Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada
Department of Family Medicine, Université Laval, Québec, Canada
Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
Abstract
Background
Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.
Methods
Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed.
Results
Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from the Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28).
Conclusion
This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.
Background
Shared decision-making (SDM) is defined as a decision making process jointly shared by patients and their health care providers
Population-based and clinically-based surveys have shown that a significant proportion of respondents would like to play an active role in decisions concerning their health
Nonetheless, shared decision-making has not yet been widely adopted by health care professionals
Methods
Search strategy
Covering the period from 1990 to March 2006 and based on a list of 51 key articles in the field of shared decision-making (including a list of 17 studies that dealt with barriers and/or facilitators to implementing shared decision-making in clinical practice), specific search strategies were developed by an information specialist for the following databases: PubMed, Embase, CINHAL, et PsycINFO (see
DOC/Search strategies by data source
Click here for file
Selection criteria
A study was eligible for inclusion in the review if: 1) it was an original collection of data, 2) participants included health professionals, and 3) results included perceived barriers and/or facilitators to shared decision-making. Shared decision-making was defined in an inclusive manner as a joint process between health professionals and patients to make decisions
Study identification and data extraction
One individual (KG) screened all references. Two reviewers (FL and KG) extracted data independently using a data extraction sheet. At the time this review was conducted and to the best of our knowledge, there was no taxonomy for assessing barriers and facilitators to the implementation of shared decision-making in clinical practice. Therefore, a data extraction sheet was created by using a template analytic approach, "beginning with a basic set of codes based on
Taxonomy of barriers and facilitators and their definitions
Knowledge
Lack of awareness
Inability to correctly acknowledge the existence of shared decision-making (SDM) [27]
Lack of familiarity
Inability to correctly answer questions about SDM content, as well as self-reported lack of familiarity [27]
Forgetting
Inadvertently omitting to implement SDM [41]
Attitudes
Lack of agreement with specific components of shared decision-making
• Interpretation of evidence
Not believing that specific elements of SDM are supported by scientific evidence [27]
• Lack of applicability
○ Characteristics of the patient
Lack of agreement with the applicability of SDM to practice population based on the characteristics of the patient [27]
○ Clinical situation
Lack of agreement with the applicability of SDM to practice population based on the clinical situation [27]
• Asking patient about his/her the preferred role in decision-making
Lack of agreement with a specific component of SDM such as asking patients about their preferred role in decision-making [27]
• Asking patient about support or undue pressure
Lack of agreement with a specific component of SDM such as asking patients about support and/or undue pressure [27]
• Asking about values/clarifying values
Lack of agreement with a specific component of SDM such as asking patients about values [27]
• Not cost-beneficial
Perception that there will be increased costs if SDM is implemented [28]
• Lack of confidence in the developers
Lack of confidence in the individuals who are responsible for developing or presenting SDM [27]
Lack of agreement in general
• "Too cookbook" – too rigid to be applicable
Lack of agreement with SDM because it is too artificial [27]
• Challenge to autonomy
Lack of agreement with SDM because it is a threat to professional autonomy [27]
• Biased synthesis
Perception that the authors were biased [27]
• Not practical
Lack of agreement with SDM because it is unclear or impractical to follow [28]
• Total lack of agreement with using the model (not specified why)
Lack of agreement with SDM in general (unspecified) [27]
Lack of expectancy
• Patient's outcome
Perception that performance following the use of SDM will not lead to improved patient outcome [27]
• Health care process
Perception that performance following the use of SDM will not lead to improved health care process [28]
• Feeling expectancy
Perception that performance following the use of SDM will provoke difficult feelings and/or does not take into account existing feelings [28]
Lack of self-efficacy
Belief that one cannot perform SDM [27]
Lack of motivation
Lack of motivation to use SDM or to change one's habits [27]
Behaviour
External barriers
• Factors associated with patient
○ Preferences of patients
Perceived inability to reconcile patient preferences with the use of SDM [27]
• Factors associated with shared decision-making as an innovation
○ Lack of triability
Perception that SDM cannot be experimented with on a limited basis [30]
○ Lack of compatibility:
Perception that SDM is not consistent with one's own approach [30]
○ Complexity
Perception that SDM is difficult to understand and to put into use [30]
○ Lack of observability
Lack of visibility of the results of using SDM [30]
○ Not communicable
Perception that it is not possible to create and share information with one another in order to reach a mutual understanding of SDM [30]
○ Increased uncertainty
Perception that the use of SDM will increase uncertainty (for example, lack of predictability, of structure, of information [30]
○ Not modifiable/way of doing it
Lack of flexibility in the degree to which SDM is not changeable or modifiable by a user in the process of its adoption and implementation [30]
• Factors associated with environmental factors
○ Time pressure
Insufficient time to put SDM into practice [30]
○ Lack of resources
Insufficient materials or staff to put SDM into practice [28]
○ Organizational constraints
Insufficient support from the organization
○ Lack of access to services
Inadequate access to actual or alternative health care services to put SDM into practice [28]
○ Lack of reimbursement
Insufficient reimbursement for putting SDM into practice [28]
○ Perceived increase in malpractice liability
Risk of legal actions is increased if SDM is put into practice [28]
○ Sharing responsibility with Patient*
Using SDM lowers the responsibility of the health professional because it is shared with patient
* Only for the facilitator assessment taxonomy
Both reviewers independently read each publication and identified the unit of text (a sentence or paragraph representing one idea) relevant to each of the main outcomes of interest (barriers or facilitators to the implementation of shared decision-making in clinical practice). Each unit of text was then coded according to the relevant and pre-established code list and entered into an Excel spreadsheet. Units of text which could not be coded were discussed by the two assessors and new codes were created as necessary, thus refining and expanding the preliminary list of codes. Discrepancies between the coders were resolved through iterative discussions. During the coding process, codes (e.g., lack of agreement with the applicability of shared decision-making to practice population based on the age of the patient) were aggregated into themes (e.g., lack of agreement with the applicability of shared decision-making to practice population based on the characteristics of the patient), which in turn were nested under the main theme – lack of agreement with the applicability of shared decision-making. Themes were ordered according to the number of studies in which they were identified.
Quality assessment
Study characteristics were abstracted and included: country of origin, year and language of publication, main objective of the study, operationalization of shared decision-making, use of a conceptual framework to assess barriers and/or facilitators to the implementation of shared decision-making in practice, design of study within which barriers and facilitators were elicited, characteristics of participants, sampling strategy, response rate, and methodological approach, including data collection strategies.
Quality assessment of included studies was based on an existing framework and its set of validated tools
Results
Included studies
From PubMed, Embase, CINHAL, PsycINFO et Dissertation Abstracts, we screened 9580 references and assessed the full text of 170 documents. Thirty one publications
DOC/Number of publications/studies included at the various stages of the review process
Click here for file
Study characteristics
The characteristics of included studies are shown in
DOC/Characteristic of included studies (n = 28)
Click here for file
Only two studies were explicit in their use of a conceptual framework pertaining to the assessment of barriers and/or facilitators to the implementation of best practices in clinical practice
Quality assessment of included studies
Table
Quality assessment of included studies
Qualitative studies
Study identification
Criteria
[60]
[37]
[38]
[39]
[29]
[41]
[43]
[44]
[45]
[51]
[54, 55]
[58]
[59]
[47]
[48]
[49]
[56]
[50]
Question/objective sufficiently described?
2
2
2
2
2
1
2
0
2
2
2
2
1
2
2
2
2
2
Study design evident and appropriate?
2
2
2
2
2
2
2
0
2
2
2
1
1
1
1
2
1
2
Context for the study clear?
2
2
2
2
2
2
2
1
2
1
2
2
2
2
2
2
2
2
Connection to a theoretical framework/wider body of knowledge?
2
2
2
2
2
2
2
0
1
1
2
2
2
1
1
2
2
2
Sampling strategy described, relevant and justified?
1
1
1
1
1
2
1
0
2
2
1
1
1
1
1
2
1
2
Data collection methods clearly described and systematic?
2
2
2
2
2
2
2
0
2
2
2
2
2
2
2
2
1
2
Data analysis clearly described and systematic?
2
2
2
2
2
2
2
0
2
2
2
2
1
2
1
2
0
2
Use of verification procedure(s) to establish credibility?
0
2
2
0
1
0
1
0
1
0
0
0
0
0
0
0
0
0
Conclusions supported by the results?
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
0
2
Reflexivity accounted for?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Total score/possible maximum score
15/20
17/20
17/20
15/20
16/20
15/20
16/20
3/20
16/20
14/20
14/20
14/20
12/20
13/20
12/20
16/20
9/20
16/20
Quantitative studies
Study identification
Criteria
[53]
[33]
[34]
[40]
[11]
[46]
Question/objective sufficiently described?
2
2
2
2
2
2
Study design evident and appropriate?
2
2
2
2
2
2
Method of subject/comparison group selection or source of information/input variables described and appropriate?
1
2
2
1
2
2
Subject (and comparison group, if applicable) characteristics sufficiently described?
2
2
2
2
2
2
If interventional and random allocation was possible, was it described?
N/A
N/A
N/A
N/A
N/A
N/A
If interventional and blinding of investigators was possible, was it reported?
N/A
N/A
N/A
N/A
N/A
N/A
If interventional and blinding of subjects was possible, was it reported?
N/A
N/A
N/A
N/A
N/A
N/A
Outcome and (if applicable) exposure measure(s) well-defined and robust for measurement/misclassification bias? Means of assessment reported?
2
2
2
2
2
2
Sample size appropriate?
N/A
N/A
N/A
N/A
N/A
N/A
Analytic methods described/justified and appropriate?
2
2
2
2
2
2
Some estimate of variance is reported for the main results?
N/A
2
0
2
2
1
Controlled for confounding?
N/A
N/A
N/A
N/A
N/A
N/A
Results reported in sufficient detail?
2
2
2
2
2
2
Conclusions supported by the results?
2
2
2
2
2
2
Total score/possible maximum score
15/16
18/18
16/18
17/18
18/18
17/18
Mixed methods studies
Study identification
[21, 35, 36]
[42]
[57]
[52]
Assessment of the qualitative component of the study
Criteria
Question/objective sufficiently described?
2
2
2
2
Study design evident and appropriate?
2
2
2
2
Context for the study clear?
2
2
2
2
Connection to a theoretical framework/wider body of knowledge?
2
2
2
2
Sampling strategy described, relevant and justified?
1
1
1
1
Data collection methods clearly described and systematic?
2
2
2
2
Data analysis clearly described and systematic?
2
2
2
2
Use of verification procedure(s) to establish credibility?
0
2
0
0
Conclusions supported by the results?
2
2
2
2
Reflexivity of the account?
0
2
0
0
Assessment of the quantitative component of the study
Question/objective sufficiently described?
2
2
2
2
Study design evident and appropriate?
2
2
2
2
Method of subject/comparison group selection
1
2
1
2
Subject (and comparison group, if applicable) characteristics sufficiently described?
2
2
2
2
If interventional and random allocation was possible, was it described?
2
N/A
N/A
N/A
If interventional and blinding of investigators was possible, was it reported?
2
N/A
N/A
N/A
If interventional and blinding of subjects was possible, was it reported?
2
N/A
N/A
N/A
Outcome and (if applicable) exposure measure(s) well-defined and robust for measurement/misclassification bias? Means of assessment reported?
2
2
2
2
Sample size appropriate?
2
N/A
2
N/A
Analytic methods described/justified and appropriate?
2
2
1
N/A
Some estimate of variance is reported for the main results?
2
2
1
N/A
Controlled for confounding?
1
N/A
1
N/A
Results reported in sufficient detail?
2
2
2
2
Conclusions supported by the results?
2
2
2
2
Total score/possible maximum score
41/48
37/38
33/42
29/34
2: Yes
1: Partial
0: No
N/A: Not applicable
Barriers and facilitators
Six publications focused solely on identifying barriers
Perceived barriers and facilitators to implementation of shared decision-making in clinical practice
Factor as a barrier/facilitator
Barriers (number of studies in which this factor was identified as a barrier) [reference number]
Facilitators (number of studies in which this factor was identified as a facilitator) [reference number]
Knowledge
Lack of awareness/awareness
0
0
Lack of familiarity/familiarity
5 [29, 37, 39, 44, 49]
0
Forgetting
1 [41]
Not applicable
Attitude
Lack of agreement with specific components of shared decision-making/agreement with specific components of shared decision-making
• Interpretation of evidence
1 [29]
• Lack of applicability/applicability
○ Characteristics of the patient
12 [21, 29, 34, 37, 41, 43, 47-49, 53-55, 59]
4 [29, 35, 51, 54, 55]
○ Clinical situation
12 [11, 29, 34, 36-38, 47-49, 53-55, 59]
3 [37, 46, 51]
• Asking patient about his/her preferred role in decision-making
7 [11, 38, 40, 42, 43, 50, 59]
2 [42, 50]
• Asking patient about support or undue pressure
0
1 [34]
• Asking about values/clarifying values
0
0
• Not cost-beneficial/Cost-beneficial
3 [21, 29, 45]
1 [42]
• Lack of confidence in the developers/Confidence in the developers
0
1 [29]
Lack of agreement in general/Agreement in general
• "Too cookbook" – too rigid to be applicable
2 [29, 48]
0
• Challenge to autonomy
1 [11]
0
• Biased synthesis
1 [29]
0
• Not practical/Practical
2 [29, 54, 55]
6 [29, 33, 41, 54-57]
• Total lack of agreement with using the model (not specified why)
2 [47, 50]
0
Lack of expectancy/expectancy
• Patient's outcome
1 [33]
10 [33, 34, 37, 42, 46, 50-52, 54-56]
• Process expectancy
1 [56]
11 [11, 29, 33, 34, 36, 41, 42, 50, 51, 54, 55, 57]
• Feeling expectancy
0
1 [34]
Lack of self-efficacy/Self-efficacy
6 [21, 34, 37, 48, 50, 53]
0
Lack of motivation/Motivation
4 [21, 37, 51, 52]
15 [33, 35, 36, 38, 39, 41-44, 47, 49, 51, 52, 54, 55, 57, 58]
Behaviour
External factors
• Factors associated with patient
○ Preferences of patients
9 [21, 39, 41, 42, 45, 47, 48, 52, 54, 55]
4 [34, 39, 42, 52]
• Factors associated with shared decision-making as an innovation
○ Lack of triability/Triability
2 [29, 49]
1 [29]
○ Lack of compatibility/Compatibility:
2 [29, 33]
2 [29, 33]
○ Complexity/Ease of use
3 [21, 29, 45]
2 [29, 56]
○ Lack of observability/Observable
1 [29]
1 [29]
○ Not communicable/Communicable
3 [29, 38, 49]
0
○ Increase uncertainty/Decrease or manage one's own uncertainty
1 [45]
1 [37]
○ Not modifiable/Modifiable
1 [37]
1 [29]
• Factors associated with environmental factors
○ Time pressure/Save time
18 [29, 34-39, 41-43, 47, 48, 50, 51, 53-57, 60]
3 [29, 42, 54, 55]
○ Lack of resources/Resources
4 [35, 47, 50, 53]
1 [50]
○ Organizational constraints/Organizational support
0
0
○ Lack of access to services/Access to services
2 [41, 60]
0
○ Lack of reimbursement/Reimbursement
0
0
○ Perceived increase in malpractice liability/Perceived decrease in malpractice liability
2 [47, 48]
0
○ Sharing responsibility with Patient
Not applicable
3 [37, 42, 51]
In order of frequency, the five most often identified facilitators were: motivation of health professionals (n = 15)
Possible positive impacts on process included: believing that involving patients in decision-making promotes trust and honesty and, in turn, leads to better diagnosis and care
Discussion
In 1999, Frosch and Kaplan observed that there were few surveys of large samples of physicians on how they perceived shared decision-making
Except for "lack of awareness," that is, the inability of health professionals to state that shared decision-making exists, the whole range of barriers initially proposed by Cabana and colleagues (1999) was identified
Lack of agreement with some specific aspects of SDM was the second and third most often cited theme of barriers for implementing shared decision-making in practice. It included the perceived lack of applicability due to the characteristics of patients and the lack of applicability due to the clinical situation. Perceived patient preferences for a decision-making model that does not fit SDM and not agreeing with asking patients about their preferred role in decision making were the fourth and fifth most reported barriers. Taken together, these are important because they suggest that health professionals might be screening
The three most frequently reported facilitators clustered under attitude were: 1) motivation of health professionals to put shared decision-making into practice, 2) their perceptions of patient outcome expectancy (the perception that putting SDM into practice will lead to improved patient outcomes), and 3) process expectancy (the perception that putting SDM into practice will lead to improved health care processes). These results are congruent with the literature on the changing behaviour of health professionals
Other interesting results from this systematic review are as follows. Lack of self-efficacy and lack of familiarity with SDM were mentioned as perceived barriers to the implementation of shared decision-making in six
Notwithstanding its interesting results, our systematic review has some limitations. First, although we searched systematically and thoroughly for articles on perceived barriers and/or facilitators of implementing shared decision-making in clinical practice by health professionals, this is not a well-indexed field of research. Therefore, it is possible that some eligible studies were not included in this review. However, our search strategy had an estimated predictive positive value for key articles in shared decision-making of 10%–20%. Also, we were able to show that some of the barriers and facilitators were quite consistent across a large number of studies. Second, like other researchers
Conclusion
Given that implementation of shared decision-making in clinical practice is a relatively recent phenomenon of interest
These results also can be used to help target priorities for future implementation studies of shared decision-making. For example, future studies on barriers and facilitators to the implementation of SDM could target nurses and pharmacists, two disciplines that have not been well studied but that have had a significant impact on the development of shared decision-making
In this review, the same factor was sometimes identified as both a barrier and a facilitator to implementing shared decision-making. This situation has been reported previously in a study that explored the gap between knowledge and behaviour of physicians
Competing interests
All authors declare that they have no conflicting financial interests.
One of the authors of this review, IG, also is the author of one of the included studies.
Authors' contributions
FL conceived the study, supervised KG's student project, validated the methods, validated the article selection, assessed the quality of the included studies, second-coded all included articles, analysed the results, and wrote the paper. KG selected the articles, assessed the quality of the included studies, first-coded all included articles, analysed the results, and reviewed the paper. IG validated the methods, analysed the results, and participated actively throughout the writing of the paper. FL is its guarantor.
Acknowledgements
We thank Mr. Hugh Glassco for reviewing this manuscript. Dr. Légaré is Tier 2 Canada Research Chair in Implementation of Shared Decision-Making in Primary Care. Dr Ian Graham is Vice-President of Knowledge Translation at Canadian Institute of Health Research.