Agency as a catalyst in pulmonary rehabilitation implementation: Physiotherapists' perspectives.

Background: Chronic respiratory diseases (CRDs) are a major global health burden, and pulmonary rehabilitation (PR) is a well-established, evidence-based intervention that improves functional capacity and quality of life for persons affected. Despite this, access to PR is limited globally and within South Africa. Insight into how PR programmes (PRP) are established and sustained in practice may help explain the persistence of this implementation gap. Aim: To explore physiotherapists' experiences of establishing outpatient PRP in the Cape Metropole. Setting: The study included public and private physiotherapists in the Cape Metropole, Western Cape Province, South Africa. Methods: An exploratory qualitative descriptive design was employed using semi-structured interviews with six physiotherapists who had attempted to establish outpatient PRP. Data were analysed using reflexive thematic analysis, with Social Cognitive Theory informing interpretation of interactions between environmental conditions, clinician agency and programme outcomes. Results: Three interrelated themes were identified. Firstly, practice contexts, including funding structures, referral systems, organisational support and physical resources, shaped the feasibility of PRP. Secondly, clinician agency, expressed through motivation, self-efficacy, advocacy and adaptive capacity, influenced how physiotherapists navigated these contextual conditions. Thirdly, PRP followed divergent trajectories over time, with outcomes more predominantly shaped by how individual physiotherapists interpreted early experiences and feedback rather than by context alone. Conclusion: PRP implementation was shaped by dynamic interactions between contextual conditions and clinician agency. Participants faced similar challenges, however differences in their agency influenced whether PRP were sustained, adapted or remained partial. Strengthening physiotherapists' self-efficacy, behavioural capability and access to mentorship may support more sustainable PR provision in contexts where services remain limited. Contribution: This study highlights clinician agency as a critical mechanism in PR implementation and suggests that interventions to expand PR services should address both structural barriers and the development of physiotherapists' adaptive capacity.