Background
Methods
Description of the training program
Distribution order | Decision Box title | Interest in the title, on a scale from 0 to 100 with 100 high Mean (SD); (n = 47) |
---|---|---|
1 | Choosing a non-pharmacological treatment to manage agitation, aggression, or psychotic symptoms | 87 (11) |
2 | Choosing an option to maintain quality of life | 85 (13) |
3 | Choosing a support option to decrease caregiver burden | 80 (18) |
4 | Deciding whether or not to stop driving following diagnosis | 78 (30) |
5 | Deciding whether or not to prepare a power of attorney for personal carea | 67 (32) |
Study design
Participants
Implementation strategy
Quantitative data collection
Survey
Access data
Qualitative data collection
Selection of a participant subsample
Procedure
Analyses
Results
Participants
Participant Characteristics | Frequency (Total N = 47) | |
---|---|---|
n | % | |
Age (years) a | ||
Under 30 | 7 | 15.2 |
30–39 | 15 | 32.6 |
40–49 | 15 | 32.6 |
50–59 | 8 | 17.4 |
60–69 | 1 | 2.2 |
Gender | ||
Female | 39 | 83.0 |
Male | 8 | 17.0 |
Profession | ||
Physician | 17 | 36.2 |
Nurse | 10 | 21.3 |
Social worker | 10 | 21.3 |
Occupational therapist | 6 | 12.8 |
Nursing assistant | 1 | 2.1 |
Dietician | 1 | 2.1 |
Pharmacist | 1 | 2.1 |
Physiotherapist | 1 | 2.1 |
City size where practice locatedb | ||
Rural area | 0 | 0.0 |
Small city | 6 | 12.8 |
Mid-size city | 0 | 0.00 |
Large city | 41 | 87.2 |
Years of practicec | ||
< 10 | 18 | 38.3 |
10–19 | 11 | 23.4 |
20–29 | 12 | 25.5 |
30–39 | 3 | 6.4 |
Do not recall | 3 | 6.4 |
Received prior SDM training | ||
Yes | 9 | 19.2 |
No | 38 | 80.9 |
Level of participation in the training program
Interview findings: factors influencing participation in the training program
Factors encouraging participation
Factor | Sample citation (source)a |
---|---|
Attitude | |
The program is useful for learning about SDM | “For me it was an introduction to the concept of shared decision making, it raised my awareness about it.” (Occupational therapist #29, home support service #3) |
The program is useful for practice | |
Provides ideas on ways to manage NCDs problems | “It has all kinds of information sources that are useful for my practice. I’ve had a slew of interventions in BPSD (behavioural and psychological symptoms of dementia) recently, and it was a good source of inspiration.” (Occupational therapist #29, home support service #3) “I thought the Decision Boxes were fun. They helped give us ideas on how to conduct interviews using shared decision making. Even though there are some topics that don’t have Decision Boxes, they were still useful tools for understanding how to interact with patients.” (Dietician #9, home support service #1) |
Provides an introduction to DBs | “It was interesting to learn that decision aids exist. And they were well made. The training was well organized, and it included information on the Laval University and Ottawa sites where you can find them. It was good to know.” (Dietician #9, home support service #1) |
DBs cover topics of interest for practice | “I found the topics interesting and felt they could be very useful in my practice.” (Physician #55, Clinic #1) |
DBs help meet clinical needs | “The training informed me of alternative non-pharmacological treatments to meet the needs of clients.” (Nurse #65, Clinic #1) |
DBs present various interventions and their pros and cons | “It helps us move beyond the scope where the nurse has the answer, since it’s the client, instead, who has to choose. But at the same time, to make a choice, they need to understand the pros and cons, so they can make an informed decision. In some cases, it’s not as easy as that, but with these Decision Boxes, it really gives us a good idea of what the options are, as well as the pros and cons, in pretty simple terms. It’s good.” (Nurse #26, Clinic #4) |
DBs facilitate the communication of information to patients | “It’s something I consider necessary, that is, being able to provide information that is easily understood by our clientele, by the patient, and their loved ones. The training program gives us an appreciation of the work that’s been done to help facilitate our task of delivering information in a format that’s easy to understand, and that can be consulted by the patient’s family not during the encounter, but afterwards.” (Physician #73, Clinic #2) “The training gives us a good understanding of how to guide patients using evidence, according to the topic, like driving or how to provide support to caregivers—things like that. I think it helps us see all the possible avenues, with their pros and cons, and it helps us provide guidance to the people we work with.”(Physiotherapist #46, home support service #2) |
Beliefs about capabilities | |
Ease of access | |
DBs are printable | “I plan to print out the Decision Boxes in question. I posted them on the family medicine intranet because I, personally, find them very useful. Once I have access to a colour printer, I plan to collect them together in a binder, so I can access them in the clinic and use them in a teaching context with our resident doctors so that they, too, can use them in their interactions with patients. Plus, I’ll make available the Decision Boxes designed for patients and/or their loved ones.” (Physician #73, Clinic #2) |
Value of having one version of the DBs for clinicians and a simpler version for patients | “What’s interesting too is that there’s a part that’s really more for the professional, to guide their intervention, and a simpler part that’s more for the patient.” (Social worker #20, home support service #1) |
Access to DB information in practice is quick due to their brevity, standardized presentation of information, and separate DB for each clinical situation | “What I found interesting with the modules is that you can seek out certain specific parts. For example, if I’m faced with Problem X, I can go straight to the Decision Box on that particular topic. It’s easier than having to wade through a long module that’s not divided into topics, and where you have to search to find your information. But with the short Decision Boxes, you can quickly find what you’re looking for.” (Social worker #20, home support service #1) |
DBs are available to patients/caregivers after the consultation if they require more information | “What is also interesting is that the DBs are available in a format that can be consulted after the consultation by patients and their families.” (Physician #73, Clinic #2) |
Short modules make it easier to retrieve information from the e-learning activity | “The training module is interesting too. It’s concise, not too long, and the sheets are pretty quick to complete. I think it’s a winning formula. The fact that it’s short and concise makes it easier to use.” (Nurse #26, Clinic #4) “They’re really easy to use and to find your way around.” (Nurse #65, Clinic #1) |
The training program is easy to do: brief, concise, clear, well-explained | “I liked the fact that it’s not too long, it’s set out clearly, it’s well explained. It was quick to use.”(Nurse #65, Clinic #1) |
Flexible nature of the training program: easy to access at the most convenient time for the learner, and at their own pace | “It’s good that it is possible to access it at the moment we choose, at the right moment: it’s the flexibility.” (Physician #73, Clinic #2) |
Ease of use | |
No prerequisite for the training program | “There are not really any prerequisites; I would say that anyone working in a clinic with a minimum level of experience would be able to complete it.” (Nurse #26, Clinic #4) |
Training program provides easy-to-understand, visual and practical training | “I found it visually appealing, and the fact there were examples gave me a better ideas on how to interact with my patients.” (Dietician #9, home support service #1) |
Applicability of learnings to other clinical situations | “I think that it could be used afterwards for other types of clienteles. The Decision Boxes incorporate a slightly more standardized practice when it comes to sharing information with the clientele, and to shared decision making.” (Nurse #26, Clinic #4) |
DBs are well explained and provide concrete guidance | “The DBs are relatively short (2–3 pages), there’s not too much information. They’re easy to find your way around, easy to follow and to use in the workplace.” (Social worker #20, home support service #1) |
Extrinsic sources of motivation | |
Incentives: continuing education credits | “There’s an incentive with the training units.” (Occupational therapist #29, home support service #3) |
Participation encouraged by reminders and follow-ups during training | “I thought the emails you sent to remind us and to inform us when new Decision Boxes were available was a good approach.” (Dietician #9, home support service #1) |
Factors restricting participation in the training program
Factor | Sample citation (source)a |
---|---|
Lack of time / time required | |
Poor match between the duration of the training and learners’ time constraints | “Time is the real sticker these days. It’s very difficult in today’s home support system. We’re overloaded, we have interviews with patients to conduct using CDSSs (computerized clinical decision support systems) that last hours, we’re under enormous pressure, and we don’t have time to stop.” (Occupational therapist #45, home support service #2) |
Unfavorable period (note from author: training ran from February to May 2018) | “With the whirlwind of life, with the daily routine of my tasks as a family doctor, to do this in excess, at midnight or 1 am, it is not possible, at least not at that time, with all my tasks.” (Physician #55, Clinic #1) |
No time slot dedicated to the training activities | “If you look at our work situation, of course it’s not always easy to take the time to stop and do it. The barriers we face are that we have many other tasks to do. I’m too busy to start wearing several hats at a time, so the barriers aren’t the training itself; it’s the fact it takes time, and that you have to make that time.” (Physician #73, Clinic #2) |
Prioritization of clinical, family, or administrative activities limiting the time available for training | “I often work until midnight, and it’s not for additional training … So, training comes after all the other priorities.” (Physician #55, Clinic #1) |
Time required to take ownership of the tool may be longer for those professionals lacking experience in the topic | “Of course, taking ownership of the tool also takes time.” (Physiotherapist #46, home support service #2) |
Inconvenience of training components | |
Training fragmented into e-learning activity and evidence summaries makes it difficult to follow; multiple stages | “I think I would have preferred to do it all at once.” (Social worker #50, home support service #2) |
DB content not well adapted to some professional fields of practice (e.g., dieticians) | “The Decision Boxes are certainly interesting, but they don’t apply to every situation. There weren’t any in my area of practice. So for me, it’s a bit less motivating. I don’t think I’ll be using any of the Decision Boxes that have been mentioned to date.” (Dietician #9, home support service #1) |
Lack of information on how to use the DBs | “I gave all the information verbally. I didn’t know you could hand the DBs over to the patients. I only used the DBs designed for the clinicians and I didn’t have the reflex to use those designed for the patients.” (Nurse #26, Clinic #4) |
Technical / logistical barriers | |
The audio can be a disturbance for co-workers in a shared office | “We share our offices. I don’t have headphones, so the training has to be done at precise times, so as not to disturb my colleagues. It could be harder to find the right time, but it’s really just a very minor point.” (Occupational therapist #29, home support service #3) |
Issues finding where the learner left off in the event of pausing | “I thought that when we paused the training and came back to it later, we could just pick up where we left off. But that’s not what happened. Every time I came back to it, I had to enter the exact place I’d left off and keep clicking on “Forward” until I got back to the right spot. So that was a bit complicated, because sometimes I couldn’t remember where I’d got to.” (Dietician #9, home support service #1) |
Issues with Internet | “As far as I’m concerned, I have a lot of trouble with things on the Internet. I’m the type to be more face-to-face.” (Dietician #9, home support service #1) |
DB not optimized for viewing on smartphones | “I don’t have a computer at home, so I did it on my cellphone, and it wasn’t easy to do.” (Social worker #50, home support service #2) |
Social barriers | |
No discussion to reflect on lessons with peers | “In my workplace, I was the only one doing it. It would have been good to have colleagues doing it at the same time so we could discuss it.” (Occupational therapist #29, home support service #3) |
Negative influence of colleagues who did not complete the training program | “I suspect I’m not the only one at the clinic who didn’t have time to complete the online training because we have a lot of reading to do, forms to fill out, a family life when we can, so adding this on top.” (Physician #55, Clinic #1) |
Lack of formal recognition of training by the employer | “It would have been good to receive more official recognition from the employer.” (Physiotherapist #46, home support service #2) |
Evidence summaries unknown to/not popular with colleagues | “There is a lack of awareness that there are decision-making tools. They should be promoted even more.” (Physiotherapist #46, home support service #2) |
Difficulty in using DBs | |
Costs associated with printing the DBs | “The printouts, especially the colour ones, which are more attractive, can generate costs, especially if you need them for the patients and their families as well.” (Physician #73, Clinic #2) |
Preparation required before using them during consultation (access, printing, etc.) | “It takes a lot of steps to go find the link to access the tool, to go on the internet, to then be able to print it. It is a good tool, but it would be good to have it at your fingertips so it can be used. And since I didn’t have it at my fingertips ...” (Physician #73, Clinic #2) |
Some figures in the DBs difficult to interpret and less relevant | “There are, for example, times when the percentages are not easy to interpret or apply. There are some that are relatively easy, like indoor gardening. As advantages, we see that agitation decreases for 64% of seniors: it is relatively easy. But for others, it is sometimes less obvious. We understand that the therapeutic touch decreases restlessness in 28–54% of cases. We understand that it can reduce agitation, but I don’t think I will use these figures, I will use the averages more.” (Social worker #20, home support service #1) |
DBs not available for all patients | “When we’re at the clinic with patients, there are often a number of priorities to be addressed. It’s rare that there’s only one reason for consulting, and that that reason happens to be one of the ones addressed in the Decision Boxes.” (Physician #73, Clinic #2) |
Other tools already handed out to patients; DBs not yet incorporated into regular practice and can be cumbersome | “We give out lots of advice and we hand out all kinds of stuff, plenty of documents. We haven’t gotten around to giving out additional tools. It just hasn’t been part of our practice so far.” (Occupational therapist #45, home support service#2) |
Strategies for improving the training program and its implementation
Strategy | |
---|---|
To improve learning modalities | |
Offer the option of receiving the DBs in a single block rather than in sections. | |
Make the online activity available in print format for regions with limited Internet access. | |
Subdivide the longer modules. | |
Use podcasts. | |
Give participants the option of skipping the modules on topics they are already familiar with. | |
Clarify the availability of the tools throughout the training program, and promote their potential as a teaching aid for interns. | |
Create the possibility for learners to adjust the speed of the narration in the videos. | |
Make headphones available to learners in shared workspaces. | |
Make it easier to pick up training again after pausing. | |
Include a user guide for learners who are less tech-savvy. | |
To improve implementation | |
Include targeted messages to help promote the training program: | |
- By clarifying learners’ preferred objectives (understanding SDM, learning about the tools, understanding the evidence about the different interventions) | |
- By highlighting the clinical issues covered by the DBs, since they are practice-oriented | |
- By promoting the usefulness of DBs to communicate information to patients | |
Maintain training credits as a source of motivation, enhance them if possible, and add other possible sources of motivation. | |
Make the training program shorter. | |
Officially incorporate the training into the participant’s schedule by negotiating with immediate superior. | |
Provide training at a more convenient time of the year, e.g., in summer. | |
Adapt training length to individual needs and experience. | |
Make DBs easier to access: | |
- Facilitate patients’ access to online DBs, e.g., by giving them the website address | |
- Create direct access links to the DBs in the EMR (Electronic Medical Record) | |
- Create direct access links to the DBs and the e-learning activity directly on clinic websites | |
- Offer colour printed versions (budget for them) or equip offices with colour printers | |
Incorporate short modules specific to each clinical intervention field. | |
Create DBs for all of the themes addressed in clinical encounters, and expand the practice areas covered. | |
Offer learners the chance to choose the DBs they wish to review, at the beginning of the training program. | |
In the online activity, present examples, clinical cases, or role-plays relating to various scopes of professional practice. | |
Simplify the data presented in the DBs. | |
In the online activity, explain how to present the wide confidence intervals associated with effect estimates. | |
Promote the tools with decision makers and employers (nursing or multidisciplinary department heads, professional bodies, universities), via webinar, for example. | |
Address the barriers mentioned during the learning program with presentations and credited workshops, in collaboration with officially recognized public authorities. | |
To improve dissemination of the tools, make them available in clinics, health institutes, libraries, and other public places. | |
Promote the option of doing the training as a group. | |
Offer incentives to participate, in the form of gifts, money, or meals. | |
Promote shared decision making in the population and directly support patients and their caregivers in participating to the clinical decision making process. | |
Promote shared decision making at level of the government. |
Survey results: effects of the training program
Outcome | Before training | After training | P-value | |
---|---|---|---|---|
Knowledge | ||||
Knowledge about SDM | Mean score (SD) (scale 1–5, with 5 high) | 4.2 (1.33) | 3.9 (1,45) | 0.31 |
Knowledge about risk communication | Number of people with correct answers, n (%) | 5 (29.4%) | 9 (52.9%) | 0.02 |
Perceived awareness of the options (3/5 Decision Boxes) | Mean score (SD) (scale 1–5, with 5 high) | 3.0 (0.78) | 3.9 (0.56) | 0.0006 |
Awareness of the options (3/5 Decision Boxes) | Mean proportion of correct answers (SD) | 16.7% (10.9%) | 42.2% (32.6%) | 0.0011 |
Clinical knowledge | ||||
Deprescribing antipsychotics | Number of people with correct answers, n (%) | 0 (0.0%) | 4 (23.5%) | 0.78 |
Impacts of stopping driving | Mean (SD) (scale 0–5, with 5 high) | 2.0 (1.2) | 4.1 (1.3) | 0.0004 |
Strategies to communicate about stopping driving | Mean proportion of correct answers (SD) | 20.0% (18.7%) | 25.9% (22.1%) | 0.07 |
Risk factors for caregiver burden | Mean (SD) (scale 0–4, with 4 high) | 3.0 (1.0) | 3.2 (1.1) | > 1.000 |
Awareness of the information to provide patients to reflect on the Power of attorney | Mean (SD) (scale 0–4, with 4 high) | 2.7 (1.1) | 2.6 (0.8) | 0.72 |
Characteristics of the power of attorney | Mean (SD) (scale 0–4, with 4 high) | 2.6 (1.1) | 3.3 (0.6) | 0.082 |
Elements to check before recommending a treatment to a vulnerable senior | Mean proportion of correct answers (SD) | 32.4% (30.3%) | 35.3% (29.4%) | 0.79 |
Intention to adopt SDM | Mean score (SD) (scale 1–7, with 7 indicating high intention) | 5.88 (0.99) | 5.94 (0.90) | 0.83 |
Perceived ability to adopt SDM (IcanSDM) | Mean score (SD) (scale 1–10, with 10 indicating high ability) | 6.54 (1.58) | 6.85 (1.25) | 0.43 |
Role preference | Number of participants n (%) | |||
I make the decision alone, relying on the best scientific evidence available | 0 (0.0%) | 0 (0.0%) | 0.82 | |
I make the decision, but strongly considering the opinion of the patient | 0 (00.0%) | 3 (17.7%) | ||
The patient and I make the decision together equally | 4 (23.5%) | 4 (23.5%) | ||
The patient makes the decision, but strongly considering my opinion | 5 (29.4%) | 2 (11.8%) | ||
The patient makes the decision alone, after obtaining information on the best available scientific evidence | 8 (47.06) | 8 (47.1%) | ||
Self-reported use of the training material to answer questions after training | ||||
Yes | Proportion n (%) | NA | 9 (53) | NA |
No | NA | 6 (35) | NA | |
No answer | NA | 2 (12) | NA |