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Table 2 Barriers and facilitators to implementing SDM data mapped to the Theoretical Domains Framework (Cane et al., 2012) from multiple perspectives

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

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] - Lack of training to do SDM [46, 48, 50, 51, 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 colleagues do not want to do SDM [55, 57]
- Patient has no or limited ongoing primary care [50, 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]
- Nurse is involved in SDM [49, 54]
- 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]
- SDM is too much effort [56, 57]
- 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]
- Disease is too acute for SDM [47, 52, 56, 57]
- Lack of applicability of the clinical situation [45, 50]
- 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]
- Non-adherence with treatment plan [54, 56]   - 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   - Patient lack of engagement or ambition [50, 54]    
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
- Cultural beliefs [45, 49, 56]
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]
- Establish site champions for SDM [44, 57]
 
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 “missing something” [45, 56, 57] - 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   - Not following treatment plans [47, 54]    
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]