Scaling-up Shared Decision Making in Multidisciplinary Osteoarthritis Care Teams: A Qualitative Study Using the Consolidated Framework for Implementation Research With Three Demonstration Sites


 BackgroundDespite the development of theory-driven frameworks to guide implementation strategies, their application thus far has largely been limited to evaluating effectiveness within specific contexts. This study describes the use of these frameworks to inform a scale-up strategy for shared decision making (SDM) implementation across a state-wide government-funded health program. MethodsTailored SDM strategies were implemented in three multidisciplinary osteoarthritis care teams over a 3-6 month period during 2019-20 in New South Wales, Australia. Staff interviews occurred across 3 timepoints based on the Organisational Readiness for Change Scale, the Theoretical Domains Framework and the Preparation for Decision-Making (PreP-DM) Scales. Patient interviews based on the PreP-DM were also completed. A hybrid inductive-deductive thematic analysis was followed by mapping the results to the Consolidated Framework for Implementation Research (CFIR) and the OMERACT core domains for SDM. Finally, a ranked list of Expert Recommendations for Implementing Change (ERIC) was derived using a published tool.Results47 interviews were conducted with 18 staff along with 20 interviews with patients. We identified 39 themes for SDM implementation across the five CFIR domains: 1) Interventions need to be flexible to align with different clinical workflows and busy clinics; 2) Outer Settings such as senior managers should formally endorse SDM and clinical protocols and standards need to better align with an SDM approach; 3) Inner Setting teams need early engagement, role clarification and communities of practice in SDM; 4) Individuals are strongly motivated by better patient outcomes and need SDM training and support; and 5) Processes such as patient-reported measures and feedback along with adequate resourcing were key. Recommended strategies therefore focussed on Stakeholder Engagement, Evaluative and Iterative Strategies, Education and Training and Adaptation/Tailoring to the Context. Skills in the identification of decision points, values clarification and deliberation were particularly challenging for staff.Conclusions﻿Theory-driven scale-up strategies can be developed using qualitative research within demonstration sites. By combining the CFIR and TDF frameworks and prior mapping to the ERIC strategies, health system and program planners can obtain a relevant and evidence-informed roadmap for implementation across complex health systems.

This paper describes a novel theory-driven approach to developing a scale-up strategy for shared decision making in multidisciplinary osteoarthritis care teams. We used a combination of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains

Framework (TDF) to identify organisational and individual barriers and facilitators to implementation
We extended previous work that had mapped the theoretical frameworks to each other and to evidence-based implementation strategies by applying them to a 'real world' example. This was possible over a range of team sizes and composition, models of care and geographical settings The partnership between government, clinical teams and academic researchers facilitated this approach to developing a theory-driven scale-up strategy from demonstration sites. We believe this method could be used in other settings and lead to more targeted and effective use of resources and uptake.
Background Shared decision making (SDM) is a process where a healthcare professional and patient participate jointly in making a health decision, having discussed the options, their bene ts and harms, the patient's values and preferences and also their personal circumstances. [1,2] Although SDM is rmly embedded within health policy in many countries worldwide, [3][4][5][6] there is less evidence for how to convert this policy sustainably into practice at a system-level.
[7] An Australian case study of implementation barriers conducted in 2017 recommended that initial efforts should focus on workforce skills development, motivation, communication and marketing, service provision and creating receptive work environments. [8] Furthermore, an analysis of SDM implementation in nine countries completed in 2018 proposes a framework for system-wide implementation that includes policy, professional and patient leadership, development of basic infrastructure (including training, tools and public campaigns), practical support and learnings from demonstration projects, standardised measurement and feedback, together with practical support and coordination of implementation efforts. [9] There has been increasing interest in the implementation of SDM with most research focussing on speci c SDM strategies and/or particular clinical decisions. They have highlighted the importance of embedding SDM within the clinical work ow, importance of staff understanding the purpose and effect of SDM strategies, the need for clinical champions, a team-based organisational culture and positive social and implementation supports. [10,11] An analysis of SDM in aged care also highlighted capacity and organisational readiness as important. [12] However, very few studies have used a theoretical foundation to drive the process of implementing SDM in clinical practice, [13] despite theory being important for overcoming implementation barriers and providing structure for evaluation. [14,15] The Consolidated Framework for Implementation research (CFIR) provides a pragmatic structure for identifying potential in uences on implementation. [14,16,17] It is based on 19 implementation models and has most recently been aligned with 73 implementation strategies called the Expert Recommendations for Implementing Change (ERIC). [18] Within the current policy context of healthcare, there is an urgent need to develop an evidence-base for the implementation of SDM in clinical practice. This paper reports on a study that used the CFIR to develop recommendations for scaling up the implementation of SDM across government-funded health services in the state of New South Wales (NSW), Australia. It also used a set of core domains for SDM in osteoarthritis care [19] to document staff and patients' experiences of SDM during implementation.

Methods
Setting and Research Context: The study was conducted in three Osteoarthritis Chronic Care Program (OACCP) clinics in the state of New South Wales (NSW), Australia, spanning three separate Local Health Districts. The sites were identi ed by expression of interest in 2018 through the Agency for Clinical Innovation (ACI) and agreed to participation in the SDM Demonstration project over a 3-6 month period. The ACI is a pillar organisation of NSW Health and leads health innovation and improvement across the health system (https://aci.health.nsw.gov.au/about/about-us). The research was conducted for and funded by the ACI with the aim of evaluating the process and outcomes of SDM implementation in a small number of demonstration sites. The results were to inform strategies for scaling up SDM implementation across the NSW government-funded health system. Each of the sites had unique features. One was within a large Sydney teaching hospital, one was in a large rural town and the third was split across two sites in a large urban centre. The size and composition of the clinical service teams varied, as did their models of care (e.g. time between follow-up visits, treatments available, etc) and clinic facilities (e.g. waiting room spaces). All site teams were multidisciplinary in nature and included one or more physiotherapists, dieticians, and administrative support staff, with some sites also including one or more occupational therapists, psychologists, and/or nurses.

Intervention Selection and Development
Given a modest and xed budget and focus on 'real world' implementation, SDM strategies at the sites were based, where possible, on the adaptation and implementation of existing resources in consultation with the clinical service teams.
Initial face-to-face visits to each site were conducted by representatives of the research team (LT, DM, OM) to discuss the project, learn about team composition and model of care, and engage in preliminary discussion about SDM and potential SDM strategies and tools. Each site was asked to select two strategies for a more focussed implementation effort. As a result of these discussions, sites were also given access to a larger suite of resources via a website. Since all three sites had indicated the need for a concise, locally-relevant, paper-based patient decision aid (PtDAs), the University team developed a new set of PtDAs. These were designed for use within the consultation and provided a single page for each category of non-surgical interventions (exercise, weight loss, physical and psychological, medical). In addition, one site requested a brief consumer training tool for use in their initial group-based consultation. Although the development of new tools was beyond the original scope of the project, the team decided that this was necessary to support implementation. It was clear from the consultation process that the existing resources (see Supplementary File 1) were not entirely t for purpose and the teams expressed a need for additional tools. We therefore chose a pragmatic approach to adapting our own consumer training materials [20] and developing brief decision aids on tear-off pads, for use within consultations.
Each site selected slightly different SDM strategies for implementation and all reported some adaptation during the implementation period. The selection of strategies was heavily in uenced by the model of care and work ows (e.g. patient groups, average time spent in waiting area etc), the con guration of the clinic space (e.g. waiting area with TV) and staff re ection on their own needs. The adaptation of tools and strategies was completed by the clinical teams themselves, usually after a trial period. Some adaptations were shared between sites, both at the team-and professional discipline-level. The researchers became aware of these adaptations during follow-up site visits and also through the telephone interviews. (See Table 1) (Insert Table 1) Study Design and Overarching Theoretical Framework: We studied the implementation process using qualitative interviews with both site staff and patients. The Consolidated Framework for Implementation Research (CFIR) was the overarching theoretical framework for our analysis. [16] This framework allowed us to capture key barriers and facilitators in the processes of SDM implementation and linked them to Expert Recommendations for Implementing Change (ERIC) recommendations for scale up.
[18] The CFIR has ve domains: 1) Intervention Characteristics, 2) Outer Setting, 3) Inner Setting, 4) Characteristics of Individuals and 5) Processes. We also measured staff and patients' experiences of SDM across a set of seven core domains for osteoarthritis care. [19] Staff Interviews

Participants and Recruitment
All clinical and non-clinical staff (including reception and team managers) working in the OACCP teams at the three participating clinics were sent an invitation email by their hospital managers. Consent forms were then sent to the University research teams to preserve con dentiality.

Data Collection
Staff interviews were conducted via telephone by MB from the Bond University team to allow for some independence from the implementation process. Participants were interviewed on up to three occasions: baseline, midpoint, and completion. Interviews were audio-recorded and transcribed verbatim by a commercial transcription company.
For the baseline and completion interviews, we adapted questions from the Organisational Readiness for Implementing Change (ORIC) scale which has been mapped onto the CFIR previously. [21,22] For the midpoint interview, we adapted questions from the Theoretical Domains Framework (TDF) [23] to explore 'Individual' barriers and facilitators. For the midpoint and completion interviews, we also adapted the Preparation for Decision Making (PrepDM) scale to qualitatively capture staff experiences of SDM. [24]

Analysis
We used a hybrid inductive and deductive approach to our thematic analysis of the data. [25,26] Since we were exploring different aspects of SDM implementation across three timepoints, the data from each timepoint was analysed separately. In other words, the verbatim transcripts from all baseline interviews were analysed rst, followed by the midpoint and then nal interviews.
The process we took with each timepoint dataset was as follows. One researcher (MB) had conducted all of the interviews and was familiar with the whole dataset. The transcripts were also allocated across ve researchers (OM, LT, RT, MB, HS) ensuring that each person received data from a range of sites and staff roles within the timepoint dataset. Codes and themes were derived inductively as the rst step. These were collated and discussed amongst the researchers. A second round of analysis was completed by the researchers on the same data, this time applying the theoretical frameworks outlined above as a template. Each theoretical construct was discussed over a series of meetings to reach consensus on the key themes for that dataset. This process was then repeated for the midpoint and nally the completion datasets, resulting in themes across the ORIC framework at baseline and completion as well as themes across the TDF at the midpoint. We also collated and reported separately on staff experiences of SDM using OMERACT group's core domains of SDM as the theoretical template. [19] The TDF, ORIC and CFIR frameworks have previously been mapped to each other [22,27] and we used this published work to align our results with the ve CFIR domains and its constructs.
[17] Furthermore, to assist in policy development and provide recommendations for scale-up, we used the CFIR mapping tool [17] to derive a ranked list of recommended implementation strategies to address our identi ed barriers and facilitators for SDM implementation. [18] Patient Interviews

Participants and Recruitment
New patients who received care at one of the three participating sites during the implementation period were recruited by the clinical teams at their rst visit. Each month, up to two patients per site were randomly selected and invited to complete a once-only interview, following their second visit to the clinic.

Data Collection
All patient interviews were conducted by OM via telephone, were recorded and transcribed verbatim. The PrepDM scale [24] was adapted for the patient interviews, allowing for a detailed description of SDM experiences.

Analysis
Patient interview transcripts were also analysed using a hybrid inductive-deductive thematic approach. Two researchers (OM and LT) inductively derived codes and themes across the entire patient interview dataset as an initial step. The same data was analysed a second time using the SDM core domains published by the OMERACT group.
[19] By using the same framework for staff and patients' SDM experiences these could be reported side-by-side allowing for inferences about alignment and mismatches.

Results
During the implementation study, eighteen staff members from the three sites participated in at least one of the baseline, midpoint, and completion interviews conducted with staff (Site A: n=7, Site B: n=5, Site C: n=6). Overall, there were 47 staff interviews available for analysis and twenty patient interviews (Site A: n=12, Site B: n=6, Site C: n=2). See Tables 2 and 3.

Key themes for SDM implementation
We identi ed 39 themes for SDM implementation across the ve CFIR domains. These are described below and summarised with supporting quotes in Table 4. CFIR Domain 1: Intervention characteristicsSDM interventions should have a clear alignment to health professionals' scope of practice and have endorsements from relevant professional disciplines. Concerns about the e cacy of SDM tools and strategies are likely to be mitigated if positive outcomes are seen for their patients, as this was a strong motivator for implementation. Interventions need to be easy to use for time-poor clinicians and not too burdensome for patients. They should be adaptable and able to accommodate individual clinicians' communication styles, work ows, team compositions, available resources, options and models of care. The design and packaging of SDM interventions should include a substantive SDM training component, as tools alone were seen to be a potential 'hindrance'. CFIR Domain 2: Outer SettingThe creation of an authorising environment for SDM implementation by higher authorities such as senior hospital management and the ministry of health were important to staff. Importantly, there was concern that SDM implementation may impact negatively on key performance indicators and benchmarks if patients chose an intervention that was outside the current protocols. Clinical standards and protocols are frequently focussed on clinician recommendations based on best pratice rather than shared decisions and this was seen to be a potential barrier to implementation. CFIR Domain 3: Inner SettingSDM implementation within teams requires an enthusiastic and supportive team coordinator/manager and a concerted effort from the outset to involve all team members. This can be challenging with frequent changeover of staff and part-time employment. A culture of patient-centred care and good team communication with sharing of experiences and 'troubleshooting' can be effective facilitators of implementation. Communication across the team, consideration of work ows and structural prompts such as reminders can all be helpful. SDM-speci c support from outside the team with access to relevant information and training was seen to be highly bene cial. There also appeared to be bene t from peer-support discussions between sites at the professional discipline level, similar to an informal community of practice. CFIR Domain 4: Characteristics of Individuals At the outset, most clinicians believed that they were already practising SDM but their understanding of the term evolved during the project. In many cases, this evolution shifted from good patient-centred communication with goal setting, to a more explicit discussion of options and the evidence for their bene ts. There was some ongoing discomfort discussing the potential harms of treatments but a developing awareness of individual patients' variable preferences for involvement in decisions. For some team members, there was a move away from clinician-directed recommendations as the norm, towards a greater empowerment of patients in decisions. The con dence of team members appeared to increase with SDM practice, with the sustainability and development of skills enhanced by SDM-speci c support and site visits by experts.
CFIR Domain 5: ProcessThere needs to be clear roles and responsibilities for SDM coordination, resource support and engagement of all team members. Structured team meetings for troubleshooting, the ability to log SDM within health records and the integration of patient-reported measures with feedback were also seen to be helpful for implementation.
Staff and patient experiences of SDM Table 5 summarises the staff and patient experiences across core domains for SDM in osteoarthritis care.
[19] It was clear that staff skills in SDM were evolving and that patients' experiences were variable. Core SDM domains were missing from this limited sample of patients' narratives. Better clarity around SDM decision points within clinical work ow and across the team was needed and greater development of deliberation and values clari cation skills.
Systems-level Recommendations for Scaling Up SDM: Table 6 shows the top 30 recommended ERIC strategies that were generated using the CFIR-ERIC mapping tool after it was populated with our results. These are shown within their ERIC clusters to illustrate the relatively large number of recommended strategies relating to 'Develop stakeholder interrelationships', 'Use evaluative and iterative strategies' and 'Train and educate stakeholders'. The ranking provided through this method also allows health services to select a smaller number of strategies for initial scale-up (See Figure 1) Similarly, the results in Table 3 could be used to inform training during SDM scale-up with particular attention to the core domains that were not as easily implemented -identifying decisions, values clari cation and deliberation.

Discussion
This study illustrates a theory-driven approach to developing scale-up strategies for SDM implementation in a government-funded multidisciplinary osteoarthritis care progam. The partnership between a government agency, SDM researchers and clinical demonstration sites enabled existing SDM resources to be adapted for implementation and evaluated, and for an evidence-based approach to planning and resourcing to occur. Thirty nine themes were identi ed for SDM implementation across the ve domains of the CFIR and our use of the CFIR-ERIC mapping tool generated a ranked list of recommended strategies that had a strong emphasis on developing stakeholder interrelationships, using iterative and evaluative strategies and training and educating stakeholders.
We believe this methodology could be replicated in other settings with different implementation examples. Whilst others have used the CFIR to guide and evaluate implementation of various interventions, [28-30] more recent thinking in implementation science has argued for the combined use of the CFIR and TDF [27] and the linkage of these to evidence-based implementation strategies from the ERIC framework, which we have also found to be a useful approach. [18,31] A recent scoping review of SDM implementation speci cally found 22 published projects, most of them in the USA, with many focussed on the implementation of patient decision aids.
[32] Although organisation and system-level characteristics appeared to play a substantive role in the failure to implement SDM, they found it to be infrequently studied. Nevertheless, their preliminary results align well with our own, highlighting the importance of organisational leadership, culture, teams, work ows, clinical guidelines, and education. One study used the CFIR quantitatively to 'score' clinics as low, medium and high adopters of SDM in an effort to measure the effectiveness of implementation.
[33] Unlike this study, ours was interested in developing scale-up strategies rather than evaluating effectiveness.
Whilst this project ran on a limited budget across only three sites, it represents a pragmatic, 'real world' attempt at SDM implementation across multidisciplinary teams of different compositions, resources and models of care. In particular, this study was novel in that it evaluated SDM implementation in a multipdisciplinary, allied health team environment.
In addition, this study was impacted somewhat by the Covid-19 pandemic. Interviews were completed at baseline, midpoint and completion but two staff had left the teams and two were redeployed before the completion interviews. The requirements of the Ethics Committee impacted signi cantly on the recruitment of patients for the consumer component of the evaluation. Consent was only permitted at the second visit to allow time for consideration of the study and could only be obtained by a trained health professional. Some sites had long time periods between initial and subsequent visits (sometimes months) and this created signi cant delays and low patient participation rates, particularly with the additional impact of COVID-19. In March 2020, the outpatient clinics were closed due to the COVID-19 pandemic. At that point in time, one site had completed the full six months of implementation, one had completed four months and the third had only completed two months. This impacted on the number of patients recruited. It is also likely to have impacted on the staff experiences, particularly at the site that only had 2 months of implementation.

Conclusions
With the combined use of the CFIR and TDF, alongside a mapping tool to ERIC, a theory-driven approach to developing a scale-up strategy from a small number of demonstration sites was feasible. We used this method with three multidisciplinary osteoarthritis care teams to inform a wider scale-up framework, with implementation strategies particularly focussing on developing stakeholder interrelationships, using iterative and evaluative strategies, training and educating stakeholders, and adapting and tailoring to the local context. This method could potentially be used in other settings with other implementation programs.

Declarations
Ethics approval and consent to participate Ethics approval was obtained from NSW Health (#ETH09793) along with site-speci c clearances. For the staff interviews, invitations were sent to all team members by hospital managers and written consents were returned to the researchers to preserve con dentiality. For the patient interviews, staff at each site obtained patient participants' written consent to participate in an interview during their visit and periodically forwarded completed consent forms to the University of Sydney research team.

Consent for publication
Not applicable Availability of data and materials Materials are jointly owned by the Universities and ACI and are copyrighted. Copies can be obtained for non-commercial purposes by contacting the authors.

Competing interests
LT, and OM, and RT are authors of the patient decision aids used in this implementation research. LT and SH are authors of the AskShareKnow questions and DM developed the patient training intervention used at one site. RT is an editor of a book on shared decision-making and receives royalties from the sale of this book. TDB and RO are employees of the agency that funded this research.

Funding
The research was funded by the NSW Agency for Clinical Innovation (Agreement number TJS:071860) and a National Health and Medical Research Council (NHMRC) Centre of Research Excellence Grant (APP1106452). The NSW Agency for Clinicial Innovation was involved in the design of the study, the interpretation of data, and the writing of the manuscript and were required to give permission for its publication. Other funding sources supported authors' time contributing to this work as follows: Western Sydney Local Health District Westmead Fellowship (DMM), University of Sydney (LT, HS), Bond University (TH).
Authors' contributions LT: Lead investigator, conceptual design of study and interventions, site visits and support, staff training, governance committee engagement, data analysis, manuscript and report writing as lead author. OM: Intervention development, conducted patient interviews, data analysis and interpretation, revision of manuscript. DMM made substantial contributions to the study design and planning, led the development of the brief SDM training intervention for patients, and was involved in conducting staff training at the implementation sites. DMM has critically reviewed and revised the manuscript for important intellectual content and has approved the nal version to be published. MB: conducting staff interviews, analysis of staff interviews, revision of manuscript. HS: Study development and data collection design, data analysis and interpretation, revision of manuscript. TDB: Conceptual development, governance committee and revision of manuscript. RO: Conceptual development, governance committee and revision of manuscript. NB: To reduce any con icts of interest, TDB and RO were not involved in the intervention development, implementation or any data collection and anlaysis simce they were employed by the funder. TH: Initial study development and design, data interpretation, revision of manuscript. RT: intervention development, design of data collection approaches and materials, analysis and interpretation of data, revision of manuscript. All authors read and approved the nal manuscript. 4. ACI. Consumer enablement: A Guide for Clinicians. Availabe online: https://www.aci.health.nsw.gov.au/networks/primary-care/consumer-enablement/consumerenablement/guide (accessed on 31 August).
.       'For some patients it's really helpful to have that in a written format that they can look at and be involved.' '…as a clinician we have an idea of what we think may be best for the patient…that can be quite a challenge if somebody's opted for hydrotherapy and we know that might give them some bene t but at the back of our minds we know that land-based will give them much more bene t'

Relative Advantage
Strongly motivated by improved patient outcomes 'We were all genuinely keen to give it a trial and see whether it was effective, whether it's something we can use with our patients to provide a better quality service. We were initially quite nervous, but I think as time went on we could see there were some bene ts with some patients.' 'I think the incentive is to get the most bene t for your patient to make sure they feel empowered and listened to' 'I think the barrier or sort of the resistance comes up when maybe tools don't match practitioners' viewpoints or it lacks options or isn't aligned to what a service offers' 'I didn't feel it tted how our program ran, but once we were able to make an adjustment to that and have something that was a bit more appropriate and a bit more realistic with our level, then I felt ne' 'one of the issues that sometimes comes up is overwhelming the patient' 'it's been a bit unfamiliar sometimes for the elderly population…they wouldn't naturally ask questions or they may not tell you so much about themselves.' "Our shared decision making tool has a lot of reference to the evidence from clinical trials in there and the strength of evidence in a lot of these trials is very poor, and that seems to be the nature of a lot of things involving exercise, for example, and weight loss. It's very hard to have a very strong paper, a strong evidence clinical trial being done. So a lot of the evidence that we have in there is poor quality. So poor quality evidence is di cult to put a lot of weight behind. However, our tools are full of all this evidence, which is of poor quality. I guess we don't want the patients to be looking at this evidence -level of evidence seeing that it's poor quality evidence and have that as a main determining factor of whether or not they choose one treatment over the other because evidence itself, that's one thing that we can go off. But the other thing we can go off is clinician experience and what we see in clinical practice which doesn't necessarily get captured in a paper. So that was one of the things that was a bit of a di culty, is that it's so heavily reliant on the evidence rather than what we do as clinicians and expert clinicians in the eld." "This is di cult for us to show people that, yes, you might try and do a strengthening exercise but the evidence is poor." 'So when we use a decision-making tool, for example, the hydrotherapy pool, we can't really use that with con dence, because we feel a bit embarrassed to show it to the patient because the evidence is not strong. But we still recommend it.'

Design Quality & Packaging
Training was perceived as useful and possibly more than tools 'the actual physical tools were maybe a hindrance, boxing you in on what you could offer, but the face-toface support and contact was helpful' 'my colleagues felt that the training did help them to understand the process a lot more. For me, I haven't had that training so I'm not quite sure'.
'They seem much more con dent now after the initial training. I think that was quite positive. They are con dent to be able to do that'.
'the training and information we've had to date, I feel had probably been -it's been quite positive' 'the concept of shared decision-making is probably something I feel we support anyway. We just probably don't do this in a very formal way.
'I know for sure that we do already our, sort of own version of shared decision-making if you like, and we do provide options tailored to the individual' 'I had assumed we were using shared decision-making by asking, but I have learned from that workshop that there's a few more steps involved' 'But now I feel that we have a clear understanding of what constitutes shared care decision-making, and I feel that we're able to implement that, using the language and using the -a small number of the tools' Self-e cacy Con dence improves with practice Reinforcement and training assists implementation '[I'm] de nitely more con dent than when I rst started… I guess it's just practice and familiarity with the tool and getting comfortable with certain questions about it.' 'I think once we had that interaction more and had that training and discussed what we thought with the resources that we had and all of that, I did feel more con dent to implement that' A mechanism for recording SDM in health records helps team ' working as a team as we do, if we're having di culties or anyone is having particular challenges, it's something we will try and work on or resolve' 'there was troubleshooting things and working through things...we were probably a little less con dent but then as we got to the point of starting and we worked through any concerns we had' 'there's no formal mechanism for me to document it in my notes to keep track of…perhaps if I logged it in the notes..'

Re ecting & Evaluating
Patient-reported measures would be helpful 'I'd be keen to see if it is helpful for the patient and I'd be quite keen to see how that's measured actually.' 'I think sometimes patients prefer to be told or to be led through treatment and I think that for some, it can be overwhelming or confusing' (staff) "So I think as a clinician we have an idea of what we think may be best for the patient and obviously don't force that on them but I think obviously that can be quite a challenge if somebody has opted for hydrotherapy and we know that might give them some bene t but in the back of our minds we know that land-based will give them much more bene t. It's sort of I guess encouraging a patient to really consider those options, making sure they're informed and accepting even though we think we might know what might be best for a patient, it is up to them to decide at the end of the day" (staff) "I think our role as clinicians is to guide patients. While they might see that something might have a low level of evidence, but it's something they're attracted to, I think our role is to guide patients more toward something that's going to help them" (staff) "Of course, the biggest challenge is going to be a lot of patients don't want to make a decision, they just want to be told what to do" 'They have the opportunity to express their needs and their wants and therefore, they'll get a better outcome. If nothing else, they'll feel happier because someone's listening to them.' (staff) The other strategy is acknowledging that things can change for them over time, so it would be different, we might be looking at different things when they come back as a review appointment' (staff) "there might have been some times when patients have picked options that might not have been my rst choice, but then that's their decision. Then in later reviews if we did relook at options, they could think, okay, well, I've tried that one and it didn't work, I might move onto this one now" Very positive about their care 'I think the information is really, really good and the team that worked there seem to be really enthusiastic and keen' (patients)