Contributions to the literature
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Both surgeons and patients, regardless of conversation aid used and socioeconomic status, recommended the early-stage breast cancer conversation aids be used in future breast cancer care.
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Tailoring the use of conversation aids to existing clinical workflows, flexibility of use, and taking into account patient characteristics and preferences, like health literacy, can facilitate sustained implementation.
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Normalization Process Theory (originally focused on health professionals’ perspectives) can also feasibly be used to analyze the patient perspective about the sustainable implementation of conversation aids into diverse practices.
Introduction
Methods
Interventions
Setting and participants
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All participating surgeons after trial involvement (n = 16). Prior to starting the trial, all surgeons underwent training that included information about the trial protocol, shared decision-making, and communication skills. Training for surgeons in intervention arms included videos and role plays on how to use their assigned conversation aid and when (during the surgical consultation). Surgeons in intervention arms were also provided feedback on their use of the conversation aid throughout the trial period, during scheduled supervision visits. As decided by the parent trial team (including patient partners), we included usual care surgeons to understand their experience in the trial and gauge their interest in using the conversation aids once the trial was over.
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A purposive sample of trial patient participants in intervention arms who agreed to be contacted for a 3-month post-operative interview. Family of invited patient participants were allowed to join the patient’s interview if they were involved when the intervention was used. Please see the parent trial protocol for participant inclusion criteria [35].
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Clinical and non-clinical stakeholders, including nurse practitioners, nurses, physician assistants, social workers, administrators, and electronic health record (EHR) specialists. Most interviewed clinical stakeholders and one non-clinical stakeholder were part of integrating the trial activities in the clinics where they worked. Some non-clinical stakeholders, in administration, provided initial support for the conversation aids’ use.
Theoretical framework and interview guides
Procedure
Patient interviews
Surgeon and stakeholder interviews
Observations and field notes
Data management and analysis
Data management
Analysis
Construct component | Surgeon and stakeholder definition | Patient definition |
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Coherence — What is the work? | ||
Differentiation | I can see how the Option Grid/Picture Option Grid differs from usual ways of working. | The Option Grid/Picture Option Grid seemed different/didnʼt seem different from other tools/things I’ve received since my diagnosis. |
Communal specification | Staff in this organization have a shared understanding of the purpose of this Option Grid/Picture Option Grid. | No codes came from this component. |
Individual specification | I understand how the Option Grid/Picture Option Grid affects the nature of my own work. | I understand how the Option Grid/Picture Option Grid affected the nature of my appointment with my surgeon. |
Internalization | I can see the potential value of the Option Grid/Picture Option Grid for my work. | I'd recommend that other patients use this tool. |
Cognitive participation — Who does the work? | ||
Initiation | There are key people who drive the Option Grid/Picture Option Grid forward and get others involved. | No codes came from this component. |
Legitimation | How likely I am to recommend the tool to another health professional. | How likely I am to recommend the tool to a friend or family member. |
Enrollment | I'm open to working with colleagues in new ways to use the Option Grid/Picture Option Grid. | How I hypothetically would like to receive the tool. |
Activation | I will continue to support the Option Grid/Picture Option Grid. | I will continue to support the Option Grid/Picture Option Grid. |
Collective action — How does the work get done? | ||
Interactional workability | I can easily integrate the Option Grid/Picture Option Grid into my existing work. | The Option Grid/Picture Option Grid was/was not well integrated into my visit with the surgeon. It seemed like the Option Grid/Picture Option Grid was a usual part of the appointment with my surgeon. |
Relational integration | The Option Grid/Picture Option Grid disrupts working relationships. I have the confidence in other people's ability to use the Option Grid/Picture Option Grid. | No codes came from this component. |
Skill set workability | Work is assigned to those with skills appropriate to the Option Grid/Picture Option Grid. Sufficient training is provided to enable staff to use the Option Grid/Picture Option Grid. | Work is assigned to those with skills appropriate to the Option Grid/Picture Option Grid. |
Contextual integration | Sufficient resources are available to support the Option Grid/Picture Option Grid. Management adequately supports the Option Grid/Picture Option Grid. | No codes came from this component. |
Reflexive monitoring — How is the work understood? | ||
Systemization | I am aware of reports about the effects of the Option Grid/Picture Option Grid on outcomes and workflows. | I understand how the Option Grid/Picture Option Grid affected me and my decision I had to make. |
Communal appraisal | The staff agree that the Option Grid/Picture Option Grid is worthwhile. | No codes came from this component. |
Individual appraisal | I value the effects the Option Grid/Picture Option Grid has had on my work. | I understand the effect the Option Grid/Picture Option Grid had on my surgeon's work. |
Reconfiguration | Feedback about how the Option Grid/Picture Option Grid can be used to improve it in the future. I can modify how I work with the Option Grid/Picture Option Grid. | Feedback about how the Option Grid/Picture Option Grid can be used to improve it in the future. |
Results
Participant characteristics
Patients
Characteristic | Interviewed (n = 43) | Declined interview (n = 33) | p-value* |
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Age, mean (SD) | 56.6 (12.0) | 62.4 (13.7) | 0.05 |
Race/ethnicity, n (%) | 0.04 | ||
Black, non-Hispanic | 10 (23) | 8 (24) | |
Hispanic | 2 (5) | 9 (27) | |
Asian | 3 (7) | 1 (3) | |
White, non-Hispanic | 28 (65) | 15 (45) | |
Primary language, n (%) | 0.01 | ||
English | 41 (95) | 24 (73) | |
Spanish | 1 (2) | 8 (24) | |
Mandarin | 1 (2) | 1 (3) | |
Education, n (%) | 0.03 | ||
Never attended high school | 1 (2) | 3 (9) | |
Some high school | 0 (0) | 6 (18) | |
High school diploma (or equivalent) | 11 (26) | 6 (18) | |
Some college | 9 (21) | 5 (15) | |
2-year degree | 6 (14) | 6 (18) | |
4-year degree or higher | 16 (37) | 7 (21) | |
SES, n (%)** | 0.01 | ||
Higher SES | 32 (74) | 15 (45) | |
Lower SES | 11 (26) | 18 (55) |
Surgeons and stakeholders
Characteristic | |
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Arm, n (%) | |
Option Grid | 5 (31%) |
Picture Option Grid | 6 (38%) |
Usual Care | 5 (31%) |
Female sex, n (%) | 13 (81%) |
Years since graduating medical school, m (range) | 23 years (10-44) |
Years at current site, m (range) | 10 (< 1 to 30) |
Interest in SDM before trial | 16 (100%) |
Setting and interview characteristics
Major themes according to NPT construct
NPT construct | Major themes |
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Coherence | Patients thought the Option Grids were easier to understand and more concise than other breast cancer materials. Using the Option Grids felt like usual care for surgeons. |
Cognitive participation | Patients and surgeons recommended using Option Grids and were open to receiving and using them in various ways. |
Collective action | Surgeons (after a few uses) and patients perceived the Option Grids were a part of a normal work routine. |
Reflexive monitoring | Surgeons did not feel the Option Grids increased their consultation time. |
Major themes related to coherence — “What is the work?”
“It was more concise. Other materials I received, you had to read through a whole bunch of things before you could get to the end and decide." — Patient, Option Grid, Lower SES
When you're sitting there and actually showing them the picture and they can visualize what you're telling them, it does help, especially in our patient population where they don't necessarily understand everything we are saying to them. — Clinical stakeholder
Major themes related to cognitive participation — “Who does the work?”
I would give it to me on paper, but I would also send it to my email - it doesn’t have to be one way. It could be two ways, it could be three ways. — Patient, Picture Option Grid, Higher SES
I think having something beforehand, even if it’s just a heads-up, would be helpful. — Surgeon, Option Grid
Major themes related to collective action — “How does the work get done?”
...because it flowed into our appointment so seamlessly. It definitely seemed like part of how [the surgeon] would present the information. — Patient, Picture Option Grid, Higher SES
Well, it became pretty much second-hand for me actually. I got really used to using it. It just became part of my routine. — Surgeon, Picture Option Grid
Major themes related to reflexive monitoring (“How is the work understood?”)
I had a lumpectomy instead of a mastectomy because the information contained in the grid helped me understand that I didn’t need one [mastectomy]. — Patient, Picture Option Grid, Higher SES
...as I got faster, I got more used to it. It did help the rhythm. At first, it took me a little bit longer than I think it would’ve been, but not much. Then, at the end, I think it ultimately helped structure things. It might have made things as efficient or more efficient. — Surgeon, Option Grid
Comparing major themes by participant SES
I interacted with the piece of paper a hundred times more than I would with the downloaded file if somebody had just sent that to me to look at before my appointment. — Patient, Option Grid, Higher SES
I’d say it really influenced it [my decision]. — Patient, Option Grid, Lower SES
I would recommend it to everybody. — Patient, Option Grid, Lower SES
Comparing major themes by intervention
Completely influenced [my decision] — Patient, Option Grid, Higher SES
It needs to be something they can see online in MyChart. It should also be in a doctor’s office so that a woman can, you know, “Let me read this.” — Patient, Picture Option Grid, Lower SES
Well, it became pretty much second-hand for me actually. I got really used to using it so I don’t know. It just became part of my routine. — Surgeon, Picture Option Grid