Practitioners’ views on shared decision-making implementation: A qualitative study

Anshu Ankolekar; Karina Dahl Steffensen; Karina Olling; Andre Dekker; Leonard Wee; Cheryl Roumen; Hajar Hasannejadasl; Rianne Fijten

doi:10.1371/journal.pone.0259844

Peer Review History

Original SubmissionJuly 13, 2021
17 Aug 2021 Decision Letter - Chaisiri Angkurawaranon, Editor PONE-D-21-20569 Clinician motivation in shared decision-making implementation: A qualitative study PLOS ONE Dear Dr. Fijten, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 01 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”. Please include your amended statements within your cover letter; we will change the online submission form on your behalf. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: This is a well-written and interesting manuscript on clinicians’ experiences with implementing SDM within a hospital setting that is known for successful use of SDM in routine practice. I have two primary concerns with this manuscript. First, the purpose/focus of the study appears to change throughout the manuscript and is thus unclear. At times, it seems that the authors are interested in learning about clinicians’ experience of the implementation process (e.g., descriptive accounts of the SDM training and PDA development process), while at others it appears that the authors are specifically focused on perceived barriers and facilitators to SDM implementation. Further, the title of the manuscript leads one to believe that the focus is on factors that motivate clinicians to implement SDM, which is not consistent with the more comprehensive focus of the manuscript. The authors should further clarify the purpose of the study and ensure that it remains consistent throughout. Second, themes derived from the data are briefly mentioned in the results section, but not elaborated upon in a coherent way. After mention of the themes, results are organized according to experiences at various stages of the implementation process rather than by theme. Further, Figure 1 does not appear to map on to any of the named themes. This makes evaluation of how themes were derived and what data support them difficult. The authors might consider a re-organization of the results section to better elucidate themes. Additional comments on specific sections of the manuscript are below. Abstract: The abstract should clearly describe all themes that were derived from the data. Methods: Citations are needed when referencing specific methods (e.g., thematic analysis). How was it determined that participants had the relevant experience with SDM implementation in order to participate effectively in the interviews? Was the decision to include both those who had undergone SDM training and those in leadership strategic (i.e., part of the purposive sampling strategy)? p. 11 (lines 177-181): This paragraph is unclear. Were only open codes compared? Or both open and axial codes? How were open codes further categorized and who performed this step? Results: For context, it would be helpful if the SDM training were described in greater detail. For instance, what SDM model was this training based on? Reviewer #2: Review report Manuscript Number: PONE-D-21-20569 Manuscript Title: Clinician motivation in shared decision-making implementation: A qualitative study This manuscript addresses an important theme and is well written. The relevance for this study to the practice field is high. A major revision is needed regarding the analysis and presentation of the results, in addition to some minor revisions. I do believe that this can become a good contribution to the field. Abstract and introduction 1) Abstract p.2: “The goal was to identify implementation barriers, strategies used to address them, and remaining challenges.” Introduction p.6: ” The aim of this study, therefore, is to gain insight into how clinicians at Vejle Hospital experience the introduction of a SDM initiative into their workflow, the training process, and the impact on their daily practice.” Discussion p.20: “The purpose of this qualitative study was to examine practitioners’ experiences of the Center’s efforts to introduce SDM and PDAs into clinical practice.” The aim/ goal/purpose of the study should be consistent throughout the manuscript. 2) The research question should be reported. Methods 3) I recommend the authors to give the description of the authors’ contribution under each related section, for example “The interviews were conducted by AA..” could preferable have been described under the heading data collection. “Participants were recruited by means of purposive sampling [16] and were identified through KDS..” is related to study population and could preferable have been described under this heading. Ethical guidelines: 4) The contribution of the authors AA, KDS and HH is described but the role of the other authors is unknown. What was their contribution in this study? This is important to describe according to the Vancouver recommendations. 5) Anonymization of the participants is important in research and the authors should outline how anonymity is facilitated. Data collection: 6) The interview guide is presented with two themes numbered 5. 7) Please report who transcribed the interviews. 8) The authors report a study consisting of semi-structured interviews. This design is not compatible with “observations were recorded as field notes” (p.11). If the field notes are included in the data material in addition to the interviews the study design should be revised. Analysis: 9) Please include a reference to thematic analysis method. 10) It is unclear how the field notes were analysed. Did the author mix the two different data sets, the interviews and the field notes? Can the authors elaborate this? 11) Please elaborate what the interpretations were based on. 12) The last section in “Data analysis” focuses on the interviews and should be moved to related section (data collection). Results, discussion, conclusions 13) The quote on p.16 is not identified (participant no.) 14) It is unclear if the results reflect the data material (the participants’ answers of the 6 themes in the interview guide). The aim of this study was to gain insight into how clinicians at Vejle Hospital experience the introduction of a SDM initiative into their workflow, the training process, and the impact on their daily practice. Only “The challenges encountered by our participants at each phase and the strategies they used to address them are summarized in Figure 1 and elaborated below” (p.12) are presented as results. The authors are advised to look at the entire data material in light of the research question (which must be presented in the manuscript) and make an analysis were the results reflect the whole data material and the aim of the study. 15) Figure 1 presents an overview of challenges to SDM implementation and strategies to overcome them at different phases of implementation. It is unclear if these items are the themes, categories and codes. The authors are encouraged to provide a description of the coding tree. There should be clarity of themes were the themes are clearly presented in the results and clarity of categories and codes with a description of diverse cases or discussion of these in the results. 16) The conclusion should answer the aim and research question and must be reconsidered. 17) The patient perspective is the onus of SDM. This study reflects only the clinicians’ perspective and should have been reported as a limitation and discussed. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes:** Lise Sæstad Beyene [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0259844.r001
Revision 1
15 Oct 2021 Author Response Reviewer #1: This is a well-written and interesting manuscript on clinicians’ experiences with implementing SDM within a hospital setting that is known for successful use of SDM in routine practice. I have two primary concerns with this manuscript. First, the purpose/focus of the study appears to change throughout the manuscript and is thus unclear. At times, it seems that the authors are interested in learning about clinicians’ experience of the implementation process (e.g., descriptive accounts of the SDM training and PDA development process), while at others it appears that the authors are specifically focused on perceived barriers and facilitators to SDM implementation. Further, the title of the manuscript leads one to believe that the focus is on factors that motivate clinicians to implement SDM, which is not consistent with the more comprehensive focus of the manuscript. The authors should further clarify the purpose of the study and ensure that it remains consistent throughout. Second, themes derived from the data are briefly mentioned in the results section, but not elaborated upon in a coherent way. After mention of the themes, results are organized according to experiences at various stages of the implementation process rather than by theme. Further, Figure 1 does not appear to map on to any of the named themes. This makes evaluation of how themes were derived and what data support them difficult. The authors might consider a re-organization of the results section to better elucidate themes. Authors’ response: We thank the reviewer for highlighting the two general issues regarding the study’s focus and the presentation of the results. We have made the following changes: - The research question has been formulated more explicitly in the final paragraph of the Introduction, namely that the purpose of the study is to investigate practitioners’ views of SDM implementation in their practice, in particular: their initial attitudes towards SDM, factors that supported them in implementing SDM, and perceived outcomes. These changes can be found on pg 5, lines 79-86. The title of the manuscript has also been adjusted to reflect the aim of the study. - The results section has been re-organized based on the three components of the research question described above. We have described the themes that emerged under each of the components and replaced Fig 1 with the thematic map that resulted from our analysis (pg 12). Additional comments on specific sections of the manuscript are below. Abstract: The abstract should clearly describe all themes that were derived from the data. Authors’ response: In the ‘Results’ subsection of the abstract, we have added the four themes that emerged as factors facilitating the SDM implementation, namely: raising awareness, reinforcing the new behaviors associated with SDM, flexibility in adapting the SDM process to different contexts, and leadership. This information has been added on pg 1,lines 14-22. Methods: Citations are needed when referencing specific methods (e.g., thematic analysis). Authors’ response: We have added a reference to Braun and Clarke’s thematic analysis method on pg 10 (lines 168-169) and added a more detailed description of the six-step thematic analysis process in the ‘Data analysis’ subsection (pg 11, lines 172-199). How was it determined that participants had the relevant experience with SDM implementation in order to participate effectively in the interviews? Was the decision to include both those who had undergone SDM training and those in leadership strategic (i.e., part of the purposive sampling strategy)? Authors’ response: The criteria used in the purposive sampling strategy was that the participants should be well-acquainted with SDM, either through direct practice, such as clinicians, or general awareness of the concept, such as those in a more strategic leadership role (pg 7, lines 109-112). p. 11 (lines 177-181): This paragraph is unclear. Were only open codes compared? Or both open and axial codes? How were open codes further categorized and who performed this step? Authors’ response: We have rewritten the paragraph so that each phase of the thematic analysis process is described along with the researchers who performed the steps (pg 11, lines 172-199). Results: For context, it would be helpful if the SDM training were described in greater detail. For instance, what SDM model was this training based on? Author’s response: We have added further details on pg 17 (lines 301-303) on the SDM training, which was based on the SDM model conceptualized by Elwyn et al (2012) and developed on the basis of a participatory action research study. Reviewer #2: Review report Manuscript Number: PONE-D-21-20569 Manuscript Title: Clinician motivation in shared decision-making implementation: A qualitative study This manuscript addresses an important theme and is well written. The relevance for this study to the practice field is high. A major revision is needed regarding the analysis and presentation of the results, in addition to some minor revisions. I do believe that this can become a good contribution to the field. Abstract and introduction 1) Abstract p.2: “The goal was to identify implementation barriers, strategies used to address them, and remaining challenges.” Introduction p.6: ” The aim of this study, therefore, is to gain insight into how clinicians at Vejle Hospital experience the introduction of a SDM initiative into their workflow, the training process, and the impact on their daily practice.” Discussion p.20: “The purpose of this qualitative study was to examine practitioners’ experiences of the Center’s efforts to introduce SDM and PDAs into clinical practice.” The aim/ goal/purpose of the study should be consistent throughout the manuscript. Authors’ response: We thank the reviewer for pointing out the inconsistencies regarding the study aim. We have adjusted the phrasing in the abstract to be consistent with the Introduction and Discussion. We have also reformulated the research question in the final paragraph of the Introduction on pg 5, lines 79-86 (see our response to comment 2 below). 2) The research question should be reported. Authors’ response: We have reformulated the research question in the final paragraph of the Introduction (pg 5) as follows: “The purpose of this study is to gain insight into practitioners’ views on the introduction of a SDM initiative into their workflow at Vejle Hospital, in particular: (i) their initial attitudes towards SDM as a concept; (ii) their experience of the implementation process and factors that they found helpful; and (iii) perceived outcomes.” Methods 3) I recommend the authors to give the description of the authors’ contribution under each related section, for example “The interviews were conducted by AA..” could preferable have been described under the heading data collection. “Participants were recruited by means of purposive sampling [16] and were identified through KDS..” is related to study population and could preferable have been described under this heading. Authors’ response: We have moved descriptions of each author’s contributions to the relevant subsections as suggested. We used the Vancouver recommendations as outlined by the ICMJE as a guideline (see our response to comment 4 below). Ethical guidelines: 4) The contribution of the authors AA, KDS and HH is described but the role of the other authors is unknown. What was their contribution in this study? This is important to describe according to the Vancouver recommendations. Authors’ response: In terms of the Vancouver recommendations, the contribution of all authors are as follows: Conception and design: AA, KDS, AD, LW, RF Data acquisition: AA, KDS, KO Data analysis: AA, HH, RF, CR We have added a description of their involvement in the subsections ‘Study design’, ‘Data collection’, and ‘Data analysis’ respectively. Furthermore, all authors were involved in drafting/revising the manuscript and gave their approval for its submission for publication. 5) Anonymization of the participants is important in research and the authors should outline how anonymity is facilitated. Authors’ response: We have added a brief description of how confidentiality and anonymity were preserved in the Ethics subsection (pg 9, lines 137-140). Data collection: 6) The interview guide is presented with two themes numbered 5. Author’s response: We thank the reviewer for noting the error and we have changed the final item of the interview guide to ‘(6)’ on pg 6, line 99. 7) Please report who transcribed the interviews. Authors’ response: We have added the information that AA transcribed the interviews to the ‘Data collection’ subsection (pg 10, line 156). 8) The authors report a study consisting of semi-structured interviews. This design is not compatible with “observations were recorded as field notes” (p.11). If the field notes are included in the data material in addition to the interviews the study design should be revised. Authors’ response: The field notes were recorded by AA as a reflection on the SDM process. The notes did not form a part of the data material that was analyzed under the thematic analysis method. As a result, to maintain clarity, the reference to field notes has been removed. Analysis: 9) Please include a reference to thematic analysis method. Authors’ response: We have added a systematic description of the six phases of the thematic analysis method we followed, namely that described by Braun and Clarke (2006), along with a reference to the same. These details are given on pg 10-12, lines 168-199. 10) It is unclear how the field notes were analysed. Did the author mix the two different data sets, the interviews and the field notes? Can the authors elaborate this? Authors’ response: As mentioned in our response to comment 8, the field notes did not form a part of the data analysis and the reference has therefore been removed. 11) Please elaborate what the interpretations were based on. Author’s response: Analysis was conducted based on a collaborative reflexive approach based on the researchers’ interpretation of the data and prior theoretical knowledge. Our approach was inductive and prioritized engaging with the data and discuss multiple interpretations as opposed to achieving a specific consensus. This clarification has been added under the ‘Data analysis’ subsection on pg 12, lines 190-193. 12) The last section in “Data analysis” focuses on the interviews and should be moved to related section (data collection). Authors’ response: As suggested, we have moved the paragraph to the end of the ‘Data collection’ subsection. Results, discussion, conclusions 13) The quote on p.16 is not identified (participant no.) Authors’ response: We have added the participant no. to the quote (pg 16, lines 279-280). 14) It is unclear if the results reflect the data material (the participants’ answers of the 6 themes in the interview guide). The aim of this study was to gain insight into how clinicians at Vejle Hospital experience the introduction of a SDM initiative into their workflow, the training process, and the impact on their daily practice. Only “The challenges encountered by our participants at each phase and the strategies they used to address them are summarized in Figure 1 and elaborated below” (p.12) are presented as results. The authors are advised to look at the entire data material in light of the research question (which must be presented in the manuscript) and make an analysis were the results reflect the whole data material and the aim of the study. Authors’ response: Following the reformulation of the research question into three specific components in the Introduction section, we have reorganized the Results section so that the themes derived for each component are systematically presented and clarified (pg 12-22). 15) Figure 1 presents an overview of challenges to SDM implementation and strategies to overcome them at different phases of implementation. It is unclear if these items are the themes, categories and codes. The authors are encouraged to provide a description of the coding tree. There should be clarity of themes were the themes are clearly presented in the results and clarity of categories and codes with a description of diverse cases or discussion of these in the results. Author’s response: As suggested, we have replaced the original Figure 1 with a thematic map showing the themes and subthemes corresponding to each of the three components of the research question (pg 13, lines 211-213). 16) The conclusion should answer the aim and research question and must be reconsidered. Authors’ response: We have expanded the conclusion to include the answers to all three parts of the research question formulated in the Introduction (pg 29, lines 532-542). 17) The patient perspective is the onus of SDM. This study reflects only the clinicians’ perspective and should have been reported as a limitation and discussed. Authors’ response: We thank the reviewer for the suggestion and have added the lack of patient perspective as a limitation and discuss the implications for our conclusion as well as future research (pg 28, lines 520-530). Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0259844.r002
28 Oct 2021 Decision Letter - Chaisiri Angkurawaranon, Editor Practitioners’ views on shared decision-making implementation: A qualitative study PONE-D-21-20569R1 Dear Dr. Fijten, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Chaisiri Angkurawaranon Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: (No Response) ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0259844.r003
Formally Accepted
2 Nov 2021 Acceptance Letter - Chaisiri Angkurawaranon, Editor PONE-D-21-20569R1 Practitioners’ views on shared decision-making implementation: A qualitative study Dear Dr. Fijten: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Chaisiri Angkurawaranon Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0259844.r004

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