Study design and context
We conducted an observational study design with quantitative methods. The workshop was held at Tabriz University of Medical Sciences, East Azerbaijan, Tabriz, Iran in December 2016. Using email and text messages, we invited a purposeful sample of healthcare professionals, including trainees (n = 60) affiliated with the Tabriz University of Medical Sciences. No limitations were defined for age, ethnicity, gender, or years of clinical experience. The workshop was held in a conference room equipped with audio-visual technology. Ethical approval for the research component of the intervention was granted by Tabriz University of Medical Sciences, and prior to the workshop, all participants signed an informed consent form. This paper is written according to the reporting guideline for group-based behavior-change interventions [17] which was designed for behavior interventions, like ours, that are delivered by at least one facilitator to at least three participants (Additional file 1).
The workshop: continuing professional educational intervention on SDM
The SDM workshop was a half day, designed to be interactive and adapted to Iranian cultural context. We validated it by both Iranians and Canadians who were experts in SDM, continuing professional development, knowledge translation, and implementation science.
Workshop implementation
The interactive workshop was held at the Tabriz University of Medical Sciences, East Azerbaijan, Tabriz, Iran (December 22, 2016). It was facilitated by the first author (SAR), who has expertise in SDM, and coordinated by two healthcare professionals from Tabriz University of Medical Sciences (AS, AMN). Neither the coordinators nor the facilitator had any previous relationships with the participants. The duration of the workshop designed to be 4 h, including a 15-min break. The content of the workshop had three foci: (1) overall concept of SDM, (2) SDM tools, and (3) measurement of SDM. It was delivered using an interactive combination of lectures individual and group activities (Fig. 1). For the lectures, instructional materials were PowerPoint slides and illustrative videos. For the activities, handouts were provided, namely a patient decision aid on prenatal screening for Down Syndrome [18], the International Patient Decision Aids Standards (IPDAS) checklist (for use in individual and group activities) [19].
The workshop was structured as follows. First, participants completed the sociodemographic questions and a questionnaire to evaluate their knowledge about SDM and intention to use it in clinical practice. Second, the overall concept of SDM (focus 1) was presented. Third, participants watched two videos that illustrated the behaviour (performing SDM in two clinical contexts). The first showed an orthopedic surgical patient who was using an SDM process to make a decision about knee replacement surgery [20], and explaining his experience. The second video showed two simulated consecutive prenatal follow-up consultations during which a pregnant woman, her partner, and a healthcare professional used a PtDA about Down Syndrome prenatal screening [21, 22]. Other studies which, similarly, applied vignettes for explaining SDM, showed that healthcare professionals’ knowledge and intention to engage in SDM has increased [23]. Fourth, participants completed a questionnaire evaluating the 12 domains of TDF. Fifth, SDM measurement was presented. Sixth, participants were asked to individually evaluate a patient decision aid for prenatal screening using IPDAS checklist.
Seventh, participants were randomly divided into groups of three to six people. Participants were asked to either remember or imagine a situation in which they could practice SDM in their clinical setting and discuss it in their groups with guidance from the questions on the group activity handout. These questions were: When and where could you use SDM in your clinical setting? What are the potential advantages and disadvantages of practicing SDM in this situation? How could SDM practices be facilitated in your clinical setting? What are the barriers?
Data collection
For data collection, at the beginning of the workshop, we used a sociodemographic questionnaire and a self-report questionnaire to assess their familiarity with SDM. Then we used a questionnaire based on the Theoretical Domains Framework (questionnaire 1). This framework is composed of 12 theoretical domains relevant to behavior change [24]: 1) knowledge, 2) skills, 3) social/professional role and identity (self-standards), 4) beliefs about capabilities (self-efficacy), 5) beliefs about consequences (Anticipated outcomes/attitude), 6) motivation and goals (intention), 7) memory and attention, 8) environmental context and resources (environmental constraints), 9) social influences (norms), 10) emotion 11) behavioral regulation, and 12) nature of the behaviors. We defined behavior as follows: performing SDM (action) among Iranian health professionals (target) in any clinical setting (context).
During the workshop activities, participants also responded a questionnaire about their perceived facilitators and barriers of implementing SDM in their clinical practice (questionnaire 2). The workshop concluded with participants completing two questionnaires i.e., continuous professional development (CPD) reaction questionnaire (questionnaire 3), and workshop evaluation questionnaire. The first, adapted from previous work in the field, assessed the impact of the workshop, i.e. to evaluate whether healthcare professionals were likely to implement what they learned [25]. This questionnaire is based on constructs (i.e. intention, social influences, beliefs about capabilities, moral norm, and beliefs about consequences) [25] and scored on a 7-point Likert scale, except for one question which is scored on a 5-point percentage scale. The second, evaluated the content, design, instructor, and results of the workshop via nine questions scored on a 5-point Likert scale. This questionnaire included space for participants to provide suggestions to help us further improve the workshop. Figure 1 shows the detailed steps of the workshop and questionnaires.
Data analysis
All analyses were performed using R version 3.4.3. We first calculated descriptive statistics on the participants’ responses. We used the mean with standard deviation for continuous and ordinal variables (age, experience, theoretical domains, and workshop evaluation questions) and frequency with percentage for categorical variables (gender, type of healthcare professional, prior knowledge about SDM, facilitators and barriers). Then we performed multiple linear regression of the healthcare professionals’ intention on the psychological constructs together in the same model. This allowed us to estimate the influence of each construct on intention to use SDM while adjusting for the other constructs. The data related to the facilitators and barriers were coded by two researchers, and their frequency and percentage were calculated.