When Deviation Is Necessary: Balancing Intervention Fidelity and Contextual Adaptation in Haemodialysis Physiotherapy

Exercise-based physiotherapy is recommended as a core component of haemodialysis care; however, its implementation in routine clinical practice remains inconsistent. While intervention fidelity is considered essential for ensuring evidence-based practice, little is known about how physiotherapists adapt rehabilitation protocols in response to the complexities of real-world clinical environments.

To explore how physiotherapists balance intervention fidelity with contextual adaptation during haemodialysis rehabilitation and to examine the cognitive, social, and contextual factors influencing clinical decision-making.

A qualitative interpretive study was conducted across four haemodialysis centres using semi-structured interviews with 16 physiotherapists. Participants were recruited through purposive maximum-variation sampling to capture diverse clinical experiences and practice settings. Data were analyzed using reflexive thematic analysis, with findings subsequently interpreted through the Mindlines model.

Four interrelated themes were identified: Safety Overrides Protocol, Experience as the Primary Guide, Context Shapes Practice, and Guidelines as Flexible References, which collectively informed the overarching theme of Adaptation as Skilled Practice. Physiotherapists consistently prioritised patient safety by modifying interventions according to physiological status and individual patient needs. Clinical decisions were informed by experiential knowledge, interprofessional interactions, and organisational constraints, with guidelines serving as flexible reference points rather than prescriptive rules. The findings demonstrate that context-sensitive adaptation represents deliberate clinical reasoning rather than simple protocol non-adherence.

Intervention fidelity in haemodialysis physiotherapy should be understood as a dynamic process that accommodates appropriate contextual adaptation while preserving the core intent of rehabilitation. Recognizing adaptive clinical expertise may strengthen the implementation of evidence-based physiotherapy in complex healthcare settings.