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Table 3 Level of agreement with statement and % of HCPs deeming the factor essential for the implementation of SDM in stroke care

From: Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey

STATEMENT Entirely disagree
(% HCPs)
(% HCPs)
(% HCPs)
(% HCPs)
Entirely agree
(% HCPs)
Average level of
agreement (% HCPs)
Essential implementation factorHCP recommendations
No 12345 % 
The care provider and the preconditions regarding the organisation
 Strong agreement (≥ 4.0) & essential for SDM implementation (≥ 75%)
8If SDM is to be implemented properly, all the healthcare professionals involved must be trained in it.071353274.080• e-learning
• in-company training
• regional training (a meeting place)
• use of tools for making choices
5To promote the implementation of SDM, the “preferences, wishes and worries” of the patients must always be covered when discussing the follow-up treatment at the multidisciplinary meeting.003320474.180• a broad approach, not only stroke
• good preparation for the multidisciplinary meeting: fixed point of contact to request preferences
• in a knowledge broker project
 Less strong agreement (<  4.0), however essential for SDM implementation (≥ 75%)
2I need to convince my colleagues that SDM has added value. Quote: “If you can show a few examples, it’ll help me get my colleagues on board.”07137373.880• collect examples/case studies
• in-company training
• in an electronic medical record
6Secondary healthcare professionals find it difficult to get a clear picture of the quality and content of what is available for stroke patients in primary care. Who has the expertise? What care is provided, exactly? What are the potential pros and cons for the patient?727273373.180• ‘work charts’ with the care options
• overview of the expertise available within the care chain (social map)
 Strong agreement (≥ 4.0), however less essential
12Listening to an audio recording of a consultation lets me reflect upon how I conduct my conversations for SDM and improve it.001353334.260• in training
1I need to agree with my colleagues who is doing what in the SDM process.072040334.067• discuss the division of roles for SDM
• create ‘work charts’ in the care chain meeting or other meetings
• reporting
• peer review
 Less strong agreement (<  4.0) and less essential (<  75%)
7In SDM, transfer to another care provider must also include communication about going through the SDM process and its results.071360203.973• digital decision-making tools
9SDM means that you as the care organisation provide less care that is unnecessary or redundant. Quote: “If the patient has made the right choice, they’re much more likely to stick to the therapy, so we have fewer no-shows.”003347203.960• added value of SDM in the media
• in quality standards
• explanation of ‘time investment’
• encouragement via health insurers
4If SDM is to be implemented properly as the patient’s care progresses, all the healthcare professionals involved must be trained in it.00276773.873• reflection with healthcare professionals
• setting up decision-making tools
• via the professionals
16If the patient chooses an option that I think is less good, I will still assist them. I think it is important to give the patients room. Quote: “Someone can make what I think is the ‘wrong’ decision, but still be perfectly happy with it.”772033333.873• state in the electronic medical records
13For the implementation of SDM, I need to reflect regularly with my colleagues on how we conduct consultations.073347133.760• in peer review
11An internal ambassador is needed for implementing SDM in my organisation.7132040203.553• implementation on a project basis
10For SDM in the stroke care chain, the healthcare professionals have to know each other personally. Quote: “If you know who you are referring people to, it all goes much more smoothly.”013404073.440• joint training or meetings
• make agreements in regional networks
3My colleagues assume incorrectly that they are already using SDM: they are ‘unconsciously incompetent’.713473303.153• put on the media’s agenda
• use role models
• reflect upon specific cases together
14It is taking me longer than I thought to implement SDM in practice.713472773.147• explanation of time
17Stroke patients sometimes have a limited picture of their condition. If they make a ‘wrong’ decision, I’ll try to block it. That’s my responsibility as a care provider.1320333302.973• communicate better
• good explanations for patients and their relatives
• involve the relatives
18My colleagues don’t have enough time to implement SDM properly in their practices.1320402072.940• raise the issue if necessary with health insurers
15I think that I don’t have enough time to implement SDM properly in my practice.2720331372.527• good planning
• making the roles clear
System-related factors
 Strong agreement (≥ 4.0) & essential for SDM implementation (≥ 75%)
19For the further implementation of SDM, healthcare professionals need to make time free to practice and apply SDM.002060204.080• start-up an internal improvement project
• arrange it throughout the organisation
• on-the-job coaching
 Less strong agreement (<  4.0), however essential for SDM implementation (≥ 75%)
26The management must create the conditions for the staff to be able to learn SDM and implement it more broadly.071457213.986• in the organisation’s mission
• in regular meetings
• appoint an ambassador
• facilitate training and time for exercises
• demonstrate the added value to staff
 Statement of low concern; low level of agreement/disagreement of HCPs and non-essential (≤ 2.0 and/or ≤ 25%)
21The new privacy rules are obstructing SDM because they limit the options for exchanging information.215029002.114• patient/relative as the data manager
24The care funding model means that healthcare professionals feel forced to be creative with the remuneration rules for SDM. For example, formulating an extra goal because a treatment in the rehabilitation centre would otherwise have to be discontinued. Or formulating an indication for taxi transport differently so that it will be remunerated.2121361472.614 
22The culture in my organisation is obstructing the implementation of SDM. Quote: “… because there is in fact a culture of ‘it’s my way or the highway’.”214336002.121• training
25High staff turnover of the healthcare professionals I work with is obstructing my efforts to apply SDM.214336002.121• good agreements
• work using the same methods
20Documenting the process of SDM in the electronic health records lets you account for any deviations from a care protocol.072733333.953• make agreements
23Care insurers must also shoulder their share of the responsibility for implementing SDM. They can for instance take a look at their purchasing processes to see what factors inhibit and encourage SDM in the stroke care chain.7212129213.436• in discussions with health insurers
27Patients who are discharged from the rehabilitation centre to primary care are incorrectly restricted in their freedom to choose ‘care closer to home’ by the funding system.140641473.029• social maps/work charts
• avoid incorrect bed occupancy
SDM as innovation
 Strong agreement (≥ 4.0) & essential for SDM implementation (≥ 75%)
33If I am to apply SDM, it is important that I use understandable language.70729574.379• be aware of the jargon
• insights into health skills
• treatment plan and decision-making tools in understandable language for the patient/relative
• learn to communicate and practice it
• use teach-back methods
34If I am to apply SDM, it is important to use teach-back methods.07757294.179• awareness
• in training
38SDM makes the intrinsic motivations of the patient clearer.07757294.186• take time
 Less strong agreement (<  4.0), however essential for SDM implementation (≥ 75%)
31I think presenting the explanation of the treatment options neutrally is complex if I do not think they are fully equivalent.73643772.786• strength of your own expertise
• acceptance of other choices
• transparency about the evidence
• simple working charts showing the features instead of the pros and cons
• practice, get feedback, listen to recordings of conversations, reflection
 Strong agreement (≥ 4.0), however less essential
28The core of SDM is allowing the treatment to focus on the patient’s objectives more. Quote: “If you’ve got a clear picture of what the patient wants, you have a better idea of what possible treatments there are.”001464214.164• embed in the RAPP methodology
• in training: learn to set objectives
• listen properly to the patient
 Statement of low concern; low level of agreement/disagreement of HCPs and non-essential (≤ 2.0 and/or ≤ 25%)
30I find it difficult to discuss the role the patient can take in the SDM process with them. Quote: “I don’t yet really know how I can discuss the role the patient can take or would like to take with them.”433621001.850• training (on the job)
• open attitude towards the patient
39SDM is not a new method – we were doing it implicitly anyway; there is just a theoretical framework for it now.014572173.221• awareness of the paternalistic method
• self-reflection
• quality of life as the starting point instead of the limitations
37SDM leads to improved therapy compliance. “If this means a patient gets special shoes made, they’re really going to wear them.”073636213.757• express the message (increased therapy compliance and explanation of the alternatives)
• be aware of changes that the patients themselves show – let them take more actions themselves for trying out the options, etc.
35SDM makes the discussion is more pleasant.005029213.757 
40Applying SDM is turning out to be more awkward than I thought in the first instance. Now that I’m aware of what I’m doing, I can see that I’m not always applying all five steps properly. I’ve become ‘consciously incompetent’.0144329143.457• in training
36SDM seems to cost a lot more time, but I have not needed any extra consultations for taking decisions together with the patient.14212921143.050• express the message
• agree within the team who will work out the details of the options. Preliminary work done by the contact
32SDM is costing me too much time. Quote: “You really do have to sit down properly with the patient for it. It takes a lot of time.”212143772.657• explanation of time (therapy compliance)
• the management provides room
29You have to learn the points in the care process for an individual patient at which you should use SDM. Quote: “SDM is tricky in practice: what situations are there where a decision could depend on preferences?”142943772.657• awareness
• training and reflection
Factors related to the patient and their relatives
 Strong agreement (≥ 4.0) & essential for SDM implementation (≥ 75%)
49A stroke patient’s relatives play a major role in SDM.072136364.079• always involve the relatives
• evenings for informal caregivers
 Statement of low concern; low level of agreement/disagreement of HCPs and non-essential (≤ 2.0 and/or ≤ 25%)
45Stroke patients don’t want to be involved in the decision because they don’t want to take any responsibility.64029701.829• a principle for care
41The acute phase of stroke care is not really suitable for SDM.1436212172.721• see what is possible for each situation
43The implementation of SDM must in fact also be driven by the patients and their relatives (bottom up). They must ask for SDM from the healthcare professionals. For instance, the patient or relatives must spontaneously ask the care provider about other options and the pros and cons of those options, or they must state their own values so that a good decision can be made.072150213.957• via patients’ organisations
• use decision-making tools
• information about SDM
50SDM puts the lives of patients more at the centre.003636293.950• focus on the quality of life
48In the chronic phase, almost all stroke patients can help decide about the care.703621363.850• informal caregiving is always a possibility
42SDM is difficult if I have doubts about the mental competence of the patient.7142129293.643• involve a relative
• peer review
51The implementation of SDM must in fact also be driven by the patients and their relatives. They must explicitly start choosing care organisations or care professionals who provide scope for SDM.0144329143.443• pay attention in the media
44I think it is easy to estimate what role the patient will be able to take in SDM throughout the recovery process. Quote: “Sometimes it starts with very small choices: do you want a raspberry drink or a lemon drink... you can get the patient used to taking decisions again.”1472929213.436• be aware that the patient can always have a different role in SDM
• let people take control as much as possible
47Stroke patients are inhibited by their brain damage: cognitive problems mean that they can’t assist in decision-making.291450702.457• keep looking for the possibilities for each patient
• involve the relatives
46Stroke patients don’t want to join in the decision-making because they think the healthcare professionals – such as me – know what’s best.4314291402.136• a care provider must support the patient in this regard