The aim of this study is to explore the clinical reasoning (CR) processes and decision-making of pelvic health physiotherapists (PHPTs) while assessing and treating patients with urinary incontinence (UI) in the United Kingdom (UK) and Kingdom of Saudi Arabia (KSA). This is the first study that compares PHPTs reasoning and decision-making (DM) between two countries from different individual and organisational cultures. Studies conducted in various ethnic groups suggested that Muslim women and other minor ethnicity only seek help after having severe urinary leakage. The culture of secrecy and sense of shame is limiting seeking help in UI women from minor ethnicity. Incontinence has a negative impact on their emotional, working lives, well-being and restricting physical activities, such as walking, running and dancing. There is limited study on PHPTs decision making and CR while managing patients with UI and from minor ethnicity.

Using a qualitative design, PHPTs’ were interviewed with semi-structured topic schedules guiding conversations on their thinking processes while managing patients with UI. Focus groups to discuss factors influencing PHPTs’ decision-making were undertaken with experienced PHPTs in the UK and KSA. Participants from the UK were invited via Pelvic Obstructive Gynaecology Physiotherapy association, the area representative of the UK pelvic health physiotherapists. While, the KSA participants were invited via Saudi Physical Therapy Association, the area representative of KSA pelvic health physiotherapists. Recruitment continued until no new key themes arose for two consecutive interviews and in focus groups the research was considered to be addressed sufficiently. The interviews and focus groups were transcribed verbatim. A framework analysis approach was used to interpret the data for the exploration of the CR models and the factors that affect the DM of PHPTs. Data collection took place between September 2018 and December 2019.

Twenty-eight participants from across both countries took part in interviews and another 20 participants were recruited to three focus groups in each country. Four main themes were found; contextual factors (individual and organisational culture), PHPTs factors (knowledge, experience, and emotional intelligence) in addition to patients’ factors and the last theme used sense making theory to understand physiotherapist’s clinical reasoning processes. Several factors were found to influence PHPTs DM and CR related to patients, individual PHPTs and the organisational/country wide context. There were key similarities and differences between KSA and the UK. The impact of these factors on DM and CR varied slightly between the UK and KSA participants due to differences in the cultural and religious context, resources, organisational culture, patients’ characteristics and PHPTs training level. Further factors include patient demographics, socioeconomic status, comorbidities and preferences for treatment options (e.g. equipment versus exercise). Culture was the biggest differentiation between the two countries. The more diverse UK throws up more challenges such as language barriers and accessibility. Hierarchies within the organisational culture and lack of collaboration between multi-disciplinary teams were seen as a challenge in providing effective treatment to patients in KSA more than the UK. Furthermore, PHPTs in both countries used different models of CR, mainly forward and backward reasoning but to understand their thinking process; those CR models were not enough to fully describe DM, because the models did not cover organisational culture. As a result, sense-making theory by Weick et al. (2005) was used to interpret their sense making process. For instance, PHPTs tried to make sense of any uncertainties and ambiguity and make plausible rather than accurate decision. In addition, one of the UK PHPTs were making sense of the extracted cues such as patient’s low mood and tension in pelvic floor muscles to understand the cause of unclear picture of UI.

This research explored the views, opinions and assertions of PHPTs while managing patients with UI in the UK and KSA, two countries that have different individual and organisational cultural perspectives. Sense-making theory was used to understand how PHPTs CR and DM was influenced by the organisational culture (Figure 1).In both countries, the participants were making sense of patients’ factors, contextual factors in addition to their personal characteristics, experience and knowledge to overcome uncertainty and make a decision. Religion plays a key role but should not be singled out as a key determining factor in influencing CR and DM, this ties into tradition and norms that should be respected for patients with minor ethnicity to adhere to treatment. Individual and organisational cultures were significant factors influencing PHPTs decision-making partly due to the differences between the two countries institutional logic and properties(Greenwood et al., 2017). For instance, institutional logic guided PHPTs identity. In KSA, family centre care might guide the PHPTs decision to avoid asking questions that would led to disclosure of sensitive issues. This is because there is unclear clinical pathway to manage patients’ sensitive or ethical issues. As a result, participants’ use of emotional intelligence appeared to vary between the two countries and PHPTs in the UK might encouraged patients disclosing sensitive issues more than in KSA. PHPTs in both countries were extracting cues from patients and influenced by contextual factors in addition to social context that lead to decision focused on plausibility rather than accuracy.

This is the first study in PHPTs that explores in-depth CR and DM in two different cultures. The differences identified between the CR of PHPTS in the two countries led to the identification of new findings that recognises the critical impact of individual and organisational culture on PHPTs sense making and CR processes. There is an urgent need to consider individual and organisational cultures in any attempts to introduce new evidence or implement clinical guidance especially among Muslim women and other minor ethnicity.