What do stakeholders need to implement shared decision making in routine cancer care? A qualitative needs assessment

Family medicine residents' perspectives on shared decision-making: A mixed methods study

OBJECTIVES

To 1) examine the willingness of residents to undertake shared decision-making and 2) explore whether the willingness to engage in shared decision-making is influenced by the perceived stakes of a clinical situation.

METHODS

Sequential mixed methods design. Phase One: Family Medicine residents completed IncorpoRATE, a seven-item measure of clinician willingness to engage in shared decision making. Mean IncorpoRATE scores were calculated. Phase Two: We interviewed residents from phase one to explore their perceptions of high versus low stakes situations. Transcripts were analyzed using qualitative content analysis.

RESULTS

IncorpoRATE scores indicated a greater willingness to engage in shared decision-making when the stakes of the decision were perceived as low (7.59 [2.0]) compared to high (4.38 [2.5]). Interviews revealed that residents held variable views of the stakes of similar clinical decisions.

CONCLUSION

Residents are more willing to engage in shared decision-making when the stakes of the situation are perceived to be low. However, the interpretation of the stakes of clinical situations varies.

PRACTICAL IMPLICATIONS

Further research is needed to explore how shared decision making is understood by residents in Family Medicine and when they view the process of shared decision-making to be most appropriate.

The Barriers and Facilitators of Shared Decision Making in Pediatric Otolaryngology: A Qualitative Study

OBJECTIVE

To identify barriers and facilitators to implementing shared decision making (SDM) in pediatric otolaryngology.

STUDY DESIGN

A qualitative study.

SETTING

Semistructured interviews of pediatric otolaryngologists.

METHODS

The Theoretical Domains Framework (TDF) was used as a guide for data collection and analysis to consider capability, opportunity, and motivation (COM-B) factors. The focal surgical procedures were tonsillectomy, adenoidectomy, and tympanostomy tube placement. Deductive and inductive coding of interview transcripts according to TDF/COM-B domains were performed by 2 separate reviewers.

RESULTS

A total of 11 interviews were conducted to achieve data saturation. The 4 dominant themes were: (1) inconsistent inclusion of SDM elements in practice, (2) social influences from parents, (3) environmental context, and (4) applicability of SDM in otolaryngology. Theme 1 identified that surgeons perceived SDM as a feature of their practice. However, the discussion of parents' values was seen as less explicit and structured interview formats were not commonly employed. Theme 2 demonstrated that surgeons saw parents' preconsult "agenda" as influencing their openness to consider multiple treatment options. Theme 3 pointed to the barriers of short appointment times, challenges in the use of support staff and lack of decision aids. Theme 4 emphasized surgeons' belief in the value of SDM and that parents' involvement in decision making reduced likelihood of decisional regret.

CONCLUSION

Pediatric otolaryngologists strongly support the value of SDM during clinical encounters, particularly to allow parent ownership of decisions regarding treatment. The major barriers were lack of clinical translation of SDM knowledge, social influences, and environmental factors.

Development of an electronic health record-integrated patient-reported outcome-based shared decision-making dashboard in oncology

Objectives

Patient-reported outcomes (PROs) describe a patient's unique experiences with disease or treatment, yet effective use of this information during clinical encounters remains challenging. This project sought to build a PRO based dashboard within the electronic health record (EHR), prioritizing interpretability and utility of PROs for clinical decision-making.

Materials and Methods

Codesign principles were used to define the goal, features, and visualization of the data elements on the dashboard. Codesign sessions occurred between February 2019 and May 2020 and involved a diverse group of stakeholders. Pilot evaluation of dashboard usability was performed with patients and clinicians not involved in the codesign process through qualitative interviews and the Systems Usability Scale.

Results

The dashboard was placed into a single tab in the EHR and included select PROM scores, clinical data elements, and goals of care questions. Real-time data analytics and enhanced visualization of data was necessary for the dashboard to provide meaningful feedback to clinicians and patients for decision-making during clinic visits. During soft launch, the dashboard demonstrated "good" usability in patients and clinicians at 3 and 6 months (mean total SUS score >70).

Discussion

The current dashboard had good usability and made PRO scores more clinically understandable to patients and clinicians. This paper highlights the development, necessary data elements, and workflow considerations to implement this dashboard at an academic cancer center.

Conclusion

As the use of PROs in clinical care is increasing, patient- and clinician-centered tools are needed to ensure that this information is used in meaningful ways.

Changes in intention to use an interprofessional approach to decision-making following training: a cluster before-and-after study

BACKGROUND

Health professionals in home care work in interprofessional teams. Yet most training in decision support assumes a one-on-one relationship with patients. We assessed the impact of an in-person training session in interprofessional shared decision-making (IP-SDM) on home care professionals' intention to adopt this approach.

METHODS

We conducted a secondary analysis of a cluster stepped-wedge trial using a before-and-after study design. We collected data among home care professionals from November 2016 to February 2018 in 9 health and social services centers in Quebec, Canada. The intervention was an in-person IP-SDM training session. Intention to engage in IP-SDM pre- and post-session (dependent variable) was compared using a continuing professional development evaluation scale (CPD-Reaction) informed by the Godin's Integrated Behavioral Model for health professionals. We also assessed socio-demographic and psychosocial variables (beliefs about capabilities, beliefs about consequences, social influence and moral norm). We performed bivariate and multivariate analysis to identify factors influencing post-intervention intention. We used the STROBE reporting guidelines for observational studies to report our results.

RESULTS

Of 134 respondents who provided complete pairs of questionnaires (pre- and post-), most were female (90.9%), mean age was 42 (± 9.3) years and 66.9% were social workers. Mean intention scores decreased from 5.84 (± 1.19) to 5.54 (± 1.35) (Mean difference = -0.30 ± 1.16; p = 0.02). Factors associated with higher intention post-intervention were social influence (ß = 0.34, p = 0.01) and belief about capabilities (ß = 0.49, p < 0.01).

CONCLUSION

After in-person IP-SDM training, healthcare professionals' intention to engage in IP-SDM decreased. However, the scope of this decrease is probably not clinically significant. Due to their association with intention, beliefs about capabilities, which translate into having a sense of self-competency in the new clinical behavior, and social influences, which translate into what important others think one should be doing, could be targets for future research aiming to implement IP-SDM in home care settings.

Multi-pilot implementation experiences of patient-centered pathology reports: lessons learned for the advancement of patient-centered tools for cancer decision-making

PURPOSE

New federal legislation in the United States grants patients expanded access to their medical records, making it critical that medical records information is understandable to patients. Provision of informational summaries significantly increase patient perceptions of patient-centered care and reduce feelings of uncertainty, yet their use for cancer pathology is limited.

METHODS

Our team developed and piloted patient-centered versions of pathology reports (PCPRs) for four cancer organ sites: prostate, bladder, breast, and colorectal polyp. The objective of this analysis was to identify common barriers and facilitators to support dissemination of PCPRs in care delivery settings. We analyzed quantitative and qualitative data from pilot PCPR implementations, guided by the RE-AIM framework to explore constructs of reach, effectiveness, adoption, implementation, and maintenance.

RESULTS

We present two case studies of PCPR implementation - breast cancer and colorectal polyps-that showcase diverse workflows for pathology reporting. Cross-pilot learnings emphasize the potential for PCPRs to improve patient satisfaction, knowledge, quality of shared decision-making activities, yet several barriers to dissemination exist.

CONCLUSION

While there is promise in expanding patient-centered cancer communication tools, more work is needed to expand the technological capacity for PCPRs and connect PCPRs to opportunities to reduce costs, improve quality, and reduce waste in care delivery systems.

Supporting care engagement in primary care; the development of a maturity matrix

BACKGROUND

Care engagement or active patient involvement in healthcare contributes to the quality of primary care, but organisational preconditions in routine practice need to be aligned. A Maturity Matrix for Care Engagement to assess and discuss these preconditions in the general practice team was developed and tested on feasibility and acceptability in general practice.

METHODS AND FINDINGS

A systematic user-centred approach was applied, starting with a scoping literature search to describe the domains on the horizontal axis of the maturity matrix. The domains and growing steps (vertical axis) were refined by patients (n = 16) and general practice staff (n = 11) in three focus group discussions and reviewed by six experts (local facilitators and scientists). Seven domains could be distinguished: Personalised Care, Shared Decision Making, Self-Management, Patient as Partner, Supportive Means, Patient Environment, and Teamwork among Healthcare Professionals. The growing steps described three to six activities per domain (n = 32 in total) that contribute to care engagement. Local facilitators implemented the tool in two general practice teams according to a user guide, starting with a two-hour kick-off meeting on care engagement. In the next step, practitioners, nurses and assistants in each practice indicated their score on the domains individually. The scores were discussed in the facilitated practice meeting which was aimed at SMART improvement plans. Feasibility and acceptability were assessed in interviews showing that the tool was well received by the pilot practices, although the practice assistants had difficulties scoring some of the activities as they did not always relate to their daily work. An assessment after three months showed changes in practice organisation towards increased care engagement.

CONCLUSIONS

The maturity matrix on care engagement is a tool to identify the organisational practice maturity for care engagement. Suggested adaptations must be implemented before large-scale testing.

Utilization of Screening Mammography in Women Before 50: Cross-Sectional Survey Results from the National Health Interview Survey

OBJECTIVE

While the American College of Radiology recommends annual screening mammography starting at age 40 years, the US Preventive Services Task Force (USPSTF) recommends that screening mammography in women younger than age 50 years should involve shared- decision making (SDM) between clinicians and patients, considering benefits and potential harms in younger women. Using a nationally representative cross-sectional survey, we aimed to evaluate patient-reported reasons and predictors of screening mammography utilization in this age group.

METHODS

Respondents aged 40-49 years from the 2018 National Health Interview Survey (NHIS) without a history of breast cancer were included (response rate 64%). Participants reported sociodemographic variables and reasons they did not engage in mammography screening within the last two years. Multiple variable logistic regression analyses were performed to evaluate the association between sociodemographic characteristics and patient-reported screening mammography use, accounting for complex survey sampling design elements.

RESULTS

1,948 women between the ages of 40-49 years were included. Of this group, (758/1948) 46.6% reported receiving a screening mammogram within the last year, and 1196/1948 (61.4%) reported receiving a screening mammogram within the last two years. The most common reasons for not undergoing screening included: "No reason/never thought about it" 744/1948 (38.2%), "Put it off" 343/1948 (17.6%), "Didn't need it" 331/1948 (16.9%), "Doctor didn't order it" 162/1948 (8.3%), and "I'm too young" 63/1948 (5.3%). Multiple variable analyses demonstrated that lack of health insurance was the strongest predictor of mammography non-engagement (p< 0.001).

CONCLUSION

Deficits in shared- decision-making in women younger than 50 years related to mammography utilization exist. Radiologists may be key in addressing this issue among ambulatory care providers and patients, educating about the benefits and harms of screening younger women, particularly in racial/ethnic minorities and uninsured patients, who experience additional barriers to care and SDM discussions.

Moving towards patient-centered care and shared decision-making in Germany

The main focus of this paper is to describe the development and current state of policy, research and implementation of patient-centered care (PCC) and shared decision-making (SDM) in Germany. What is the current state in health policy? Since 2013, the Law on Patients' Rights has standardized all rights and responsibilities regarding medical care for patients in Germany. This comprises the right to informed decisions, comprehensive and comprehensible information, and decisions based on a clinician-patient partnership. In addition, reports and action plans such as the German Ethics Council's report on patient well-being, the National Health Literacy Action Plan, or the National Cancer Plan emphasize and foster PCC and SDM on a policy level. There are a number of public organizations in Germany that support PCC and SDM. How are patients and the public involved in health policy and research? Publishers and funding agencies increasingly demand patient and public involvement. Numerous initiatives and organizations are involved in publicizing ways to engage patients and the public. Also, an increasing number of public and research institutions have established patient advisory boards. How is PCC and SDM taught? Great progress has been made in introducing SDM into the curricula of medical schools and other health care providers' (HCPs) schools (e.g., nursing, physical therapy). What is the German research agenda? The German government and other public institutions have constantly funded research programs in which PCC and SDM are important topics. This yielded several large-scale funding initiatives and helped to develop SDM training programs for HCPs in different fields of health care and information materials. Recently, two implementation studies on SDM have been conducted. What is the current uptake of PCC and SDM in routine care, and what implementation efforts are underway? Compared to the last country report from 2017, PCC and SDM efforts in policy, research and education have been intensified. However, many steps are still needed to reliably implement SDM in routine care in Germany. Specifically, the further development and uptake of decision tools and countrywide SDM trainings for HCPs require further efforts. Nevertheless, an increasing number of decision support tools - primarily with support from health insurance funds and other public agencies - are to be implemented in routine care. Also, recent implementation efforts are promising. For example, reimbursement by health insurance companies of hospital-wide SDM implementation is being piloted. A necessary next step is to nationally coordinate the gathering and provision of the many PCC and SDM resources available.

Patient participation in treatment decision-making of prostate cancer: a qualitative study

PURPOSE

Despite increasing development in decision-making strategies for patients with prostate cancer, little is known about patients' individual experience and perception throughout the decision-making process. The objective of this study was to explore patients' experiences and perceptions towards treatment decision-making.

METHODS

We conducted a qualitative interview study with 30 patients diagnosed with prostate cancer. We transcribed interviews verbatim and inductively identified codes. Thematic analysis was used to develop and refine a codebook that aided in the identification of themes.

RESULTS

Three key themes and nine subthemes emerged, which were as follows: I. less involved in treatment decision-making, (i) passive decisional control, (ii) lack of medical knowledge, and (iii) domination by family members; II. the right to be informed of the disease condition and to choose treatment options, (i) sociocultural influences, (ii) patients believe that they should know the true facts of the disease, and (iii) patient autonomy during treatment; and III. future consideration and advance care planning, (i) fewer future concerns, (ii) advance care planning is poorly understood, and (iii) acceptance of advance care planning.

CONCLUSION

The study results show that patients with prostate cancer have a diversity of needs to cultivate their ability to make treatment decisions, and healthcare professionals should empower patients, as well as provide decision aids or decision support for patients.

Evaluation of a program for routine implementation of shared decision-making in cancer care: results of a stepped wedge cluster randomized trial

BACKGROUND

Shared decision-making (SDM) is preferred by many patients in cancer care. However, despite scientific evidence and promotion by health policy makers, SDM implementation in routine health care lags behind. This study aimed to evaluate an empirically and theoretically grounded implementation program for SDM in cancer care.

METHODS

In a stepped wedge design, three departments of a comprehensive cancer center sequentially received the implementation program in a randomized order. It included six components: training for health care professionals (HCPs), individual coaching for physicians, patient activation intervention, patient information material/decision aids, revision of quality management documents, and reflection on multidisciplinary team meetings (MDTMs). Outcome evaluation comprised four measurement waves. The primary endpoint was patient-reported SDM uptake using the 9-item Shared Decision Making Questionnaire. Several secondary implementation outcomes were assessed. A mixed-methods process evaluation was conducted to evaluate reach and fidelity. Data were analyzed using mixed linear models, qualitative content analysis, and descriptive statistics.

RESULTS

A total of 2,128 patient questionnaires, 559 questionnaires from 408 HCPs, 132 audio recordings of clinical encounters, and 842 case discussions from 66 MDTMs were evaluated. There was no statistically significant improvement in the primary endpoint SDM uptake. Patients in the intervention condition were more likely to experience shared or patient-lead decision-making than in the control condition (d=0.24). HCPs in the intervention condition reported more knowledge about SDM than in the control condition (d = 0.50). In MDTMs the quality of psycho-social information was lower in the intervention than in the control condition (d = - 0.48). Further secondary outcomes did not differ statistically significantly between conditions. All components were implemented in all departments, but reach was limited (e.g., training of 44% of eligible HCPs) and several adaptations occurred (e.g., reduced dose of coaching).

CONCLUSIONS

The process evaluation provides possible explanations for the lack of statistically significant effects in the primary and most of the secondary outcomes. Low reach and adaptations, particularly in dose, may explain the results. Other or more intensive approaches are needed for successful department-wide implementation of SDM in routine cancer care. Further research is needed to understand factors influencing implementation of SDM in cancer care.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03393351 , registered 8 January 2018.

Shared decision making in cancer treatment: A Dutch national survey on patients' preferences and perceptions

Objective

Shared decision making (SDM) for cancer treatment yields positive results. However, it appears that discussing essential topics for SDM is not fully integrated into treatment decision making yet. Therefore, we aim to explore to what extent discussion of therapy options, treatment consequences, and personal priorities is preferred and perceived by (former) cancer patients.

Methods

An online questionnaire was distributed by the Dutch Federation of Cancer Patient Organisations among (former) cancer patients in 2018.

Results

Among 3785 (former) cancer patients, 3254 patients (86%) had discussed treatments with their health care provider (HCP) and were included for analysis. Mean age was 62.1 ± 11.5; 55% were female. Discussing the option to choose no (further) treatment was rated by 2751 (84.5%) as very important (median score 9/10—IQR 8–10). Its occurrence was perceived by 28% (N = 899), and short‐ and long‐term treatment consequences were discussed in 81% (N = 2626) and 53% (N = 1727), respectively. An unmet wish to discuss short‐ and long‐term consequences was reported by 22% and 26%, respectively. Less than half of the (former) cancer patients perceived that personal priorities (44%) and future plans (34%) were discussed.

Conclusion

In the perception of (former) cancer patients, several essential elements for effective SDM are insufficiently discussed during cancer treatment decision making.

Development and testing of the shared decision-making attitudes scale among nurses in Taiwan: a cross-sectional scale development study

OBJECTIVE

Shared decision-making (SDM) enhances medical care, but an appropriate tool for evaluating nursing staff's attitudes towards SDM in clinical practice is lacking. The objective of this study is to develop the Nursing Shared Decision-Making Attitude (NSDMA) scale and verify its psychometric properties.

DESIGN

Instrument design study.

PARTICIPANTS

A sample of 451 nursing staff.

INTERVENTION

This study comprised two phases. In phase 1, qualitative research and expert content validity were adopted to develop the first draft of the scale. In phase 2, Taiwanese nursing staff were recruited through convenience sampling, and the sample was divided into a calibration sample and a validation sample. An objective structured clinical examination of SDM attitudes was administered to 100 nursing staff to determine the scale's cut-off score.

MAIN OUTCOME MEASUREMENTS

Exploratory factor analysis and confirmatory factor analysis were used to obtain the underlying factors of the NSDMA scale; McDonald's omega value was used to determine the reliability; known-group validity was used to test the construct validity; and the receiver operating characteristic curve was adopted to determine the scale's cut-off score.

RESULTS

In total, two factors were identified from the instrument results, which were termed 'empathic communication' and 'mastery learning'. The McDonald's omega value of the overall scale was 0.92. Known-group validity testing was performed based on the staff's participation in SDM courses and experience of SDM, and the results exhibited significant differences (t=5.49, p<0.001; t=2.43, p<0.05). Based on the receiver operating characteristic curve, the optimal cut-off for SDM attitudes was determined as 48.5 points.

CONCLUSIONS

The NSDMA scale enables the evaluation of SDM attitudes among clinical nursing staff and nursing managers; the results may serve as a reference for incorporation of SDM into nursing policy formulation.

Doctors' Attitudes to Patient Question Asking, Patient-Generated Question Lists, and Question Prompt Lists: A Qualitative Study

BACKGROUND

Participation by patients in their own health care improves quality and safety. Question prompt lists (QPLs) can improve participation, particularly with doctors' endorsement. Few data have explored doctors' attitudes on these tools. We sought the experiences and attitudes of general practitioners and other specialists toward patient question asking and QPLs in their practice.

METHODS

In-depth, semistructured interviews and focus groups with purposively selected Australian doctors were conducted. Interview guides were used to explore doctors' experiences of patient question asking, patients' lists, and a sample QPL created using an Australian government-funded online tool, "Question Builder." Recordings were transcribed verbatim and data analyzed thematically using the method by Braun and Clarke.

RESULTS

Focus groups with 3 to 9 participants and a further 17 individual interviews were conducted. There was a total of 40 participants, 23 general practitioners and 17 other specialists (e.g., physicians, surgeons, pediatricians). Our analysis was summarized into several themes. 1) The doctors expected, encouraged, and had significant experience of patient question asking and patients' lists. They described many barriers for patients and their efforts to ensure patients had the information they needed. 2) The doctors felt responsible for creating an environment conducive to patient question asking, the delivery of answers, having strategies for unanswered questions, and balancing the agendas of both parties in the consultation. 3) Structured QPLs that prepared patients and facilitated the consultation agenda were viewed positively. The degree of time pressures participating doctors experienced in their context had a strong influence on how they responded to the sample QPL.

CONCLUSION

Doctors in this study expected patients to ask questions and endorsed the benefits of QPLs. However, there were more diverse views about the feasibility of implementing them in practice. Designing QPLs to fit within current workflows, via more succinct and tailored designs, may result in wider doctor acceptance and endorsement, hence maximizing the benefits of QPLs with improved patient participation and patient safety.

Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review

Background

Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives.

Methods

The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM.

Results

Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations.

Conclusions

SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs.

Trial Registration

The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01142-y.

Shared clinical decision-making experiences in nursing: a qualitative study

Background

Shared decision making (SDM) is a patient-centered nursing concept that emphasizes the autonomy of patients. SDM is a co-operative process that involves information exchange and communication between medical staff and patients for making treatment decisions. In this study, we explored the experiences of clinical nursing staff participating in SDM.

Methods

This study adopted a qualitative research design. Semistructured interviews were conducted with 21 nurses at a medical center in northern Taiwan. All interview recordings were transcribed verbatim. Content analysis was performed to analyze the data.

Results

The findings yielded the following three themes covering seven categories: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors.

Conclusions

The results of this study describe the experiences of clinical nursing staff participating in SDM and can be used as a reference for nursing education and nursing administrative supervisors wishing to plan and enhance professional nursing SDM in nursing education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00597-0.

Adaptation and qualitative evaluation of Ask 3 Questions - a simple and generic intervention to foster patient empowerment

BACKGROUND

Patients are often not actively engaged in medical encounters. Short interventions like Ask 3 Questions (Ask3Q) can increase patient participation in decision-making. Up to now, Ask3Q was not available in German.

OBJECTIVE

To translate Ask3Q and evaluate its acceptability and feasibility.

METHODS

We translated and adapted several English versions of Ask3Q using a team translation protocol and cognitive interviews. Acceptability and feasibility of the final German Ask3Q version were assessed via focus groups and interviews with patients and healthcare professionals (HCPs). Data were analysed via qualitative content analysis.

RESULTS

Translation and adaptation were successful. Participants of focus groups and interviews perceived Ask3Q as a tool to empower patients to ask more questions. Moreover, it was seen as a guideline for physicians not to forget conveying important information. Several characteristics of patients, HCPs, the clinical setting and the intervention were identified as facilitators and barriers for an effective implementation of Ask3Q.

CONCLUSION

We provide the German version of Ask3Q. According to participants, implementation of Ask3Q in the German healthcare system is feasible. Future studies should evaluate if positive effects of Ask3Q can be replicated for patient participation and communication behaviour of HCPs in Germany.

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Understanding decision making about major surgery: protocol for a qualitative study of shared decision making by high-risk patients and their clinical teams

INTRODUCTION

Surgical treatments are being offered to more patients than ever before, and increasingly to high-risk patients (typically multimorbid and over 75). Shared decision making is seen as essential practice. However, little is currently known about what 'good' shared decision making involves nor how it applies in the context of surgery for high-risk patients. This new study aims to identify how high-risk patients, their families and clinical teams negotiate decision making for major surgery.

METHODS AND ANALYSIS

Focusing on major joint replacement, colorectal and cardiac surgery, we use qualitative methods to explore how patients, their families and clinicians negotiate decision making (including interactional, communicative and informational aspects and the extent to which these are perceived as shared) and reflect back on the decisions they made. Phase 1 involves video recording 15 decision making encounters about major surgery between patients, their carers/families and clinicians; followed by up to 90 interviews (with the same patient, carer and clinician participants) immediately after a decision has been made and again 3-6 months later. Phase 2 involves focus groups with a wider group of (up to 90) patients and (up to 30) clinicians to test out emerging findings and inform development of shared decision making scenarios (3-5 summary descriptions of how decisions are made).

ETHICS AND DISSEMINATION

The study forms the first part in a 6-year programme of research, Optimising Shared decision-makIng for high-RIsk major Surgery (OSIRIS). Ethical challenges around involving patients at a challenging time in their lives will be overseen by the programme steering committee, which includes strong patient representation and a lay chair. In addition to academic outputs, we will produce a typology of decision making scenarios for major surgery to feed back to patients, professionals and service providers and inform subsequent work in the OSIRIS programme.

Training Interventions to Equip Health Care Professionals With Shared Decision-Making Skills: A Systematic Scoping Review

INTRODUCTION

To support the development, implementation, and evaluation of shared decision-making (SDM) training programs, this article maps the relevant evidence in terms of training program design and content as well as evaluation outcomes.

METHOD

A systematic scoping review methodology was used. To identify studies, the databases PubMed, Medline, and CINAHL were searched from 2009 to 2019, and reference lists of included studies were examined. After removal of duplicates, 1367 articles were screened for inclusion. To be included, studies were to be published in peer-reviewed journals, and should not merely be descriptive but report on evaluation outcomes. Articles were reviewed for inclusion by both authors, and data were extracted using a purposely designed data charting form implemented using REDCap.

RESULTS

The review identified 49 studies evaluating 36 unique SDM training programs. There was considerable variation in terms of program design and duration. Most programs included an overview of SDM theories and key competencies, as well as SDM skill development through role plays. Few programs provided training in reflective practice, in identifying and working with patients' individually preferred decision-making style, or in relation to SDM in a context of medical uncertainty or ambiguity. Most programs were evaluated descriptively, mostly using mixed methods, and there were 18 randomized controlled trials, showing that training was feasible, well received, and improved participants' knowledge and skills, but was limited in its impact on patients.

DISCUSSION

Although there is limited capacity to comment on which types of training programs are most effective, overall training was feasible, well received, and improved participants' knowledge and skills.

Applying the Behavioural and Social Sciences Research (BSSR) Functional Framework to HIV Cure Research

INTRODUCTION

The search for an HIV cure involves important behavioural and social processes that complement the domains of biomedicine. However, the field has yet to tap into the full potential of behavioural and social sciences research (BSSR). In this article, we apply Gaist and Stirratt's BSSR Functional Framework to the field of HIV cure research.

DISCUSSION

The BSSR Functional Framework describes four key research domains: (1) basic BSSR (understanding basic behavioural and social factors), (2) elemental BSSR (advancing behavioural and social interventions), (3) supportive BSSR (strengthening biomedically focused clinical trials), and (4) integrative BSSR (building multi-disciplinary combination approaches for real-world implementation). In revisiting and applying the BSSR Functional Framework, we clarify the importance of BSSR in HIV cure research by drawing attention to such things as: how language and communication affect the meaning of "cure" to people living with HIV (PLHIV) and broader communities; how cure affects the identity and social position of PLHIV; counselling and support interventions to address the psychosocial needs and concerns of study participants related to analytical treatment interruptions (ATIs); risk reduction in the course of ATI study participation; motivation, acceptability, and decision-making processes of potential study participants related to different cure strategies; HIV care providers' perceptions and attitudes about their patients' participation in cure research; potential social harms or adverse social events associated with cure research participation; and the scalability of a proven cure strategy in the context of further advances in HIV prevention and treatment. We also discuss the BSSR Functional Framework in the context of ATIs, which involve processes at the confluence of the BSSR domains.

CONCLUSIONS

To move HIV cure regimens through the translational research pathway, attention will need to be paid to both biomedical and socio-behavioural elements. BSSR can contribute an improved understanding of the human and social dimensions related to HIV cure research and the eventual application of HIV cure regimens. The BSSR Functional Framework provides a way to identify advances, gaps and opportunities to craft an integrated, multi-disciplinary approach at all stages of cure research to ensure the real-world applicability of any strategy that shows promise.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

Background

Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.

Methods

A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION⁵, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.

Results

Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION⁵: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.

Conclusion

The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Quality of teamwork in multidisciplinary cancer team meetings: A feasibility study

BACKGROUND

Tumor boards (TB) play an important role to formulate a management plan for the treatment of patients with a malignancy. Recent evidence suggests that optimally functioning teams (teamwork, communication and decision making) are major prerequisites to conduct efficient TB meetings. The aims of this study were i) to use a readily published tool as a template for the development of a teamwork perspective extended assessment tool and ii) to evaluate the tool in a feasibility study by clinical and non-clinical observers.

METHODS

A systematic literature search in four databases revealed the "Metric for the Observation of Decision-making (MODe)" to be consistently used. MODe served as a template for the clinical evaluation, additional, notably teamwork items were integrated, and the resulting tool was tested in a feasibility study in TBs by clinical and non-clinical observers. The percentage of agreement between observers was assessed in a two-step approach: first, agreement of raters on discussion of items by TB members, and second, agreement of raters based on ordinal scale.

RESULTS

In total, 244 patients were discussed in 27 TB sessions, thereof 136 (56%) fast track cases and 108 (44%) complex cases. In 228 (93%) of all cases an agreement for recommendation of a treatment plan was reached. Observers showed in general high agreement on discussion of the items. For the majority of items, the percentage of agreement between the different pairs of rater was similar and mostly high.

CONCLUSION

A newly developed TB team performance tool using MODe as a template was piloted in a German-speaking country and enabled the assessment of specialized multidisciplinary teams with a special focus on teamwork patterns. The developed assessment tool requires evaluation in a larger collective for validation, and additional assessment whether it can be applied equally by non-clinicians and clinicians.

Evaluation of a program for routine implementation of shared decision-making in cancer care: study protocol of a stepped wedge cluster randomized trial

BACKGROUND

Shared decision-making (SDM) has become increasingly important in health care. However, despite scientific evidence, effective implementation strategies, and a prominent position on the health policy agenda, SDM is not widely implemented in routine practice so far. Therefore, we developed a program for routine implementation of SDM in oncology by conducting an analysis of the current state and a needs assessment in a pilot study based on the Consolidated Framework for Implementation Research (CFIR). Based on these results, the main aim of our current study is to evaluate the process and outcome of this theoretically and empirically grounded multicomponent implementation program designed to foster SDM in routine cancer care.

METHODS

We use a stepped wedge design, a variant of the cluster randomized controlled trial. The intervention to be implemented is SDM. Three participating clinics of one comprehensive cancer center will be randomized and receive the multicomponent SDM implementation program in a time-delayed sequence. The program consists of the following strategies: (a) SDM training for health care professionals, (b) individual coaching for physicians, (c) patient activation strategy, (d) provision of patient information material and decision aids, (e) revision of the clinics' quality management documents, and (f) critical reflection of current organization of multidisciplinary team meetings. We will conduct a mixed methods outcome and process evaluation. The outcome evaluation will consist of four measurement points. The primary outcome is adoption of SDM, measured by the 9-item Shared Decision Making Questionnaire. A range of other implementation outcomes will be assessed (i.e., acceptability, readiness for implementing change, appropriateness, penetration). The implementation process will be evaluated using stakeholder interviews and field notes. This will allow adapting interventions if necessary.

DISCUSSION

This study is the first large study on routine implementation of SDM conducted in German cancer care. We expect to foster implementation of SDM at the enrolled clinics. Insights gained from this study, using a theoretically and empirically grounded approach, can inform other SDM implementation studies and health policy developments, both nationally and internationally.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03393351 . Registered 8 January 2018.

Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them - a scoping review

Background

Shared decision-making (SDM) is poorly implemented in routine care, despite being promoted by health policies. No reviews have solely focused on an in-depth synthesis of the literature around organizational- and system-level characteristics (i.e., characteristics of healthcare organizations and of healthcare systems) that may affect SDM implementation. A synthesis would allow exploration of interventions to address these characteristics. The study aim was to compile a comprehensive overview of organizational- and system-level characteristics that are likely to influence the implementation of SDM, and to describe strategies to address those characteristics described in the literature.

Methods

We conducted a scoping review using the Arksey and O’Malley framework. The search strategy included an electronic search and a secondary search including gray literature. We included publications reporting on projects that promoted implementation of SDM or other decision support interventions in routine healthcare. We screened titles and abstracts, and assessed full texts for eligibility. We used qualitative thematic analysis to identify organizational- and system-level characteristics.

Results

After screening 7745 records and assessing 354 full texts for eligibility, 48 publications on 32 distinct implementation projects were included. Most projects (N = 22) were conducted in the USA. Several organizational-level characteristics were described as influencing the implementation of SDM, including organizational leadership, culture, resources, and priorities, as well as teams and workflows. Described system-level characteristics included policies, clinical guidelines, incentives, culture, education, and licensing. We identified potential strategies to influence the described characteristics, e.g., examples how to facilitate distribution of decision aids in a healthcare institution.

Conclusions

Although infrequently studied, organizational- and system-level characteristics appear to play a role in the failure to implement SDM in routine care. A wide range of characteristics described as supporting and inhibiting implementation were identified. Future studies should assess the impact of these characteristics on SDM implementation more thoroughly, quantify likely interactions, and assess how characteristics might operate across types of systems and areas of healthcare. Organizations that wish to support the adoption of SDM should carefully consider the role of organizational- and system-level characteristics. Implementation and organizational theory could provide useful guidance for how to address facilitators and barriers to change.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0731-z) contains supplementary material, which is available to authorized users.

How are decisions made in cancer care? A qualitative study using participant observation of current practice

OBJECTIVES

Shared decision-making has continuously gained importance over the last years. However, few studies have investigated the current state of shared decision-making implementation in routine cancer care. This study aimed to investigate how treatment decisions are made in routine cancer care and to explore barriers and facilitators to shared decision-making using an observational approach (three independent observers). Furthermore, the study aimed to extend the understanding of current decision-making processes beyond the dyadic physician-patient interaction.

DESIGN

Cross-sectional qualitative study using participant observation with semistructured field notes, which were analysed using qualitative content analysis as described by Hsieh and Shannon.

SETTING AND PARTICIPANTS

Field notes from participant observations were collected at n=54 outpatient consultations and during two 1-week-long observations at two inpatient wards in different clinics of one comprehensive cancer centre in Germany.

RESULTS

Most of the time, either one physician alone or a group of physicians made the treatment decisions. Patients were seldom actively involved. Patients who were 'active' (ie, asked questions, demanded participation, opposed treatment recommendations) facilitated shared decision-making. Time pressure, frequent alternation of responsible physicians and poor coordination of care were the main observed barriers for shared decision-making. We found high variation in decision-making behaviour between different physicians as well as the same physician with different patients.

CONCLUSION

Most of the time physicians made the treatment decisions. Shared decision-making was very rarely implemented in current routine cancer care. The entire decision-making process was not observed to follow the principles of shared decision-making. However, some aspects of shared decision-making were occasionally incorporated. Individual as well as organisational factors were found to influence the degree of shared decision-making. If future routine cancer care wishes to follow the principles of shared decision-making, strategies are needed to foster shared decision-making in routine cancer care.

The involvement of early stage breast cancer patients during oncology consultations in Italy: a multi-centred, randomized controlled trial of a question prompt sheet versus question listing

OBJECTIVES

To investigate, prior to an oncology consultation, the use of a pre-prepared list of evidence based questions, Question Prompt Sheet (QPS), compared with a Question List (QL), a patient self-generated list of questions.

DESIGN

Multi-centred, randomised controlled trial.

SETTING

Secondary-care patients attending three outpatient oncology clinics in Northern Italy.

PARTICIPANTS

308 women completed the study. Inclusion criteria were an age between 18 and 75 years, a recent diagnosis of early stage, non-metastatic breast cancer, adequate Italian language skills, no previous oncology visits and no evidence of cognitive impairment.

INTERVENTION

Patients received the QPS or the QL prior to the consultation, completed it without suggestion or coaching session and delivered back before the visit.The consultations were audio-recorded and analysed for the number and content of questions. Multilevel linear models were used to compare the two groups.

OUTCOME MEASURES

The primary outcome was the comparison of questions asked between QPS and QL group. Secondary outcomes included satisfaction about questions asked, satisfaction with decision, and level of anxiety.

RESULTS

Patients in the QPS and QL group asked 13 and 16 questions respectively. The difference was not significant (b=1.7, CI -0.3 to 3.6, p=0.10). A mean of 22 questions was selected in the QPS, while a mean of 2 questions was written in the QL. Patients in the QPS group were significantly less satisfied (t=3.60, p<0.01) with questions asked but wanted less additional information (t=2.20, p<0.05). Levels of patient decisional satisfaction were equivalent between groups. Similarly, anxiety levels were equal between groups prior to the consultation and decreased in similar way after the consultation.

CONCLUSIONS

Both interventions have similar impact on patients' participation in terms of question asking during the consultation. Future research is needed in order to explore which components of the interventions are really useful and efficacious.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01510964.

The long way of implementing patient-centered care and shared decision making in Germany

The main focus of the paper is on the description of the development and current state of research and implementation of patient-centered care (PCC) and shared decision making (SDM) after fifteen years of substantial advances in health policy and health services research. What is the current state of SDM in health policy? The "Patients' Rights Act" from 2013 standardizes all rights and responsibilities within the framework of medical treatment for German citizens and legal residents. This comprises the right to informed decisions, comprehensive and comprehensible information for patients, and decisions based on a clinician-patient-partnership. What is the current state of SDM interventions and patient decision support tools? SDM training programs for healthcare professionals have been developed. Their implementation in medical schools has been successful. Several decision support tools - primarily with support from health insurance funds and other public agencies - are to be implemented in routine care, specifically for national cancer screening programs. What is the current state of research and routine implementation? The German government and other public institutions are constantly funding research programs in which patient-centered care and shared decision-making are important topics. The development and implementation of decision tools for patients and professionals as well as the implementation of CME trainings for healthcare professionals require future efforts. What does the future look like? With the support of health policy and scientific evidence, transfer of PCC and SDM to practice is regarded as meaningful. Research can help to assess barriers, facilitators, and needs, and subsequently to develop and evaluate corresponding strategies to successfully implement PCC and SDM in routine care, which remains challenging.