Knowledge, attitude and practice of shared decision-making among Indian physiotherapists

INTRODUCTION

Shared decision-making is a collaborative process that involves patients, physiotherapists, and clinicians making decisions regarding the patient’s health after discussing the available options; identifying the merits and demerits of each option; and considering the patient’s values, preferences, and personal circumstances.¹ It is also known as patient-centered decision-making or patient-centered shared decision-making. The growing evidence of the need of patient centric approach has made it crucial to adapt shared decision making in physiotherapy and rehabilitation process.²

Shared decision-making involves an open discussion between the therapist and the patient.² The therapist provides evidence-based information about the options and balanced information about the merits, demerits, and uncertainties of each option including watchful waiting where appropriate, and uses their communication skills to actively listen, engage, elicit patient preferences, advise the patient in accordance with their preferences and address their concerns and provide patient-centred care by encouraging patients to take an active role in the decision-making process and promotes ethical practice by respecting informed patient choices, ensuring fairness, and acting in the patient’s best interest.^3,4

Studies conducted across the globe on various population such as community dwelling, palliative rehabilitation, chronic condition and musculoskeletal conditions have shown that incorporating shared decision making in clinical practice have shown to improve patient-clinician communication, improve patients’ accuracy of their expectations of intervention benefits and harms, feeling of being informed and increase both patients’ and clinicians’ satisfaction with care providing better rehabilitative outcomes and improve in quality of life.^5-11

A top-down approach in healthcare involves policy-driven decisions from higher authorities, aiming for standardization and alignment with public health goals.¹² Shared decision making requires reciprocal communication and value-based negotiation, which may be limited in top-down models. Top-down strategies for promoting shared decision-making offer benefits like uniform expectations, resource allocation, and professional norm-setting. However, the approach has limitations without active grassroots level involvement and genuine clinician engagement, top-down initiatives may reflect institutional compliance rather than commitment.¹³

The lack of publications from low middle income countries like India is suggestive of the concern that shared decision making is still a relatively ‘foreign concept’ within physiotherapeutic consultations and management. Moreover, decision making in clinical cannot be enforced solely through policy; it demands a deeper shift in mindset, attitude change rooted in trust-building, reflective and continuous learning at every level of care. Thus, this study aimed to examine insights from grassroot level regarding shared decision making to understand the attitude and practice among physiotherapists in India regarding shared decision-making in clinical care.

METHODS

The study used an observational cross-sectional design using a survey method of physiotherapists in a metropolitan region of southern India. The study was done in a tertiary care hospital- JSS Hospital Physiotherapy department, Mysuru. from January 2025 to April 2025. The participants included were, with a minimum of a bachelor’s degree which is the minimum required qualification to practice in India. Additional inclusion criteria consisted of the participants’ ability to use phone or social media platform and comprehend written English. Any individual who is a student physiotherapist residing in India were not included in the study

The study involved two phases. Following approval for research from Institutional review committee (reference number JSSCPT/IRC/OS-11/2025-26) the Nine item shared decision-making questionnaire (SDM-Q) was chosen to measure practice. A self-developed questionnaire using inputs from available literature was utilised for knowledge and attitude assessment.^14-16

Knowledge was assessed using ten closed-ended true/false questions, with responses analysed by percentage. Attitudes toward shared decision making were measured through a five-point Likert scale across thirteen common physiotherapy conditions, evaluating agreement levels via mode and percentage. shared decision-making practice was examined using the nine-item SDM-Q questionnaire, where physiotherapists rated their agreement with statements reflecting decision-making behaviours during their most recent treatment consultation analysed using mode and percentage.¹⁴

In the phase two the two questionnaires were combined and using an online survey platform google forms. The survey was designed for dissemination among the target population. The list of registered physiotherapists as obtained from the local registration authority and a general email requesting participation was sent to all. The individuals who responded to the mail were approached individually via mail and a formal informed consent was obtained. Thereafter, the questionnaire was converted to a link and sent to the individuals who signed the informed consent. A period of four weeks was given to fill in the form, and a reminder message was sent weekly. Those who did not respond after the fourth week were not contacted again.

The responses obtained were collected and stored in a secure drive which was monitored by the IRC of the institution. The responses obtained were exported on Microsoft Excel spread sheet version 18.2503.12711.0 and used for data analysis. Data were analysed using descriptive statistics.

RESULTS

Understanding the demographic characteristics of the study participants is important for interpreting the findings. A total of 109 responses from individuals who provided consent for participants were analysed. The detailed demographic characteristics of the study participants are shown in Table 1.

The knowledge questionnaire about the shared decision making only 4 out of 109 participants answered all questions correctly that is 3.66% of physiotherapist had good knowledge about shared decision making. On an average 93.28% of physiotherapist felt that the shared decision making is necessary in physiotherapy and agreed that use of decision aid and informing patient about condition. On an average 50% of physiotherapists reported shared decision making creates confusion, time constrains and treatment choice restriction. Table 2 represents the responses obtained by participants for knowledge questions on shared decision making.

The attitude of physiotherapist towards shared decision making was assessed using the question how much they believe or agree the use of shared decision making on various conditions measured using Likert scale. Participants agreement for usefulness of shared decision making varied across patient groups. Agreement was highest for chronic musculoskeletal conditions 72%, athletes 70%, and orthopedic cases 65%. Neutral responses were common for ICU 23%, elderly care 12%, and community care 12%. Disagreement was high in ICU settings, with 35% expressing some level of disagreement but remained low in other categories. Figure 1 represents the attitude of physiotherapists towards shared decision making in rehabilitation setting.

The practice of shared decision making measured using statements related to decision-making behavior in most recent consultation that involved a treatment decision and physiotherapist were asked to indicate how much they agree or disagree that they performed the behavior. self-reported behaviors during recent treatment consultations. There is strong agreement, with 74%, for speaking with patients about their condition, followed by assisting them in understanding information at 70%. Neutral responses are relatively high for considering options and reaching agreements at 23% and asking for patient preferences at 21%. Higher levels of disagreement (both strongly and somewhat) are noted for explaining research evidence on benefits/harms, with a total disagreement of 66%, indicating potential challenges in discussing detailed clinical evidence with patients. Figure 2 represents the responses obtained by physiotherapist on shared decision-making practice.

The study found that only 3.66% of physiotherapists correctly answered all questions on shared decision-making knowledge. Over 50% had a positive attitude towards its usefulness in clinical setting for various conditions. Around 70% agreed to inform and discuss with patients about their condition, while 66% strongly disagreed with its practice in clinical settings based on evidence.

DISCUSSION

To explore the knowledge, attitude and practice of shared decision making among physiotherapist a cross-sectional research design was conducted using the survey method. Participants were recruited based on predefined inclusion and exclusion criteria.

In the study only 3.66% of physiotherapists answered all knowledge questions about shared decision making correctly. The attitude of participants towards shared decision making varied among varies condition and in participation and the behavior of practice varied by having most agreed with behaviours such as discussing patients’ conditions, supporting their understanding, and providing general information. Moderate agreement was seen for presenting options, reaching decisions together, and considering patient preferences and explaining research evidence on benefits and harms of treatment had lowest agreement which is almost like the study conducted in Australia in which 19% participants indicated that they had no knowledge of the concept of shared decision making and 2.4% reported comprehensive knowledge and perceived usefulness of shared decision making for treatment decisions for various patient groups showed variation in the extent of agreement and most frequently reported behaviours were reaching an agreement with the patient on how to proceed and speaking with the patient about their circumstances and how these related to treatment options and the behaviour with the lowest reported occurrence was explaining the relevant research evidence about the size or likelihood of the benefits and harms of the options.¹⁷

The survey conducted on Indian physiotherapists regarding shared decision-making revealed a low level of self-reported comprehensive knowledge but demonstrated a good level of knowledge for most questions. The attitudes of physiotherapists toward shared decision making in various clinical setting varied the fact that only 3.66% of physiotherapists represented knowledge indicates a considerable gap in fundamental understanding. The low shared decision-making knowledge and evidence-based discussion among graduates raises concerns about their capacity to uphold evidence based ethically relevant practice

Even with limited knowledge, 50% physiotherapists self-reported engaging in shared decision making, 93.28% acknowledged its necessity, 50% expressed positive views and about half percentage of participants neutrally agreed on that responsibility for the final treatment decision should be shared between patient and therapist Although 70% discussed conditions with patients, only 23% reviewed evidence collaboratively, and 66% lacked routine evidence-sharing. Explanation of the benefits and harms of treatments with evidence was reportedly lacking in the practice indicating possible challenges in discussing detailed clinical evidence with patients. This gap reflects commonly reported barriers such as confusion, time constraints, and limited treatment options, illustrating the constrains clinicians feel between ideal practice and practical realities. Many physiotherapists view shared decision making as a complex and time-consuming. This disconnect shows the need for targeted education to encourage clinical implementation of shared decision making.

The reported attitude and practice can be influenced by participants perception, cultural norms, and motivation like social desirability.¹⁸ Use of online method of data collection might have led to over or under reporting of practice behaviours.¹⁸ Blinded observational studies on large scale in various physiotherapy practices that explores the barriers and influencing factors shaping attitudes and practices in shared decision-making can overcome this bias.Targeted education and system-level support are essential to translate shared decision making into clinical practice in India.¹⁹

Strength of the study are large sample size of physiotherapist with various areas of practice which enhances the generalizability of the results obtained in the study population. Use of a standardized questionnaire and to assess the knowledge, attitude, and practice of shared decision making.

Limitations

Limitations of this study are the use of an online platform leads to social desirability and high subjective bias. Controlling number of men and women were challenging due to online survey and convenience sampling leading to overrepresentation of female participants. Additionally, knowledge was assessed using simplistic true or false questions, limiting depth and accuracy of evaluation.

CONCLUSION

Study highlighted a critical gap in the comprehensive knowledge of shared decision-making among Indian physiotherapists, despite a generally positive attitude and partial implementation in practice. While many physiotherapists acknowledge the usefulness of shared decision making across various patient conditions, significant barriers remain particularly in explaining evidence-based benefits and harms during clinical interactions. The findings suggest that a lack of structured training and awareness may be the barriers for adoption of shared decision making in physiotherapy and highlights the need of enhancing physiotherapists’ understanding of evidence-based approaches, promoting cultural shifts toward patient-centred care, and integrating shared decision-making education into undergraduate and continuing professional development programs.

Recommendations

Research found that Indian physiotherapists reported low levels of comprehensive knowledge. Lack of knowledge might influence the attitudes and practices regarding shared decision-making behaviour despite low level of knowledge participants agreed on usefulness of shared decision making in various rehabilitation settings and reported of practicing best shared decision-making behaviour which could be because of subjective bias. Future studies should systematically evaluate the knowledge barriers and factors influencing attitudes and practices in shared decision-making behaviour to address gaps in research findings and better understand the reasons behind its limited use in India. More than half of the therapist reported of lack of the use of evidence based clinical decision making with patient which highlights a disconnect between positive attitudes and practical implementation. Targeted education and systemic reforms are needed for effective implementation of shared decision making in Indian physiotherapy practice.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee (reference number JSSCPT/ IRC/OS-11/2025-26

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