Normalization of a conversation tool to promote shared decision making about anticoagulation in patients with atrial fibrillation within a practical randomized trial of its effectiveness: a cross-sectional study
Trials, vol. 21, pp. 395
Abstract
BACKGROUND: Shared decision making (SDM) implementation remains challenging. The factors that promote or hinder implementation of SDM tools for use during the consultation, including contextual factors such as clinician burnout and organizational support, remain unclear. We explored these factors in the context of a practical multicenter randomized trial evaluating the effectiveness of an SDM conversation tool for patients with atrial fibrillation considering anticoagulation therapy. METHODS: In this cross-sectional study, we recruited clinicians who were regularly involved in conversations with patients regarding anticoagulation for atrial fibrillation. Clinicians reported their characteristics and burnout symptoms using the two-item Maslach Burnout Inventory. Clinicians were trained in using the SDM tool, and they recorded their perceptions of the tool's normalization potential using the Normalization MeAsure Development (NoMAD) survey instrument and verbally reflected on their answers to these survey questions. When possible, the training sessions and clinicians' verbal responses to the conversation tool were recorded. RESULTS: Our study comprised 183 clinicians recruited into the trial (168 with survey responses and 112 with recordings). Overall, clinicians gave high scores to the normalization potential of the intervention; they endorsed all domains of normalization to the same extent, regardless of site, clinician characteristics, or burnout ratings. In interviews, clinicians paid significant attention to making sense of the tool. Tool buy-in seemed to depend heavily on their ability to see the tool as accurate and "evidence-based" and their perceptions of having time in the consultation to use it. CONCLUSIONS: While time in the consultation remains a barrier, we did not find a significant association between burnout symptoms and normalization of an SDM conversation tool. Possible areas for improving the normalization of SDM conversation tools in clinical practice include enabling collaboration among clinicians to implement the tool and reporting how clinicians elsewhere use the tool. Direct measures of normalization (i.e., observing how often clinicians access the tool in practice outside of the clinical trial) may further elucidate the role that contextual factors, such as clinician burnout, play in the implementation of SDM. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016.
Authors 11
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Mayo Clinic · Stanford Medicine · Stanford University
Affiliation as printed
Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Affiliation as printed
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Affiliation as printed
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Mayo Clinic · Universidad Peruana Cayetano Heredia
Affiliation as printed
CONEVID (Unidad de Conocimiento y Evidencia), Universidad Peruana Cayetano Heredia, Lima, Peru
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Mayo Clinic · Leiden University Medical Center
Affiliation as printed
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
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Affiliation as printed
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Mayo Clinic · Colorado School of Public Health · University of Colorado Anschutz · University of Colorado Denver
Affiliation as printed
Colorado School of Public Health, University of Colorado Denver Anschutz Medical Campus, Denver, CO, USA
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Affiliation as printed
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Mayo Clinic · London School of Hygiene & Tropical Medicine · Faculty of Public Health
Affiliation as printed
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Mayo Clinic · London School of Hygiene & Tropical Medicine · Faculty of Public Health
Affiliation as printed
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
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Víctor M. Montori corresponding
Affiliation as printed
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA. montori.victor@mayo.edu
Knowledge and Evaluation Research Unit, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA. montori.victor@mayo.edu
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