Exploring implementation of a shared decision-making intervention for patients following an Anterior Cruciate Ligament rupture: a qualitative investigation

Anterior Cruciate Ligament (ACL) ruptures affect over 20,000 individuals in the UK each year. To date, three randomised controlled trials have compared the two main treatment options of surgical and non-surgical management following rupture and report conflicting findings. Recent qualitative research has also reported uncertainty and confusion among patients regarding decision-making about their choice of treatment. A theory- and evidence-based shared decision-making intervention was co-developed in a prior study to support patients to decide on treatment. The aim of this study was to understand implementation factors associated with implementing a shared decision-making intervention for patients following an anterior cruciate ligament (ACL) rupture. Individual qualitative interviews, analysed using a framework approach underpinned by the Extended Normalisation Process Theory (ENPT). Data were mapped to the four ENPT constructs: potential, capacity, capability and contribution. Conducted as part of a non-randomised feasibility study in an orthopaedic and physiotherapy service at an acute National Health Service Teaching Hospital in the Midlands, UK. Five patients with a first time ACL rupture and five physiotherapists with experience of using the shared decision-making intervention. Implementation factors, including barriers and enablers to future implementation and normalisation, associated with implementing a shared decision-making intervention for patients following ACL rupture have been identified and mapped to ENPT. Both patients and physiotherapists demonstrated a clear understanding of the SDM intervention’s purpose (coherence) and individual intention to operationalise it within the pathway (potential, capacity). The intervention was further discussed to support interactional work between patients and clinicians during consultations and physiotherapists were positive about its workability and adaptability to meet patients’ needs (capability). Physiotherapists described the intervention’s role in altering the social roles of both themselves and of patients, which supported the set-up and action of SDM conversations (capacity). The communication of equipoise and context created for intervention delivery was identified to be critical to engagement (potential). The intervention was described as non-burdensome, patient participants reported they would recommend it to others following diagnosis of an ACL rupture and physiotherapist participants described utilising the intervention with patients outside the trial (contribution, capability). Implementation factors, explored through the lens of ENPT, have supported understanding of future normalisation of the intervention in clinical practice. Areas of focus ahead of further research, for example understanding equipoise, have also been identified. ISRCTN17801081. Registration date: 23.01.2024.