therapy world, there’s good and bad models out there, but the large majority, you are seeing 15, 20 patients a day in an 8-hour day, and that’s a lot. If the goal with physical therapy is to build an individualized plan of care, I do not know if that’s necessarily feasible in that setting.

(Physical Therapist 1).

It [working in home health PT] was neat… You’re working within their setting. It’s really being able to help them, show them their exercises at home, and how they can adapt to it, and get them moving in their setting.

(Physical Therapist 11).

3.3.4 |. Subtheme: discontinuity of care

Many participants also experienced poor communication during transitions between care settings, which they felt was disruptive to care continuity in rehabilitation. Specifically, participants reported physical therapists in different settings (i.e., home health, inpatient, outpatient) and surgeons sometimes provide conflicting information to patients about recovery which can lead to patient disengagement and frustration.

Yeah, I guess that [Inconsistent recovery time expectations between PT and Surgeon] could pose a challenge, then, too, because a lot of times patients are deferring to their PT for questions like this. As a PT, you also want to be on the same page as your surgeon.

(Physical Therapist 15).

It [Decisions in plan of care] was basically, those physical therapists. I do not know whether [Surgeon] ever coordinated anything with the physical therapy.

(Patient 13).

3.3.5 |. Subtheme: scheduling and insurance restrictions

Scheduling and insurance restrictions were also identified as detrimental to care continuity and patient engagement in rehabilitation. Participants reported that insurance coverage and patient co-pays sometimes influence treatment decisions like the frequency and duration of care. Both patients and physical therapists also noted that busy outpatient schedules can make it difficult to accommodate patients’ scheduling needs.

It is difficult, and we have the conversation with the patient too, and say this is what you have; this is what we have to work with. Just so they know that at some point we are going to have to call it quits, so that they can start planning mentally.

(Physical Therapist 14).

I think the biggest, to be honest with you, frustration that I have dealt with through this entire process has been dealing with the insurance.

(Patient 20).

3.4 |. Theme 3: preoperative opportunities

Both physical therapists and patients remarked upon the importance of preoperative interactions to adequately prepare patients for their rehabilitation experience. However, there were no standards identified by physical therapists to guide these interactions or to ensure they took place. Patients reported a variety of preoperative experiences including joint replacement classes and consultations with their surgical team. Patients had generally favourable views of the preoperative classes but had mixed experiences regarding interactions with their surgical team.

They have a joint-replacement class and that class was super—I mean, I’m so glad I went to that. They go over all the pieces of information you are going to need like all the equipment you are going to need.

(Patient 9).

3.4.1 |. Subtheme: expectation setting

Physical therapists felt working with patients before surgery can help set appropriate expectations and lead to decreased anxiety after surgery. However, they also reported that preoperative physical therapy was not a standard part of TKA rehabilitation for most patients. Many patients reported they were unaware that seeing a physical therapist before surgery was a possibility. Some of these patients felt unable to participate in decision making early in their rehabilitation because they did not know what to expect.

I think pre-op care is important, even though we are not involved in it as much, but I think it’s really a good time to explain to a person what things are going to be like and teach them certain things, such as gait and certain exercises before they have their operation.

(Physical Therapist 6).

Physical therapists also reported patients often do not receive adequate information about the recovery process after surgery which can lead to unrealistic expectations. Some physical therapists felt these unrealistic expectations can demotivate patients resulting in less patient effort and engagement in rehabilitation. In some cases, physical therapists believed certain patients should not have had surgery due to their health condition or physical limitations, as this sets the patient up for failure during recovery.

The length of time it’s going to take to get better. I do not think they have any idea when going into surgery. I do not think anybody tells them.

(Physical Therapist 4).

I think with the chronic pain piece and my background, the words that you use are really very important. If a provider says something like—if a doctor says something like, “We’re going to do this surgery and you’re going to be just fine,” then they might not realize the amount of work they have got to put into the rehab after the fact.

(Physical Therapist 8).

3.4.2 |. Subtheme: postoperative anxiety

Some patients experienced anxiety and strong emotional responses during their recovery. These patients felt uncertain about the expected time-line for their recovery and unprepared for their postsurgical pain. Some of these patients believed they were not given enough time or information to make an informed decision regarding surgery.

I just think they just do not really tell you how bad it actually is. I think there needs to be more talk about depression post-surgery. Kind of more of an idea of the length of time it takes to actually start feeling kind of normal again. There’s a period of time there where you are like, “Does everybody experience this? because this is horrible…”

(Patient 15).

…I should probably have asked a lot more questions. I went into it saying, “Oh, I’m not going to do it now. I’ll Google,” and that’s exactly what I did. It happened so fast. I went in on a Monday and I think I had surgery the following Monday…I did not really have time to think, and if I’d had time to think, I do not think I’d have had it done. I do not think I was at the point where I really needed it done.

(Patient 12).

3.4.3 |. Subtheme: information overload

In contrast with the lack of information provided before surgery, both physical therapists and patients identified the risk of overloading patients with information in the perioperative period. Participants felt pain and stress in the initial postoperative phase can limit patient comprehension and retention. This was identified as a possible obstruction to involving the patient more actively in their own plan of care. Patients also reported that the entire process of surgery and subsequent recovery included a lot of information that was difficult to fully take in.

I made the mistake of not setting up my physical therapy as I was told to. It was a lot of information to take in.

(Patient 9).

…I think maybe just not taking enough time to really talk with the patients…and understanding that you are in pain so you are under stress. You’re not going to remember everything that someone tells you….

(Physical Therapist 12).

4 |. DISCUSSION

This study examined decision making and patient-centered care surrounding outpatient TKA rehabilitation. Three primary themes emerged from the interview data: (1) there is variability in how patients are engaged in postoperative rehabilitation and decision-making, (2) both provider and systems-level barriers in the outpatient setting make implementing SDM challenging, and (3) preoperative patient-clinician interactions may improve patient knowledge and inform more realistic postoperative expectations, but these interactions are generally underutilized. In addition to highlighting the current challenges of SDM, we believe the identified themes present tangible strategies for improving SDM in outpatient TKA rehabilitation at both the provider and organizational level.

Many physical therapists described both prescriptive and collaborative decision-making approaches in their interviews. However, there was wide variability in the overall decision-making strategies among clinicians. This suggests the therapists in our study have each developed their own individual decision-making processes and strategies which include variable amounts of SDM. Existing SDM frameworks could be used to reduce variance in this aspect of care and promote consistent usage of SDM principles throughout a patient’s plan of care. For example, the three-talk model²⁸ provides a simple template including the following stages: (1) Choice talk: informing patients there are decisions to be made with reasonable options, (2) Option talk: providing detailed information about the options, and (3) Decision talk: supporting the patient to make a decision in line with their values and preferences. Leaders of outpatient physical therapy organizations could also consider implementing training programs to standardize SDM in TKA rehabilitation among clinicians. The training program described by Lawford et al. provides a potential template.²⁹ This program trained physical therapists in key components of patient-centered care (including SDM) in workshops spread over a three-month period. After the training, the physical therapists reported improved confidence in their ability to use SDM and felt compelled to share more responsibility for patient exercise adherence—an area identified by participants in our study as the patient’s responsibility alone.

The emphasis on achieving protocol-driven milestones was the most prominently identified barrier to SDM at the provider level. Many physical therapists reported flexion ROM goals drive their decision making; TKA rehabilitation protocols often emphasize maximizing ROM despite the lack of association between ROM and physical function once minimal thresholds are met.^30–32 The “one-size-fits-all” method of treatment and goal setting fostered by rigid protocol application is incompatible with essential elements of SDM³³ and unresponsive to patients’ unique goals and expectations related to TKA.^34,35 Instead of rigid application, physical therapists should consider using a “flexibility within fidelity” approach to treatment protocols.³⁶ This approach encourages clinicians to employ the core principles of a treatment protocol, while maintaining adequate flexibility to meet an individual patient’s unique goals and needs.³⁶ Therefore, the focus of outcome measurement and treatment can be shifted from achieving generic, protocol-driven goals to patient-specific goals.³⁷ Notably, several physical therapists described using a similar approach during their interviews, which suggests “flexibility within fidelity” can be successfully applied to outpatient TKA rehabilitation protocols.

Several features of the outpatient environment that are not conducive to SDM were also identified in the interviews. The typical outpatient physical therapy clinic is designed to support the daily tasks and routines of therapists and therefore may not be efficiently equipped to promote the goals of individual patients. For example, the presence of clinic equipment (e.g., treatment tables and goniometers) streamlines the process for ROM assessment but may offer little insight into the specific mobility issues a patient is facing at home. Thus, outpatient physical therapists may find it easier to design rehabilitation programs that address ROM, compared to programs that tailor goals specific to the patient’s home environment.^38,39 Additionally, patients sometimes feel that clinical settings make it challenging to communicate openly with their rehabilitation providers and to retain information,³⁸ which are essential elements for practicing SDM³³ and patient-centered care.⁴⁰ Outpatient physical therapists should consider incorporating goals and treatments specific to the patient’s home environment during each treatment session to continually foster patient engagement. Telerehabilitation may also be a useful tool for tailoring rehabilitation strategies to each patient’s unique home environment.⁴¹

Preoperative physical therapy consultations may offer an efficient solution to some of the identified barriers to SDM in postoperative care. Many patients after TKA (including patients in our study) express feelings of anxiety and uncertainty regarding postoperative recovery,²² and these feelings have been negatively associated with short-term outcomes.⁴² These postoperative concerns may partly reflect inadequate SDM prior to surgery. As the primary provider of postoperative TKA care, physical therapists are well-positioned to inform patients of the recovery process, explain options, and support deliberation prior to surgery, which may in turn allow for improved SDM in the postoperative phase.^35,43 Preoperative involvement could also allow physical therapists to follow patients prospectively, facilitating improved communication and continuity with various healthcare providers. Finally, these consultations could provide an additional opportunity to ensure patients are well-informed in their decision to undertake TKA. A few patients in our study felt they were not given enough time or information to make a decision before undergoing surgery. Similarly, several physical therapists believed that some patients who undertake TKA are not appropriate candidates, which may set them up for unrealistic expectations of postoperative recovery.

Many of the SDM barriers identified in this study have been observed in different patient populations and with various healthcare providers.^44,45 This consistency across studies suggests some of our conclusions may be generalizable to rehabilitation populations outside of TKA—especially post-surgical populations. Specifically, we contend that physical therapists who wish to practice SDM with patients recovering from surgery should consider using (1) a “flexibility within fidelity” approach to treatment protocols, (2) treatments and patient goals which emphasize the patient’s home environment and function in daily life, and (3) preoperative consultations to reduce patients’ postoperative uncertainty and facilitate improved communication and continuity during care transitions.

5 |. STUDY STRENGTHS AND LIMITATIONS

The inclusion of both patients and physical therapists is the primary strength of this study. This provided us with a thorough examination of the current state of decision-making practices in outpatient TKA rehabilitation. The primary limitation of our study is the lack of representation from other healthcare providers and patient family/support. These groups may have contributed additional information for a more complete understanding of decision making in postoperative TKA recovery. Also, we cannot rule out the possibility of recall bias in our study as patients were interviewed after completing rehabilitation. However, we did purposefully select patients who had recently completed rehabilitation to mitigate this factor.

6 |. CONCLUSIONS

Participants in our study shared their thoughts, beliefs, and experiences with decision making in outpatient TKA rehabilitation. Physical therapists described using heterogenous decision-making strategies with varying levels of patient involvement. Both patients and physical therapists described several barriers to routine use of SDM in the outpatient setting. However, the themes identified from our data provide a potential blueprint for a more consistent approach. Physical therapists who wish to engage in SDM should consider using an established SDM framework to guide patient interactions and should prioritize patient-specific goals over protocol-driven goals. Therapists may also consider incorporating the home environment more consistently into treatments to further align clinical decisions with the goals and priorities of individual patients. Outpatient physical therapy organizations seeking to improve patient-centered care should consider implementing training programs to promote SDM as standard practice among providers. These organizations should also consider advocating for preoperative physical therapist involvement to facilitate SDM throughout the continuum of TKA care.

DATA AVAILABILITY STATEMENT

Research data are not shared.