CFIR Domain & Constructs
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SDM Implementation Themes
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Supporting Quotes
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Intervention Characteristics
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Intervention Source
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Tools may not be accepted if perceived as external to professional scope of practice
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‘it might be a little bit of change in practice for some to have to use a tool that they haven’t created themselves’
‘perhaps look outside the GP guidelines’
‘[a team member] didn’t really engage...because there wasn’t anything provided for them.’
‘the main problems are some of the therapies on the sheets, the clinicians don’t think they should be on there, some of them, I think.’
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Evidence Strength & Quality
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Mixed views about efficacy of the tools
Concern that patients’ decisions may differ from their usual recommendations (loss of clinician autonomy)
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‘Actually with the patients, what I have found sometimes if [they] are really stressed or anxious...having something to go through with the shared decision making can actually help…actually sitting down and going through what it is you have control over’
‘For some patients it’s really helpful to have that in a written format that they can look at and be involved.’
‘…as a clinician we have an idea of what we think may be best for the patient…that can be quite a challenge if somebody’s opted for hydrotherapy and we know that might give them some benefit but at the back of our minds we know that land-based will give them much more benefit’
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Relative Advantage
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Strongly motivated by improved patient outcomes
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‘We were all genuinely keen to give it a trial and see whether it was effective, whether it’s something we can use with our patients to provide a better quality service. We were initially quite nervous, but I think as time went on we could see there were some benefits with some patients.’
‘I think the incentive is to get the most benefit for your patient to make sure they feel empowered and listened to’
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Adaptability
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Variable models of care and team composition require flexibility
Need to personalise implementation to own style of practice
Concern if options not available within the service
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‘I guess from the weight loss point of view, just working out how to fit that with my actual practice at the moment’
‘let that clinician work out how they work and not dictate that they have to use that approach`’
‘the options might not be in line with what we are able to provide the patients.. .the politics around what type of interventions are being sort of recommended on the cards’
‘I think the barrier or sort of the resistance comes up when maybe tools don’t match practitioners’ viewpoints or it lacks options or isn’t aligned to what a service offers’
‘I didn’t feel it fitted how our program ran, but once we were able to make an adjustment to that and have something that was a bit more appropriate and a bit more realistic with our level, then I felt fine’
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Trialability
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N/A
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Complexity
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Concern SDM too burdensome for some patients
Discomfort with discussing evidence and uncertainty
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‘would it confuse the patients? I’m not sure.. .finding something that’s very easy for the patient to digest and understand’
‘one of the issues that sometimes comes up is overwhelming the patient’
‘it’s been a bit unfamiliar sometimes for the elderly population…they wouldn’t naturally ask questions or they may not tell you so much about themselves.’
“Our shared decision making tool has a lot of reference to the evidence from clinical trials in there and the strength of evidence in a lot of these trials is very poor, and that seems to be the nature of a lot of things involving exercise, for example, and weight loss. It's very hard to have a very strong paper, a strong evidence clinical trial being done. So a lot of the evidence that we have in there is poor quality. So poor quality evidence is difficult to put a lot of weight behind. However, our tools are full of all this evidence, which is of poor quality. I guess we don't want the patients to be looking at this evidence - level of evidence seeing that it's poor quality evidence and have that as a main determining factor of whether or not they choose one treatment over the other because evidence itself, that's one thing that we can go off. But the other thing we can go off is clinician experience and what we see in clinical practice which doesn't necessarily get captured in a paper. So that was one of the things that was a bit of a difficulty, is that it's so heavily reliant on the evidence rather than what we do as clinicians and expert clinicians in the field.”
“This is difficult for us to show people that, yes, you might try and do a strengthening exercise but the evidence is poor.”
‘So when we use a decision-making tool, for example, the hydrotherapy pool, we can’t really use that with confidence, because we feel a bit embarrassed to show it to the patient because the evidence is not strong. But we still recommend it.’
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Design Quality & Packaging
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Training was perceived as useful and possibly more than tools
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‘the actual physical tools were maybe a hindrance, boxing you in on what you could offer, but the face-to-face support and contact was helpful’
‘my colleagues felt that the training did help them to understand the process a lot more. For me, I haven’t had that training so I’m not quite sure’.
‘They seem much more confident now after the initial training. I think that was quite positive. They are confident to be able to do that’.
‘the training and information we’ve had to date, I feel had probably been – it’s been quite positive’
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Cost
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Concern about time constraints of implementing SDM
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‘the only stress that I would have is time’ ‘ it’s just a time-poor thing’ ‘ there’s always a time challenge in the clinic, just trying to get through the patients within the allocated time’
‘ I still do feel, as I said, a little bit ambivalent about how am I going to make that fit within the process and not find myself short on time?’
‘you might only have 15 to 20 minute appointments and obviously that’s going to affect how you deliver shared decision-making, purely because you have so many other duties of care to that patient during that time’
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Outer Setting
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Patient Needs
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Believe patients’ values are core to their hospital
Concern that patients’ choices may misalign with own KPIs
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“ [The hospital] want patient centred care to be one of the main - it's like a driving force of the hospital, patient centred care.”
“So the negative things are that some of the things that we are offering in the decision aids we don’t advocate as therapists. So we might have something on there that we really probably don’t – wouldn’t recommend in our usual practice. So there’s the risk and chance that patients are selecting something that wouldn’t normally be part of our practice.”
“[Shared decision-making is disadvantageous] when the patient has very different beliefs to what we feel should happen. If they are not realistic about what they want to achieve, or not realistic about what they should be doing.”
‘One of our standards for accreditation is consumer engagement and a patient centred mode. So this kind of [aligned] with our own values and objectives’
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Cosmopolitanism
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N/A
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Peer Pressure
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Discussion with colleagues at other sites helpful (discipline-based opinion leaders)
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‘perhaps if it was all dietitians working together, that might be a bit different, but because we are all separate, we’re all different types of clinicians, then that’s probably why we didn’t support each other as much’
‘I have liaised a little bit with some of the other dieticians…in terms of establishing what we could use as a – giving the options. That was an influence of working together; that made it a bit easier, talking about it with someone else’
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External Policy and Incentives
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Support by hospital leadership and health ministry perceived as important
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‘I don’t think there was any extra support per se. It was just allowed.’
‘I don’t think the hospital would give us any more time. I would be willing to put in whatever hours are required, but I understand there’s a budget’.
“… because we still have KPIs and numbers that we are trying to get through, the issue is going to be the time in terms of if - how much extra time is this going to take. So, I think that's where management hopefully will continue to support us.”
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Inner Setting
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Structural Characteristics
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Changing team composition and part-timers is challenge
Smaller teams make it easier to change
Physical environment & model of care impacted on strategy selection
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‘Unfortunately not all team members were available at the time that was set’
‘It’s a very small team, so we’re talking about three, four team members. In that way, yes, they have their own little culture and being part of a small team it’s easier to control.
‘So, we’re a little bit limited in terms of the physical environment and the messaging that we want to put around the waiting room. I think we’re limited just with our resources, anyway. We are a part-time small team’
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Networks and Communications
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Team support and communication are important
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‘I think we’ve all been a little bit separate or siloed into each of our approach to SDM. ..we do have clinicians where their profession haven’t been included so I wouldn’t talk to them about it either’
‘it was again a group effort so we were all engaged on that and in terms of I guess we were encouraged to ask one another things if we needed to or discuss any concerns we had amongst the team.’
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Culture
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Strong commitment to patient-centred care
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‘they want good outcomes for the patients. They’re very patient-centred.’
‘our goal obviously is in patient care and ensuring that they have the outcome’
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Implementation Climate (Tension for Change, Compatibility, Relative Priority, Organisational Incentives & Rewards, Goals and Feedback, Learning Climate)
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Needs to fit within daily workflow and practice
It takes time to adapt and change
Reminders and prompts can be helpful
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‘at the beginning I did forget a few times, but found if I had my tool out on my consult desk the day of new patients it was a visual reminder for me to use it. Then that’s just a habit I’ve got into, is just to make sure that I’ve got it out so that I can see it and it reminds me to use it.’
‘so trying to keep the clinic flow and still including something new’
So from when we first started, just working out the best way to include it in our current practices and how we can fit that in?
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Readiness for Implementation (Leadership engagement, available resources, access to knowledge & information)
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Team coordinator/manager commitment important
Physical space, time & training all impacted
Access to SDM-specific support and information beneficial
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‘the coordinator of the team is an important person to drive the implementation, and also the consultant from a hierarchy point of view’ ‘so he directs what the rest of the team does or how the team functions. So if he’s on board ..then [that] encourages the rest of the team to do it’
“just [feeling] the competing interests around time and they’re a small team with a three to four month waiting list. So, there is I guess, some nervousness and stress how to fit another thing in and learn to use the tools and incorporate them.’
‘Work environment the space-wise is a bit tricky; we haven’t always got always got a lot of space to have all the tools out and sort of showing them to patients as well. So that can be challenging in certain work areas anyway’
‘We may be a little bit limited in our waiting room…we share the facility with other services. It’s a part time service shared with other part-time services. So we probably can’t use the waiting room exclusively for us’
‘We have had the support from those who are running the process. So that’s helpful to have a run through on what the expectations are with the process and to really understand there’s no right or wrong way of doing it.
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Characteristics of Individuals
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Knowledge & Beliefs about the Intervention
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Belief they already practiced SDM
Understanding of SDM components improved over time
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‘I think most if not all staff were already providing shared decision making’
‘the concept of shared decision-making is probably something I feel we support anyway. We just probably don’t do this in a very formal way.
‘I know for sure that we do already our, sort of own version of shared decision-making if you like, and we do provide options tailored to the individual’
‘I had assumed we were using shared decision-making by asking, but I have learned from that workshop that there’s a few more steps involved’
‘But now I feel that we have a clear understanding of what constitutes shared care decision-making, and I feel that we’re able to implement that, using the language and using the – a small number of the tools’
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Self-efficacy
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Confidence improves with practice
Reinforcement and training assists implementation
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‘[I’m] definitely more confident than when I first started…I guess it’s just practice and familiarity with the tool and getting comfortable with certain questions about it.’
‘I think once we had that interaction more and had that training and discussed what we thought with the resources that we had and all of that, I did feel more confident to implement that’
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Individual Stage of Change
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Sustainability and skills development helped by external SDM-specific supports and site visits
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‘the nurse said, oh, this isn’t going to work for us, then we spoke to [University team member] and it was good, they gave us a good idea, you know, don’t be tied down to what we’ve handed you...it was up to us to decide how we were going to do it, how we were going to implement it’.
‘we wouldn’t have then got to the stage we did without the personal effort ourselves then to fit it with our organisation’
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Individual Identification with Organisation
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N/A
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Other Personal Attributes
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N/A
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Process
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Planning
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Need clear role and responsibility for SDM coordination in team
Ensuring SDM resources always available helps implementation
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‘it was part of our documentation that we would be engaging in that process and as far as we structured our opening spiel that was -we had different written information, we had the resources ready to issue’
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Engaging (Opinion leaders, Formally appointed internal implementation leaders, Champions, External change agents)
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Importance of all team members being involved
Team champion is helpful
Senior medical endorsement perceived as important
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‘some of our team members their professions haven’t been included, so probably [they] won’t feel committed and that might have an effect on the team and working together on the project’
‘it’s the same sort of thing, isn’t it, it’s shared decision-making, we’re being shared in the decision of how to get it going. It just empowers you to get it done’
‘…with the tool, there will be people who don’t feature on it are not going to engage with it because of that reason’
‘I believe that the physiotherapist as the coordinator and lead for the team, has a leadership role and is perhaps the most important’
[The OACCP coordinator] is a champion in this role. If I need any information, I go to her. So I think she is modelling it and reinforcing it, and expressing it. That certainly has a positive impact on the team’
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Executing
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Troubleshooting within the team is helpful
A mechanism for recording SDM in health records helps team
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‘I would note down things like what worked or what didn’t work or if something I didn’t utilise with a patient, the rationale behind why it didn’t work…which helps you track your progress along the way’
‘ working as a team as we do, if we’re having difficulties or anyone is having particular challenges, it’s something we will try and work on or resolve’
‘there was troubleshooting things and working through things...we were probably a little less confident but then as we got to the point of starting and we worked through any concerns we had’
‘there’s no formal mechanism for me to document it in my notes to keep track of…perhaps if I logged it in the notes..’
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Reflecting & Evaluating
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Patient-reported measures would be helpful
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‘I’d be keen to see if it is helpful for the patient and I’d be quite keen to see how that’s measured actually.’
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