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Implementation Science volume 16Article number: 74 Cite this article. Metrics details. 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 Literature review shared services 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 literature review shared services their treating clinicians may add insights into the implementation of SDM, literature review shared services. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives. 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.
Titles and abstracts of articles were screened and were reviewed in full text. Fourteen articles met inclusion criteria. A wide range of barriers and facilitators across individual, organisational, and system levels were reported, literature review shared services. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations.
SDM implementation research in hospital settings appears to be literature review shared services 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.
Peer Review reports. Research has shown involving patients in their healthcare using Shared Decision Making SDM in routine practice remains slow. The current study is the first qualitative systematic review of the barriers and facilitators to SDM implementation in hospital settings, and from the perspective of multiple stakeholders including patients, clinicians, health services administrators, health service decision makers, literature review shared services, government policy makers, and researchers.
The review findings add to previous SDM reviews by highlighting factors influencing SDM that are specific to tertiary care settings and reporting on the few studies that have incorporated perspectives of stakeholders beyond the patient and clinician.
SDM involves a two-way exchange between the patient, who provides insight into their goals, values and preferences, and the clinician, who outlines the benefits, risks, and uncertainties of various care options based upon their experience and knowledge of the best available research evidence and recommendations [ 3 ].
SDM is underpinned by the practice of patient-centred care and the ethical belief that decisions should be made with patients instead of for them [ 4 ]. SDM is best suited to situations in which there is a clear need for a decision to be made, there is equipoise between care options, and it is feasible to engage in SDM conversations [ 5 ].
The SDM process can be modified to suit the context in which the decision is being made, and those involved may choose to take varying levels of responsibility for the decision literature review shared services 56 ], literature review shared services. Including patients in decisions about their health care has long been seen as an ethical imperative [ 5 ], literature review shared services.
PCC and the inclusion of patients in decisions have been shown to increase patient engagement and satisfaction [ 8 ], decrease unwanted health service variation [ 9 ], and improve outcomes for disadvantaged patients [ 10 ]. Yet, despite increased focus from both policy and research, sharing healthcare decisions with patients is not yet part of routine literature review shared services practice [ 111213 ]. Systematic reviews of barriers and facilitators of SDM were conducted in [ 14 ], [ 15 ], and [ 16 ], focusing on clinicians, patients, and paediatric care respectively.
The present review builds on this work in several substantive ways. First, prior research has focused mostly on barriers and facilitators faced by patients and clinicians [ 13171819 ]. SDM implementation, however, involves multiple stakeholders in healthcare systems. Stakeholders such as those working in health service administration or decision-making, government policy makers, literature review shared services, and researchers may have insights not yet explored by research focusing on the patient-clinician dyad.
A recent scoping review of organisational and systemic barriers and facilitators to SDM found a broad range that both drive and inhibit SDM implementation such as organisational culture and system-level guidelines and policies [ 13 ].
The present review contributes to the literature by exploring SDM barriers and facilitators from multiple stakeholder perspectives [ 2021 ]. Second, prior reviews have focused on SDM in primary and secondary care settings [ 22 ]. Primary care is usually the first point of healthcare contact and can include general practice, community health, or allied health services. Secondary care is defined as specialist care that patients are referred to by their primary care clinician and may include out-patient care or care in the community [ 23 ].
Primary and secondary care contexts i. specific appointment times and time between appointments are obvious settings to conduct SDM. Compared to primary and secondary care, little literature review shared services known about SDM in tertiary-care settings.
Tertiary care involves medical or surgical treatment for patients, including emergency care, and usually over an extended period of time as an inpatient [ 2324 ]. However, this presents challenges for SDM.
Patients are likely to be more acutely sick and there may be increased time pressures to make decisions. Furthermore, staff workflows are also variable compared with primary and secondary settings, with changing shifts, busy ward environments, and more disruptions. The present research fills this gap by exploring SDM barriers and facilitators in tertiary care.
Lastly, the last decade has seen an exponential growth in SDM research [ 25 ]. As such, this review aims to build on previous reviews by synthesising new research within the exponentially growing field. Given the numerous stakeholders involved in SDM in hospital settings, it is important to consider the barriers and facilitators from multiple stakeholder perspectives [ 2021 ] and also consider the impact of hospital settings to optimise implementation [ 26 ].
Therefore, the aim of this systematic review was to synthesise evidence on the barriers and facilitators to the implementation of SDM interventions in tertiary care from the perspective of multiple stakeholders. The review approach was based on the Cochrane Qualitative and Implementation Methods Group and Handbook for Systematic Reviews [ 27 ], and reported in line with the PRISMA literature review shared services [ 28 ].
Furthermore, experts were consulted prior to the review to ensure the relevance of the review for research and industry, literature review shared services.
These experts were especially interested in exploring the perspectives outside the patient-clinician dyad and how hospital settings may influence how SDM is implemented, literature review shared services. The search strategy, designed in consultation with a speciality university-based librarian with subject matter expertise, aimed to include articles for which barriers and facilitators to implementing SDM in hospital settings were the primary focus and qualitatively reported.
The MEDLINE, EMBASE, PsychINFO, CINAHL, Cochrane Library, and Scopus databases were searched for English language articles from January to July Reference lists of included studies were screened to identify additional eligible studies. The review used the SPIDER framework to frame inclusion and exclusion criteria Table 1, literature review shared services.
The SPIDER framework is a modified version of PICO adapted for use with qualitative studies [ 29 ]. Where studies included both hospital inpatients and outpatients, only studies where more than half of participants were involved in decisions during their stay in hospital i.
while in emergency or as an inpatient were included. Studies were excluded where barriers and facilitators to SDM were not the primary focus, for example literature review shared services studies of the impact of SDM on outcomes. Studies were excluded if the majority of results were not qualitative as qualitative data is best suited to in-depth exploration of barriers and facilitators to SDM. The study selection process followed the PRISMA Checklist for reporting systematic reviews [ 28 ] Fig.
Studies were uploaded to a purpose-built screening platform, Covidence [ 30 ]. After duplicates were removed, two reviewers AW and AL independently screened the title and abstracts of included articles, literature review shared services. When reviewers disagreed, they discussed the articles until a conclusion was reached.
When a conclusion could not be reached, a third reviewer PB adjudicated. The same process was used for full-text review. Reasons for excluding articles are reported in Fig. The methodological quality of included studies was assessed based on the Critical Appraisal Skills Programme CASP quality assessment tool for qualitative studies [ 3132 ] Additional File 3.
The CASP tool asks researchers to assess the usefulness of the articles for inclusion and to identify any methodological issues. CERQual is a novel approach to systematically assessing confidence in review findings using methodological limitations, coherence, adequacy, and relevance [ 34literature review shared services, 3536373839 ]. Analysis involved two phases.
The BFFS allows for synthesis literature review shared services be based on a previous published model. Therefore, previously published taxonomies of barriers and facilitators to SDM for patients and clinicians [ 1415 ] were used as a basis for data synthesis. These were amended through inductive coding to include barriers and facilitators for government policy makers and health services. In the second phase, the codes identified in phase one were coded to literature review shared services Theoretical Domains Framework TDF [ 43 ].
The TDF [ 43 ] was identified as the most appropriate analysis framework as this enabled affective, cognitive, social, and environmental factors influencing behaviour to be explored [ 26 ]. Mapping barriers and facilitators to the TDF for multiple stakeholders can highlight areas in which factors align. This may allow future implementation programmes to address multiple factors for multiple stakeholders. Of records, were screened for inclusion based on title and abstract Fig.
Of these, were further screened based on the full text. A review of reference lists of relevant systematic reviews did not identify any additional studies for inclusion. PRISMA diagram. Included articles used qualitative study designs, with the majority using interviews [ 44464748505152555657 ], followed by focus groups [ 44465154 ], observation [ 4953 ], literature review shared services, and conference breakout session [ 45 ].
Seven countries were represented across the included articles including the USA [ 454748555657 ], Canada [ 444957 ], Germany [ 5354 ], The Netherlands [ 46 ], Australia [ 50 ], UK [ 51 ], and France [ 57 ] Additional File 2. Of the included articles, literature review shared services majority focused on emergency department settings [ 4547485556 ] and acute mental health settings [ 505154 ], with other settings including cardiology [ 5257 ], oncology [ 53 ], stroke rehabilitation [ 44 ], and acute monitoring [ 49 ].
There were 11 authors for 14 articles, with four separate articles by Schoenfeld included [ 47485556 ]. These articles also represented the majority of articles included regarding SDM in the emergency department. A wide range of barriers and facilitators across individual, organisational, and system literature review shared services were reported with many overlapping across the TDF.
Reported barriers and facilitators to SDM in inpatient settings ranged across all 14 domains of the TDF [ 43 ] Table 2with the majority relating to clinician-related factors, followed by patient-related factors, organisation-related factors, system-related factors, and finally other stakeholder-related factors. Of the Health Care Provider clinicians perspectives included, the majority were medical doctors [ 4445464850515253545556 literature review shared services, 57 ], literature review shared services, followed by nurses [ 49505157 ] and other allied health professionals [ 505157 ].
Only four studies included the perspectives of stakeholders other than the patient-clinician dyad, such as health service programme administrators [ 44454657 ], literature review shared services, health service decision makers [ 454657 ], government policy makers [ 4657 ], and other stakeholders such as researchers [ 454657 ].
Four studies reported on barriers and facilitators in the context of implementing specific SDM programmes. Overall, study quality was high with the majority of studies clearly stating the aims of the research and using appropriate research design, recruitment, and data collection to answer the literature review shared services. Furthermore, ethical issues were taken into consideration, and data analysis and statement of findings were clear.
Some studies did not adequately report on the relationship between researcher and participants [ 45literature review shared services, 49515354 ]. Two studies were of low quality [ 4549 ], as they did not adequately report their research design or data collection. Additionally, their data analysis and findings were not clear as they did not attribute findings to participants or make clear how conclusions were drawn from the data.
Table 3Table 4Table 5and Table 6 present findings, including confidence in the evidence based on GRADE-CERQual for clinicians, patients, and other stakeholders respectively.
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