Physiotherapists’ decision-making about transition to independent walking in hospital after stroke: a qualitative study

Abstract

Purpose Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation. Methods A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated. Results Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements. Conclusions Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making. IMPLICATIONS FOR REHABILITATION Regaining independence in walking after a stroke comes with the potential risk of falls. Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition. Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence. Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.