Table 2 Barriers and facilitators to implementing SDM data mapped to the Theoretical Domains Framework (Cane et al., 2012) from multiple perspectives
Stakeholder group | Clinician-related factors | Patient-related factors | Health service administrators (HSA), Decision makers (HSDM), Government policy makers (GPM), and other stakeholder-related factors | Organisational-level factors | System-level factors |
|---|---|---|---|---|---|
1. Knowledge (An awareness of the existence of something) | |||||
Barriers | - Not knowing what SDM is [57] - Incorrect definition of SDM [46, 52, 55, 57] - Assumes patient understands information shared [53] - Does not know true risk of options [56] | - Limited or no knowledge of disease or options [46, 47, 50, 54] - Limited understanding of risk [44, 45, 50, 52, 53, 56] - Not provided adequate information for decision [53, 55] - Provided biased information [50, 55] - Not understanding jargon used by clinicians [51, 53] - Not knowing own patient history (i.e. previous drug treatment) [54] - Not having knowledge of language to describe their experience of illness [51] | - Lack of guidelines that include SDM [46] | ||
Facilitators | - Understanding of SDM and what it entails [47, 49] - Understanding of risks and benefits for treatment options [47,48,49] | - Well informed about the disease and treatment options prior to the SDM conversation [45, 47, 50, 52,53,54, 57] - Patient is able to understand consequences and risks of alternatives [45, 47, 50,51,52,53] - Knowledge of previous treatments for condition (i.e. which drugs they had been treated with previously) [54] | - Use posters/reminders to create awareness of SDM implementation programme [44, 49] - Tailored information services for patients [46] | - Support cross-site learning through regular meetings [44, 46] - Pool information from separate SDM initiatives to speed knowledge translation [46] - Promote awareness of the benefits of SDM through research [55] - Promote patient awareness of SDM through national campaign [46] | |
2. Skills (An ability or proficiency acquired through practice) | |||||
Barriers | - Lack of training in SDM [44, 48,49,50,51, 55, 56] - Lack of communication skills [51, 55] - Lack of skills to train junior doctors in SDM [48, 56] - Overreliance on clinical algorithms for determining treatment decisions [48, 56] | - Decision is left to the patient [53] - Informational capacity to make informed decisions (barrier and facilitator) [45, 47, 50, 52, 54, 56] | - Senior clinicians are expected to teach junior doctors how to do SDM without having training themselves [48, 56] | ||
Facilitators | - Communication skills, i.e. ability to explain risks and benefits of treatment option [45,46,47,48, 50,51,52,53, 56, 57] - Formal training in SDM [44, 48,49,50,51, 55, 56] - Trust in one’s own clinical skills and ability [47, 55,56,57] - Awareness of one’s own limitations as a clinician [55, 57] - Has been given education in communication with patients [48, 50, 51, 57] - Uses evidence-based data to inform treatment options [45] - Experience increases clinical skill and confidence [56] - Providing tailored information to patients based on their informational needs [50] | - Informational capacity to make informed decisions (barrier and facilitator) [45, 47, 50,51,52, 54, 56] - Ability to speak up for own preferences due to prior experience in health setting (i.e. as nurse or long-term patient) [45, 47, 54] | - Require full team interdisciplinary training to ensure language is the same across disciplines when implementing SDM [44, 50] - Provide training on use of Patient Decision Aids [44, 46, 57] - Opportunity to practice SDM with senior clinicians [48] | - SDM is part of medical student’s education [46, 48] - Including patients in SDM education [46] - Support cross-site learning through regular meetings [46] | |
3. Social/professional role and identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting) | |||||
Barriers | - Clinicians belief that their role is to make decisions and convince patients [50, 52, 56] - Not wanting to seem indecisive [48, 56] | - Belief that clinician’s role is to make decisions [47, 57] - Belief that nurses should not be involved in SDM [49] - Not wanting to be labelled “difficult” [45, 46, 53] - Perceived unacceptability of asking clinician questions [45] - Social stigma of having and seeking treatment for mental illness [50] | |||
Facilitators | - Clinician sees role as educator of patients [46, 49, 50, 52, 53] - Clinician sees role as collaborator with patient [46, 47, 49, 50, 53,54,55] - Asks for patient’s preferred role in SDM [45, 51, 53] - Interprofessional collaboration—clear communication [45, 46, 49,50,51, 55] | - Has positive/trusting relationship with clinician [47, 50, 51, 54, 55] - Belief that it is their role to be involved in decision-making with clinician (i.e. asks questions) [46, 47, 53] - Feeling more comfortable speaking with allied health (i.e. pharmacist) [50] | HSA, HSDM-related factors - Manages implementation through actively anticipating personnel/budget shifts [46] - Sees duty in aiding implementation of SDM through knowing appropriate education is being provided to clinicians and patients [57] Other stakeholder-related factors - Engage new policy makers in SDM [46] | - Engage new clinicians/patients in SDM [46] | - Include SDM in professional role descriptions for clinicians [46] - Showcase innovators of SDM [46] - Show patients their role in SDM through national campaigns [46] |
4. Beliefs about capabilities (Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use) | |||||
Barriers | - Clinician belief that patient does not want to “do” SDM [45, 50, 54, 56, 57] - Clinician belief that the patient will make the wrong choice [55, 56] | - Patient belief that patients should not disagree with the clinician [45, 47, 56, 57] | - Belief that change is too difficult, takes too long, too many resources needed [46, 57] | - Change is too difficult, takes too long, too many resources needed [46, 57] | |
Facilitators | - Belief that patients should be involved in decisions about their own care [47, 50, 52, 55] - Risk is part of medicine [52, 55] - Acknowledges own biases that may interfere with decision-making [46] | - Belief that patients should be involved in decisions about their own care [45, 47, 53, 54] | |||
5. Optimism (The confidence that things will happen for the best or that desired goals will be attained) | |||||
Barriers | - Belief that colleagues will not want to do SDM [55, 57] - Belief that SDM carries increased risk of litigation [45, 56] | - Lack of confidence in their clinician and/or outcome [56] | Change is too difficult, takes too long, too many resources needed [46, 57] | ||
Facilitators | - Having trust and patience in the treatment decision and expecting a good outcome [51, 54] | ||||
6. Beliefs about consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation) | |||||
Barriers | - Fear of a negative outcome [45, 47, 49, 55, 56] | - Fear of negative consequences of the eventual decision [47] | |||
Facilitators | - SDM reduces healthcare utilisation [55, 56] - SDM aids decision-making [52, 55, 57] - SDM improves relationships between clinicians and patients [46, 50, 55, 57] - SDM increases patient satisfaction and sense of control [55, 56] - SDM eases the burden on clinicians (i.e. makes work easier) [57] - Including patients in SDM reduces the likelihood of litigation [55] | - Patient decision aids can help stimulate SDM conversations in busy environments [46] | |||
7. Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus) | |||||
Barriers | - Potential for litigation [45, 55] - Not motivated by patient satisfaction metrics [55, 56] - Not motivated by the potential benefits of practising SDM [55] - Not motivated by reduced healthcare utilisation [55] | - Quality assurance tools do not promote SDM [46] | - Risk of litigation for clinical mistakes [55] - Lack of reward for doing SDM [46] | ||
Facilitators | - Motivated by patient satisfaction [55] - Positive experiences engaging patients in SDM [56] | - Changing legislation to reduce clinician’s risk of being sued for mistakes [55] - Use financial incentives to reimburse time spent doing SDM [46] - Include SDM in professional audits [46] | |||
8. Intentions (A conscious decision to perform a behaviour or a resolve to act in a certain way) | |||||
Barriers | - Deciding the treatment plan before speaking to the patient [47, 50,51,52,53, 55] - Intending to “sell” the patient on the chosen treatment option [47, 50, 52, 55] - Compliance as motivator [47, 48, 55, 56] - Intentionally not engaging in SDM when junior doctor is the first to see the patient [48, 56] - Leaving the patient to make the decision [53] | - Teams deciding together on the best course of action without input from the patient [53] - Not replacing personnel in charge of SDM programme [57] - Not providing support coverage for nurses to attend SDM training sessions [44] | |||
Facilitators | - Intentionally asking patient preferences [45, 50] - Seeking to understand and alleviate patients concerns [45] - Seeking to understand individual needs of the patient [45, 53] - Wanting to reduce harms of unnecessary and potentially harmful testing (i.e. CT scan) [55] | - Being open and honest with clinician about feelings, fears and preferences [50, 54] - Asking questions and providing feedback about symptoms/treatment [54] - Being open and honest in discussions around treatment [54] - Deciding to cooperate with treatment plan [54] | - Facilitate connections between multiple SDM implementation sites i.e. through community of practice [46] | ||
9. Goals (Mental representations of outcomes or end states that an individual wants to achieve) | |||||
Barriers | |||||
Facilitators | - Seeking to implement SDM using Patient Decision Aids [49, 57] | - Bringing individual programmes together with the goal of sharing learnings in order to facilitate knowledge creation [46] | |||
10. Memory, attention, and decision processes (The ability to retain information, focus selectively on aspects of the environment, and choose between two or more alternatives) | |||||
Barriers | - Interruptions make it difficult to concentrate on engaging in SDM [48, 53, 56] - Competing priorities, i.e. highly acute patients/time make it easier to order more tests rather than engage in SDM [48] - Reliance on algorithms to make clinical decisions [48, 52, 55] | - Significant decision—difficulty being objective [45, 47, 50, 57] | Fear that implementing SDM will interrupt workflows [46, 57] | ||
Facilitators | - SDM draws attention to clinician’s own biases [46] - Significant decision requires additional attention and patient preference [45] | - Increased attention recognising it is a significant decision [45] | |||
11. Environmental context and resources (Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour) | |||||
Barriers | - Condition is too acute for SDM [47, 52, 56, 57] - Lack of time to engage in SDM [44, 45, 47,48,49,50, 53, 56, 57] - Noisy or busy ward environment [47, 48, 51, 53, 56] - Lack of private space to conduct SDM conversations [47, 50, 51, 56] - Patients often placed in hallways (not feasible for SDM conversation) [47, 48, 51, 56] - Presence of family/carers [49, 51, 56] - Clinician characteristics [52] - Interprofessional collaboration allows for more time for the decision to be made [50] | - Patients characteristics such as lower socioeconomic status, multiple comorbidities, lack of clinician language, past negative health experiences [45,46,47,48,49,50,51, 55, 56] - Lack of primary care physician to follow up with treatment decisions [50, 56] - Not having sufficient time for decision-making [53] | HSA, HSDM-related factors - Implementing SDM will take too much time, or too many resources [57] Making changes within the healthcare system is too difficult [57] | - Noisy or busy ward environment [47, 48, 50, 51, 53, 56] - Lack of private space to conduct SDM conversations [47, 51, 56] - Patients placed in hallways (not feasible for SDM conversation) [47, 48, 51, 56] - Not enough clinicians [47] - Waiting time to see clinician [47, 56] [11, 12] - Resources not available to use Patient Decision Aids [57] - No process for contacting primary care physicians on discharge [56] | - Inadequate funding of SDM [46] - Lack of agreed national plan for SDM [46] - Lack of clinical guidelines supporting SDM/fragmented availability of guidelines [44, 46, 55, 57] - Lack of decision-making materials (i.e. patient decision aids) [46, 57] - Part of policy, but not enforced i.e. through quality measures [46, 55] |
Facilitators | - Clinical equipoise of treatment decision [52] - Low acuity, meaning more time for SDM discussion [52] - Including the family in SDM [45, 49, 50] - Including the patient in decision-making as soon as possible (i.e. when first arriving on the ward) [51] - Using communication tools that explain risk [56] - Having minimal people involved in SDM conversation, as too many people can bring in different opinions [56] | - Patients characteristics such as higher socioeconomic status, education, health literacy [45,46,47,48,49,50,51, 55, 56] - Presence of a carer/family [45, 47, 49,50,51, 53] - Carer/family providing translation support [54] - Using question prompt lists [46] | HSA, HSDM-related factors - Past negative experience with SDM [54] Other stakeholder-related factors - Monitor SDM implementation [46] | - Any SDM intervention is supported by evidence-based literature [46, 49] - Using a standardised channel (i.e. form) for sharing information across teams [44, 49] - Ensure forms can be modified in line with needs of the team [44] - Private spaces to conduct SDM [50] | - Change guidelines to promote use of SDM in clinical practice [44, 46, 55, 57] - Create locally based, context-specific SDM implementation evidence [44, 46] - Research into the specific benefits of SDM tools [55] - Allow patient access to medical records [46] |
12. Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours) | |||||
Barriers | - Senior clinicians not engaging in SDM [46, 48, 57] - Other clinicians not engaging in SDM [55] - Inconsistent messaging between interprofessional team members [50, 51] | - Perceived power imbalance between the clinician and patient [54] - Family pressure to choose a particular treatment option | HSA, HSDM-related factors - Not having a site champion/leaders to endorse implementation of SDM [46, 48, 57] | - Lack of team support for clinician to do SDM [57] - Lack of organisational role models promoting SDM [46, 48, 57] | - Lack of support from policy makers [57] |
Facilitators | - Senior clinicians engaging in SDM [46, 48, 57] - Consistent messaging between interprofessional team members [45, 50, 51] | - Culture of the organisation supports SDM [46, 48, 55,56,57] - Leadership engages in SDM [44, 46, 48, 57] - Conduct regular SDM implementation team meetings [44] | |||
13. Emotion (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event) | |||||
Barriers | - Fear of uncertain or negative outcomes [45, 47, 49, 55, 56] - Patient being perceived by the clinician as being “rude” or “aggressive” or not open to SDM [47, 51, 54] - Fear of being labelled difficult [46, 53, 54] - Feeling like clinicians are not listening to concerns [51] - Feeling stressed due to busy or noisy ward environment [51] - Family members are emotional and stressed [51] - Feeling powerless during involuntary admission [54] - Reduced desire to engage in active decision-making (due to illness) [54] | ||||
Facilitators | - Feeling listened to [51, 54] - Patient being calm and respectful [54] | ||||
14. Behavioural regulation (Anything aimed at managing or changing objectively observed or measured actions) | |||||
Barriers | |||||
Facilitators | - Clinician taking a full medical history to encourage patient preferences [54] | - Following treatment plan [54] - Asking to be involved in decision-making [47, 54] - Asking questions in the consultation [47, 54, 55] - Opposing treatment recommendations [47, 54, 57] - Researching own illness/treatment [54] - Giving feedback on treatment experience [54] | - Change clinician habits through changing care processes to include patient preferences [46] - Create mandatory reporting of SDM implementation programmes [44] - Posters around ward to remind nurses of SDM implementation [49] - Engaging all patients in decision-making as soon as possible when they enter the ward [51] | ||