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Table 2 Barriers to implementation of SDM and BCTs used to address them in the TTT training

From: Ready for SDM: evaluating a train-the-trainer program to facilitate implementation of SDM training in Norway

Beliefs/concerns/attitudes that constitute the barrier Attributed by whom How the barrier affects implementation Relevant BCT to address the barrier Operationalization of BCT in TTT training
Patients do not want to participate in making decisions HCP & trainer Patient involvement is not considered Use of a credible source (9.1) Evidence about patients’ preferences about taking control of their health choices and about HCPs’ flawed assumptions about what patients want are provided in Powerpoint presentation
Information about social and environmental consequences (5.3) The training refers to national and regional policies and ethical guidelines supporting SDM
Providing prompts /cues (7.1) Materials are shared: Patient activation brochure and poster, 6 steps to SDM “pocket reminder cards”
We are already doing SDM HCP & trainer Potential for improvement in patient involvement Use of a credible source (9.1) Evidence is provided on average level of patient involvement by HCPs
Instruction on how to perform the behaviour (4.1) A structure for decision-making that involves patients is suggested using: 6 steps to SDM “pocket reminder cards” and example videos
Feedback on behaviour (2.2) Feedback is provided to a model (HCP presented in a video example)
Demonstration of the behaviour (6.1) The suggested consultation structure, 6 steps to SDM, is demonstrated using video examples
Social comparison (6.2) HCP opinion-leaders are presented using video examples
Trainer feels insufficiently supported by management Trainer HCP – SDM trainings will not lead to behaviour change Provision of/enabling social support (3.1–3) Encouragement to make use of a permanent supervision offer to receive counselling communication on implementation of SDM at the hospital trusts
Information about social and environmental consequences (5.3) The training refers to national and regional policies and ethical guidelines to implement SDM
SDM takes too much time HCP & trainer Patient involvement is not considered or essential elements are omitted Use of a credible source (9.1) Evidence is presented challenging the claim that SDM is too time consuming
Instruction on how to perform the behaviour (4.1)
Demonstration of the behaviour (6.1)
A structure for consultations involving patients is suggested using: 6 steps to SDM “pocket reminder cards” and example videos
Adding objects to the environment (12.5) Trainees are introduced to Patient Decision Aids which have been developed to prepare patients for making health choices
An overarching implementation strategy is absent Trainer Ad hoc trainings might be carried out, but SDM is not implemented in a sustained fashion Provision of/enabling social support (3.1–3) Offer of assistance with implementation at their hospital trust
SDM is not relevant to us HCP & trainer Lack of awareness of preference sensitive decisions. HCPs might make decisions based on guidelines on behalf of the patients Provision of/enabling social support (3.1–3) During the training, the ambassadors are invited to a interprofessional network of SDM trainers and access to the “klarforsamvalg” webpage, hosting learning materials used in trainings is provided
Information about social and environmental consequences (5.3) The training refers to national and regional policies and ethical guidelines supporting SDM
Information about health consequences (5.1) Information is provided about effects of SDM on patient outcomes
Challenging to find the evidence for every medical problem HCP & trainer Decisions are not informed by best available evidence Tailoring (Agbadjé 2020)* Domain-specific decisions are identified using exercises
Criteria for evidence-based patient information are introduced
Adding objects to the environment (12.5) Attention is called to Patient Decision Aids that are freely available on various health platforms
SDM is only about the doctors and their patients HCP & trainer Patient involvement might happen in isolated events (eg consultations), but is not implemented as a team culture Tailoring (Agbadjé 2020) *
Problem solving (1.1)
Exercises and group discussion are used to draft solutions to interprofessional role distribution regarding typical domain-specific decision scenarios
Instruction on how to perform the behaviour (4.1) Nurse-led decision coaching is presented using a sequence of PP slides as an example for interprofessional SDM
Information about social and environmental consequences (5.3) Emphasis is given to virtues of interprofessional cooperation: confidence, respect, appreciation, sharing competences
Restructuring the social environment (12.2) Advice to restructure information flow and interprofessional collaboration to promote patient involvement
Patients do not understand this information HCP & trainer HCP avoid providing evidence-based information Use of a credible source (9.1) Evidence is presented about patients’ ability to process evidence-based information
Instruction on how to perform the behaviour (4.1) The criteria for evidence-based patient information are introduced and reference is made to the guideline evidence-based health information
Adding objects to the environment (12.5) The trainers’ attention is called to tools and methods of risk communication
The trainer lacks opportunities to deliver the training Trainer SDM INTERPROF will not be implemented Adding objects to the environment (12.5) Trainers are equipped by materials for distribution and information to leaders
Guidance of action planning (1.4) Opportunities are provided in structured exercises to make plans on by whom, where and when SDM trainings will be carried out
Ambassador does not feel sufficiently confident as a trainer Trainer SDM training is not effective or does not comply with Ready for SDM Provision of/enabling social support (3.1–3) A didactic model for planning the training is provided and assistance offered to conduct SDM trainings locally
Guidance of action planning (1.4) Opportunities are provided in structured exercises to make plans about where and when SDM trainings will be carried out and by whom
  1. Examples of barriers trainers or health care providers (HCP) meet when trying to implement SDM (shared decision making) and use of behavior change techniques (BCT) to address these barriers in the training. The generic techniques to meet barriers (acknowledging, rephrasing, information, argument and cognitive restructuring), are not specified in this table. Numbers added in brackets refer the Michie’s BCT taxonomy (2013) or additional BCTs proposed by Abadje et al.*