user-centered and theory-based design of a professional ......user-centered and theory-based design...

Lawani et al. BMC Med Inform Decis Mak (2021) 21:59 https://doi.org/10.1186/s12911-021-01396-y

RESEARCH ARTICLE

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods studyMoulikatou Adouni Lawani1, Yves Turgeon2, Luc Côté3, France Légaré4, Holly O. Witteman1, Michèle Morin5, Edeltraut Kroger6, Philippe Voyer7, Charo Rodriguez8 and Anik Giguere9*

Abstract Background: We know little about the best approaches to design training for healthcare professionals. We thus stud-ied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers.

Methods: In this mixed-methods study, healthcare professionals who worked in family medicine clinics and home-care services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A sec-ond subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants’ intention.

Results: Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowl-edge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed address-ing most weaknesses reported. Participants’ intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants’ intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users,

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*Correspondence: [email protected] VITAM Research Centre on Sustainable Health, Pavillon Landry-Poulin, Door A-1-2, 2nd floor, Room 2416, 2525 Chemin de la Canardière, Québec, QC G1J 0A4, CanadaFull list of author information is available at the end of the article

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of 25Lawani et al. BMC Med Inform Decis Mak (2021) 21:59

BackgroundNeurocognitive disorders require making several difficult decisions to ensure older adults remain independent as long as possible, while maintaining their well-being and safety [1]. These decisions may cover daily life manage-ment (e.g. being home alone, day care, transportation, home book- keeping), arranging healthcare and support (e.g. diagnosis, medications, home care, domestic help, and respite care), community life (e.g. visiting family, moving house), and representing the person with demen-tia (e.g. advanced decisions about the end-of-life) [1]. Decisions made by older adults with neurocognitive dis-orders and their caregivers are generally not only based on clinical information, but also on social considerations (e.g. financial insecurity, availability of community-based organizations, social networks), requiring professionals to expand their knowledge and scope of practice beyond the boundaries of their professions [1, 2]. Since several acceptable alternatives exist for most of these decisions, the priorities of the older adults and those of their family/friend caregivers should guide decision making, together with the scientific evidence on the benefits and harms of the available options [3]. Shared decision-making (SDM) is an ideal approach for supporting older adults and their significant others in making these decisions collabo-ratively with the interprofessional healthcare team, as SDM is typically used in the context of uncertainty when the person’s preferences are central to the decision [4]. SDM is an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences [5]. Primary healthcare professionals (HCPs) should be trained in SDM and have access to patient decision aids tailored to the needs of older adults living with neurocog-nitive disorders and their caregivers, as these profession-als play a central role in the care and services provided to community-based older adults living with neurocognitive disorders [6–8].

Although SDM can improve the quality of life of patients with neurocognitive disorders and their car-egivers [9], decision-making in this context can be

challenging. The disabling and neurodegenerative nature of neurocognitive disorders may challenge decision-mak-ing by limiting communication with the person as the disease progresses [10–12]. Consequently, neurocogni-tive disorders are a major risk factor for exclusion from decision-making [11]. Some studies have described the issues and requirements involved with implementing SDM with this population [1, 2, 13–17], but as yet, there have been no studies on the essential characteristics of a training program in SDM for HCPs in caring for older adults with neurocognitive disorders.

Initiatives aimed at increasing the use of SDM by HCPs may comprise training programs, leaflets, financial incentives or email reminders; however evidence remains scarce on their effectiveness to change professional behaviour and improve patient/caregiver participation in decision-making [18, 19]. This project focuses on two strategies to facilitate the implementation of professional training programs in SDM. Firstly, these programs should consider the logistical challenges of attending educa-tional meetings for HCPs, especially those who work in remote areas [20]. In this project, we thus propose a distance training program that is accessible to all profes-sionals, even those living away from the larger centres where continuing professional development activities generally take place. Secondly, we propose using user-centered design to tailor a professional training pro-gram to the actual needs and barriers faced by HCPs, as this is a promising approach to ensure that training on SDM leads to actual behaviour change [21, 22]. Indeed, evidence from systematic reviews shows that continu-ing professional development programs built on well-conducted needs assessments are effective in changing clinicians’ behaviours [23]. Training needs assessments have traditionally been achieved through practice audits, questionnaires, environmental scans, or interviews, but the value of user-centered design to this end remains unexplored. User-centered design, which includes design thinking, consists of involving target users in several iter-ative rounds of evaluations and modifications, to tailor the design of a product to a given task and to the user’s experience [24–27]. In the field of healthcare, preliminary

certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice.

Conclusions: A theory-based and user-centered design approach for continuing professional development inter-ventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners’ intentions to use SDM in their practice, and validate our initial interpretations of learners’ assessments during the subsequent evaluation round.

Keywords: Dementia, Aging, Continuing professional development, Curricular development, User experience, Intervention design, Behaviour change technique, Implementation


evidence suggests that user-centered design may enhance the implementation in practice of evidence-based infor-mation [26, 28, 29] and patient decision aids [30–33].

In this research project, we studied how user-centered design and theory contribute to the development of a dis-tance learning program to support HCPs in implement-ing SDM with older adults living with neurocognitive disorders and their family/friend caregivers. More specif-ically, the investigation was guided by the following over-arching research question: What are the features of the training program and design strategies that may increase HCPs’ intention to adopt SDM in this clinical context?

Theoretical frameworkSDM requires the adoption of a diverse set of behav-iours by HCPs [34, 35]. This project was thus based on the integrated framework proposed by Godin and al, according to which a behaviour may be predicted by a person’s intention (motivation) to adopt it (Fig. 1) [36]. A person’s intention may, in turn, be predicted by sev-eral determinants, including belief about consequences (the perceived advantage or disadvantage of adopting a behaviour), social influence (the perceived social pressure to adopt a behaviour), and beliefs about capabilities (per-ceived ease or difficulty of adopting a behaviour) [36]. In addition, intention can also be determined by habits/past behaviours and other social and emotional factors,

namely moral norms (the feeling of being obliged to adopt a behaviour) and role/identity (beliefs that a per-son of similar age, sex, or social position should adopt a behaviour) [36]. We then added to this general model the Technology Acceptance Model (TAM-2), which identifies usefulness and ease of use as two specific determinants which could predict users’ intention to use new informa-tion technology/information systems [37]. Despite the fact that these two domains are similar to, respectively, the Beliefs about Consequences and Beliefs about Capa-bilities domains described in the integrated framework, we added them to draw more attention to acceptance (usability and acceptability) of the two studied learning components [38], and thus complement the integrated framework, which is focused on motivation. Use of both the TAM-2 and integrated framework constructs allowed evaluating two dimensions of intention, namely motiva-tion (integrated framework) and acceptance (TAM-2).

MethodsStudy design and approachThis was a convergent, parallel, mixed-method study in which three HCP subsamples participated in the tailoring of a professional training program. A first subsample helped tailor the first component of the program (the e-learning activity), whereas the second and third helped tailor the second component (a series of five evidence summaries).

Beliefs about Capabilities

Moral Norm

Social Influence

Beliefs about Consequence

BEHAVIOUR INTENTION

Role and Identity

Individual Characteristics

Ease of Use

Usefulness

Fig. 1 Theoretical model framing the current research


We used user-centered design approaches for tailoring each component, by improving user experience of the pro-totypes during several iterative evaluations that each com-prised both quantitative and qualitative data collection [39].

Professional training program on shared decision makingDetails on the training program are reported elsewhere [40]. Briefly, the training program included two modali-ties: (1) a self-directed e-learning activity on SDM, and (2) five evidence summaries, decision boxes (DBs), to support decision-making at the point of care with older adults liv-ing with neurocognitive disorders and their caregivers. The self-directed e-learning activity covered the use of patient decision aids to implement SDM. It lasted about one hour, could be completed in several sittings, and was not specific to any clinical area. It was interactive and used narrated slides, videos, and interactive exercises. It also offered an asynchronous forum to discuss any question with an expe-rienced moderator.

The second modality of the training program consisted of a series of five evidence summaries describing the options available to older adults living with neurocognitive disor-ders who face five important and frequent decisions that we identified in a previous study [41]. These decisions were: (#1) choosing a support option to decrease caregiver bur-den; (#2) choosing a non-pharmacological treatment to manage agitation, aggression, or psychotic symptoms; (#3) deciding whether or not to stop driving following diagno-sis; and (#4) choosing an option to improve quality of life; and (#5) deciding whether or not to prepare a power of attorney (called a “protection mandate” in Quebec, Can-ada) covering health, property, and financial matters;. The evidence summaries followed the decision box (DB) tem-plate, which aims to provide stakeholders with evidence in a format that supports them in SDM [42, 43]. Biefly, these summaries met several of the standards set by the International Patient Decision Aids Collaboration [44]: (1) they described the health condition for which a decision is required; (2) they explicitly stated the decision to be taken into consideration; (3) they described all the options availa-ble for this decision; and (4) they described the positive and negative characteristics of each option. Their content was developed from rapid reviews and then revised by clinical experts, as described earlier [45]. The studied summaries

are available at www.decis ionbo x.ulava l.ca/en/ (Series on Older Adults – Problems with Thinking or Memory).

Population and recruitment strategyWe recruited convenience samples of HCPs from any profession (e.g., family physicians, nurses, and social workers) who practiced in family medicine clinics or homecare services in the province of Quebec, Canada. Of the primary care settings invited to participate in the project (46 clinics and 8 homecare services), 20 agreed to participate (16 clinics, 4 homecare services). Figure 2a, b describe the sample distribution for each training component. We carried three or four evalua-tions/tailoring rounds, with at least five HCPs during each round. These numbers respect human factors vali-dation testing [46].

Design process of the e‑learning activityE‑learning activity evaluationsAt study entry, all study participants completed a ques-tionnaire on their sociodemographic and professional characteristics. The study participants assigned to eval-uate the e-learning activity also completed a question-naire before and after exposure to the activity, to assess: (1) their preferred role in decision-making using the Control Preferences Scale [47, 48]; (2) their perception of the usefulness and ease of use of the program based on TAM-2 [49]; (3) their level of intention to adopt SDM, and the factors influencing that intention using the CPD-REACTION instrument [50]. To allow calcu-lating means for each of the studied factors, we added three items to the original CDP-REACTION instru-ment, giving it three items per domain.

These participants also assessed the e-learning activ-ity during a semi-structured think-aloud session that was screen-captured and audio-recorded using Flash-back (Blueberry Software). One of two trained mod-erators (DC, YT) conducted these sessions. After each section of the training, the moderator asked partici-pants about their perceptions on the content and learn-ing strategies used, and recorded any usability issues. At the end of the session, the moderator also asked participants to comment on the main benefits and inconveniences of SDM, which allowed us to describe the factors influencing participants’ beliefs about the

Fig. 2 User-centered design process to tailor the training program to user needs. DB #1 = Choosing a support option to decrease caregiver burden; DB #2 = Choosing a non-pharmacological treatment to manage agitation, aggression, or psychotic symptoms; DB #3 = Deciding whether or not to stop driving following diagnosis; DB #4 = Choosing an option to improve quality of life; DB #5 = Deciding whether or not to prepare a power of attorney; HCP = HCP; v = version

(See figure on next page.)

http://www.decisionbox.ulaval.ca/en/


consequences of using SDM, one of the components of the theoretical framework guiding this work (Fig. 1).

E‑learning activity tailoringInspired by Susan Michie’s mapping approach, we modified the e-learning activity by adding/enhanc-ing behaviour-change techniques targeting the factors likely to limit the adoption of SDM at each round [51, 52]. To this end, we initially imported the transcripts of the think-aloud sessions as source documents using NVivo coding software (QSR International, version 12). Two researchers (DC, AMCG) conducted a deductive/inductive thematic qualitative analysis of the factors likely to limit adoption of SDM [53]. More specifically, we initially used the theoretical domains framing the questionnaire as themes, and then added new themes as needed. We identified the weaknesses and strengths of the e-learning activity within each theme. We inter-preted qualitative and quantitative data together and, following this analysis, the coders (DC, AMCG), mod-erators (DC, YT), principal investigators (AMCG, FL), and a human factors expert co-investigator (HOW) discussed the functionality of the tutorial and modifica-tions to improve functionality and modify the program accordingly.

Design process of the decision boxes (DBs)Decision boxes evaluationsThe study participants assigned to evaluate the DBs received emails with a link to access a web-based ques-tionnaire to evaluate each DB, at a rate of one per week for five weeks. The DBs were also available on a website. The questionnaire served to (1) explain the purpose of the DB; (2) allow participants to access the DB under evaluation by clicking on a link; and (3) ask a series of questions about what they thought of the DB.

Congruent with the theoretical approach adopted, we used two questionnaires to assess the psychological con-struct ‘intention’ and its potential determinants. We used the CPD-REACTION questionnaire, which is based on the integrated framework described above and was cre-ated as a routine assessment of the impact of continuing professional education on practice [50]. We also assessed the usefulness and ease of use of the DBs, based on the TAM-2 [49]. For each of the CPD-REACTION and TAM-2 items described above, participants rated their perceptions using Likert items ranging from 1–7 (with 1 being the lowest). If ratings fell below four for any item, we then asked the HCPs to explain the reason for their rating in an open-text field, to allow us to understand the barriers they perceived to adopting SDM. At the end of the questionnaire, an open-text field also invited

participants to include any additional feedback on the DB.

We sent two weekly reminders to participants who had not completed their evaluations.

Decision boxes tailoringAfter each round, we used descriptive statistics to sum-marize participant ratings. We also imported the quali-tative comments made in the open-text fields of the questionnaire into a specialized software program (NVivo), and two researchers (MAL, AMCG) analyzed them using a thematic deductive/inductive qualitative analysis approach [53]. We initially used the theoreti-cal domains framing the questionnaire as themes, then added subthemes as needed [53]. We identified the weaknesses and strengths of the DBs within each of the theoretical domains, then broke them down further into emerging themes, to describe the weakness or strength. We resolved any disagreement by consensus between the two researchers.

An interdisciplinary expert panel subsequently met to review the qualitative and quantitative findings, and identified strategies to improve the DB, so as to limit the identified weaknesses. The panel consisted of a graphic designer (JB), a human factors engineer (HOW), an epi-demiologist (MAL), and four knowledge-translation researchers (AMCG, HOW, MAL, DC). The experts started by prioritizing each of the problems uncovered. Then, we determined the most appropriate solutions by considering the magnitude, frequency, and sever-ity of these problems, and modified the DBs so that HCPs could explain the pros and cons of health options, as understood from the DBs, to patients and their caregivers.

We used the same evaluation/tailoring process again in two more rounds, with new participants each time.

Final quantitative analysesWe used descriptive statistical analyses to summarize participants’ characteristics, their interest in each DB topic, their level of intention, and the potential predicting determinants of their intention. We used SAS (Version 9.4, copyright 2002–2012, SAS Institute Inc.) to conduct these descriptive statistics, and a significance level of 0.05.

Integration of quantitative and qualitative findingsAfter the entire series of evaluation/tailoring rounds, we integrated the quantitative and qualitative findings to generate conclusions on the factors influencing inten-tion, and on the changes in users’ intention as the rounds progressed.


ResultsStudy populationOne hundred and six HCPs from 20 clinics and home-care services located in 13 cities, agreed to participate in this study. A first cohort of 16 HCPs was assigned to help design the e-learning activity, a second cohort of 36 dif-ferent HCPs helped design the DBs in a three-round eval-uation process, and a third cohort of 54 helped design the DBs by providing comments in a fourth evaluation round. These cohorts are represented in Fig. 3.

In the three cohorts, 78% of participants were women, 60% were physicians, and 57% had fewer than 20 years of practice (Table 1).

Tailoring of the training programThe data that was used to tailor the training program is presented in this section and summarized in the Fig. 4. In the following two subsections, we successively report participants’ perceptions of the e-learning activity and decision boxes, and the strategies used to solve the problems discovered during the evaluation. In the third subsection, we present how participants’ perceptions of SDM supported the tailoring of the training program.

Tailoring of the e‑learning activity based on user experiencesParticipants expressed their appreciation of the content and design of the e-learning activity on numerous occa-sions, and in every section (Table 2). They especially liked the narrated slides, the quiz that informed them of actual patient numeracy levels, and the film depict-ing a simulated patient encounter during which SDM is implemented.

User-centered design initially allowed discover-ing several weaknesses of the e-learning activity. The approach then made it possible to remedy these weak-nesses and then evaluate the impact of the changes made during the next evaluation round. For example, participants mentioned several elements lacking clarity, either in terms of the training component or the con-tent (Table 3). We therefore systematically corrected the most specific issues (e.g. an acronym is undefined, a source is not cited) and they were not mentioned again by the participants in the following rounds. However, for the more general elements lacking clarity (e.g. the availability and content of the DBs, the main principles of SDM), we added an introductory video after Round #2. In Round #3, participants all mentioned appreciat-ing this introductory video.

106 participants were invited to participate

36 Were assigned to help design the DBs (rounds 1-3)

47 Were assigned to help design the DBs (round #4)

16 Were assigned to design he e-learning activity

99 Agreed to participate and completed the study entry questionnaire

26 Evaluated DB#1

18 Evaluated DB#3

23 Evaluated DB#2

22 Evaluated DB#4

19 Evaluated DB#5

21 Completed the evaluation in round #1

2 Answered only half of the questions



1 Answered only half the questions

6 Were lost to follow-up1 Was lost to follow-up16 Completed the study

Fig. 3 Description of participants’ samples in each of the three sub-studies. DB = decision box


Several other types of issues were corrected system-atically, such as usability issues, or features perceived as irrelevant or less valuable such as the videos with avatars, the introduction, or the training module explaining the evaluation of evidence quality. We either removed these elements, or made them optional for people interested in learning more.

We received several comments on the inapplicability of some of the examples across professions. Therefore, in the final version we diversified the professions displayed in the examples offered.

The activity required participants to extract the ben-efits and harms of patient decision aids from a scien-tific abstract of the Cochrane systematic review on their impact. Participants found the exercise difficult. We chose to try to improve the format of the exercise first, to make it easier. We therefore simplified the text of the abstract as much as possible, added pictograms and smi-ley faces to help identify the benefits and harms, and translated it into French, to further understanding of the information. We received no further negative comments from participants on this exercise thereafter.

Tailoring of the decision boxes based on user experiencesParticipants reported general interest in the topics cov-ered in the decision boxes (DBs), with an overall mean interest of 80% (± SD 11%). The DB perceived as least interesting concerned the power of attorney (67% ± SD 29%), and the one perceived as most interesting covered

Table 1 Characteristics of study participants

a City size < 1,000 = rural; 1,000–29,999 = small; 30,000–99,99 = medium; > 100,000 = large (Statistics Canada, 2011)

Participant characteristics Frequency (Total n = 99)

n %

Age (years) Under 30 16 16.1

30–39 27 27.3

40–49 27 27.3

50–59 23 23.2

60–69 5 5.1

Missing 1 1.0

Gender Female 77 77.8

Male 22 22.2

Profession Physician 59 59.6

Nurse 18 18.1

Social worker 13 13.1

Occupational therapist 6 6.1

Pharmacist 1 1.0

Physiotherapist 1 1. 0

Nutritionist 1 1. 0

City sizes of practice area a Small city 35 35.4

Medium city 7 7.1

Large city 57 57.6

Years of practice < 10 35 35.4

10–19 21 21.2

20–29 27 27.3

30–39 10 10.1

40–49 3 3.0

Unsure 3 3.0

Heathcare professional

Fun, easy, diversified

Valued content

Practical, hands-on

Visual, briefUsability,

clear navigation

Applicable across

professions

Decision box

RelevantImportantNovelInterestingComprehensiveClearTrustedRealisticFocused

Good designPractical, applied

Valued contentSpecific

SynthesizedSimple, clear

Conducive to dialogueSupport next steps

Fig. 4 HCPs’ experiences of the training program


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lear

ning

mod

ality

, cha

nges

of n

arra

tors

bet

wee

n m

odul

es a

re a

ppre

ciat

ed, i

mag

es a

nd v

isua

l des

ign

appr

ecia

ted

“I th

ink

it’s

good

bec

ause

it’s

inte

ract

ive,

ther

e’s

som

eone

talk

ing

to

you,

exp

lain

ing

it to

you

, with

slid

es. I

t’s e

asy

to u

nder

stan

d. T

hey

don’

t go

into

long

-win

ded

expl

anat

ions

.” (N

urse

#1,

Rou

nd #

1)

Film

dis

play

ing

impl

emen

tatio

n of

sha

red

deci

sion

-mak

ing:

goo

d sy

nthe

sis,

hand

s-on

, a re

alis

tic e

xam

ple

of S

DM

app

licat

ion

and

of d

ecis

ion

box

use,

the

dem

onst

ratio

n of

bes

t pra

ctic

es is

val

ued

(as

oppo

sed

to th

e de

mon

stra

tion

of b

ad p

ract

ices

), th

e in

ter-

activ

e ex

erci

se a

fter

vie

win

g of

the

film

is a

ppre

ciat

ed to

allo

w c

ritic

al a

ppra

isal

of t

he b

ehav

iour

dis

play

ed

“As

a m

atte

r of f

act,

it’s

prob

ably

the

mos

t int

eres

ting

part

bec

ause

in

the

begi

nnin

g it’

s al

l the

ory,

and

then

, it’s

mor

e ab

out p

ract

ice,

so

in m

y vi

ew, i

t’s e

xtre

mel

y re

leva

nt.” (

Phys

icia

n #5

, Rou

nd #

1)

Qui

z on

num

erac

y: a

llow

s be

com

ing

awar

e of

the

chal

leng

es o

f ris

k co

mm

unic

atio

n, re

quire

s re

flect

ion,

fun,

and

app

ropr

iate

lear

n-in

g m

odal

ity w

ith q

uest

ions

-ans

wer

s“S

ure,

it p

uts

us to

the

test

! [la

ughs

]. Bu

t it m

akes

you

real

ize

that

w

e al

l hav

e di

ffere

nt s

kills

ets,

incl

udin

g co

mpr

ehen

sion

… “

(Phy

sici

an #

3, R

ound

#1)

Exer

cise

on

the

barr

iers

/myt

hs re

late

d to

sha

red

deci

sion

-mak

ing:

app

ropr

iate

lear

ning

mod

ality

as

it is

inte

ract

ive,

real

istic

in th

at it

de

scrib

es ty

pica

l myt

hs p

ropa

gate

d by

HC

Ps“It

’s re

ally

inte

ract

ive.

I lik

e th

at. N

ot to

o m

uch

read

ing.

Poi

nt fo

rm. I

ju

st re

tain

info

rmat

ion

bett

er th

at w

ay.” (

Phys

icia

n #1

3, R

ound

#3)

Intr

oduc

tion

vide

o: c

lear

, brie

f, an

d vi

sual

“It p

uts

thin

gs in

to c

onte

xt n

icel

y. I

real

ly li

ke th

e pa

rt w

here

she

sh

ows

wha

t the

web

site

look

s lik

e an

d th

e di

ffere

nt fe

atur

es o

f it.

” (Ph

ysic

ian

#13,

Rou

nd #

3)


Tabl

e 2

(con

tinu

ed)

Them

es a

nd s

ubth

emes

Illus

trat

ive

cita

tion

Pers

onal

sto

ries

usin

g vi

deos

with

ava

tars

: int

egra

te m

uch

info

rmat

ion,

and

nic

e fo

rmat

“I’ll

rem

embe

r the

litt

le a

vata

r guy

. It’s

a g

ood

mem

ory

aid.

Lik

e po

p-up

rem

inde

rs: ‘O

h ye

ah, I

nee

d to

take

out

suc

h an

d su

ch a

th

ing’

or ‘

That

rem

inds

me

of m

y pa

tient

’… b

ecau

se w

e ha

ve n

o sh

orta

ge o

f doc

umen

ts, a

bout

ant

ibio

tics,

abou

t thi

s or

that

… I

foun

d it

inte

rest

ing,

the

use

of a

vis

ual a

spec

t lik

e th

at…

it’s

a bi

t ‘li

ghte

r’” (P

hysi

cian

#5,

Rou

nd #

1)

Ove

rall

prog

ram

: allo

ws

brin

ging

eve

ryon

e to

the

sam

e le

vel,

appr

ecia

ted

inte

grat

ion

with

the

dire

ctor

y of

dec

isio

n bo

xes,

valu

ed

the

dive

rsity

of l

earn

ing

mod

aliti

es, t

opic

s w

ell-i

llust

rate

d, a

ppro

pria

te le

ngth

, cle

ar n

avig

atio

n th

roug

hout

pro

gram

“The

inte

ract

ive

feat

ures

you

put

in w

ere

not t

oo lo

ng. T

hey

wer

e at

just

the

right

tim

e, a

nd it

mix

ed u

p th

e rh

ythm

a b

it. I

thou

ght

it w

as re

ally

goo

d.” (

Phys

icia

n #1

3, R

ound

#3)

Crit

ical

app

rais

al e

xerc

ise:

app

reci

ated

that

som

e pa

rt o

f the

text

is h

ighl

ight

ed, w

ell-s

ynth

esiz

ed, c

lear

, nov

el in

form

atio

n, a

ppre

ci-

ated

inte

ract

ivity

, cha

lleng

ing

“Of c

ours

e, I’m

real

ly o

n th

e gr

ound

and

ver

y ha

nds-

on. S

o, w

hen

I ha

ve to

dea

l with

rese

arch

find

ings

and

sci

entifi

c la

ngua

ge, y

ou

lose

me

a bi

t. Bu

t wha

t I fo

und

good

was

that

you

put

the

mai

n m

essa

ge in

bol

d. Y

ou d

on’t

have

to re

ad th

e w

hole

sta

tem

ent.

I ju

st re

ad th

e pa

rt in

bol

d an

d I g

ot th

e gi

st o

f it.”

(Soc

ial w

orke

r #1

5, R

ound

#3)

To L

earn

Mor

e se

ctio

n: a

ppre

ciat

ed“It

’s re

ally

goo

d be

caus

e th

ere

are

alw

ays

peop

le w

ho w

ant t

o le

arn

mor

e or

inve

stig

ate

furt

her.

If th

ere’

s so

met

hing

they

did

n’t

unde

rsta

nd, t

hey

can

go d

irect

ly to

the

sour

ces,

whi

ch I

thou

ght

was

goo

d.” (

Soci

al w

orke

r #15

, Rou

nd #

3)


Tabl

e 3

Wea

knes

ses

of e

-lear

ning

com

pone

nt o

f the

pro

gram

Them

es a

nd S

ubth

emes

Illus

trat

ive

cita

tion

Lack

of c

lari

tyTr

aini

ng m

odal

ity: m

ore

inst

ruct

ions

nee

ded

on w

hat i

s a

deci

sion

box

and

how

to a

cces

s th

em, e

xerc

ise

is u

ncle

ar“A

t firs

t I w

onde

red

wha

t the

dec

isio

n bo

x w

as. B

ut in

real

ity

they

’re to

ols.

It co

uld

be a

goo

d id

ea to

men

tion

wha

t it i

s, be

caus

e, in

the

begi

nnin

g, I

didn

’t kn

ow w

hat i

t was

. I th

ough

t it

was

som

ethi

ng o

ptio

nal,

but r

eally

it’s

not.”

(Phy

sici

an #

5, R

ound

#1

)

Unc

lear

con

tent

: im

port

ant i

nfor

mat

ion

shou

ld b

e hi

ghlig

hted

or b

olde

d, m

ore

prec

isio

ns re

quire

d, m

issi

ng in

form

atio

n[N

ote

from

the

auth

or: T

he p

artic

ipan

t is

disc

ussi

ng th

e cr

itica

l ap

prai

sal e

xerc

ise]

“I d

on’t

know

if p

eopl

e w

ill u

nder

stan

d it.

The

y ar

en’t

nece

ssar

ily s

impl

e te

rms.

It’s

not t

he k

ind

of th

ing

you

see

ever

y da

y. E

spec

ially

not

for c

linic

ians

who

don

’t do

muc

h re

sear

ch. F

or th

ose

who

’re in

jour

nal c

lubs

, it’s

usu

ally

abo

ut

inte

rven

tions

and

rela

tive

risks

… th

at s

ort o

f thi

ng.” (

Phys

icia

n #1

4, R

ound

#3)

Usa

bilit

yBr

owsi

ng is

sues

bet

wee

n pa

ges

or s

ectio

ns: n

ot in

tuiti

ve e

noug

h, n

eed

to c

larif

y ho

w to

mov

e to

the

next

sec

tion

afte

r com

plet

ing

an e

xerc

ise,

acc

ess

to o

ptio

nal c

onte

nt is

unc

lear

“I di

dn’t

know

whe

re to

clic

k. I’m

not

ver

y te

ch-s

avvy

. I w

asn’

t sur

e w

hat y

ou m

eant

by

‘Tar

get C

lient

ele.’

But

now

I un

ders

tand

that

it’

s pa

rt o

f the

intr

oduc

tion.

May

be y

ou c

ould

say

‘Intr

oduc

tion’

in

stea

d of

‘Tar

get C

lient

ele?

’” (Ph

ysic

ian

#11,

Rou

nd #

3)

Issu

es w

ith c

licka

ble

elem

ents

: ref

eren

ces

with

in n

arra

ted

slid

e sh

ows

shou

ld b

e cl

icka

ble,

ele

men

t dis

posi

tione

d, s

ome

slid

es

shou

ld b

e re

orde

red,

con

fusi

ons

betw

een

butt

ons

to m

ove

to th

e ne

xt p

age

“Clic

k he

re to

beg

in re

adin

g […

]. Th

e ar

row

is in

the

wro

ng p

lace

.” (P

hysi

cian

#7,

Rou

nd #

2)

Elem

ents

too

smal

l: im

ages

, nar

rate

d sl

ide

show

“It w

ould

be

good

to m

ake

the

butt

on m

ore

visi

ble.

I’m im

agin

ing

som

eone

who

’s no

t ver

y co

mfo

rtab

le w

ith c

ompu

ters

… y

ou

know

, som

etim

es, d

epen

ding

on

your

scr

een,

it c

an b

e ha

rder

to

see.”

(Phy

sici

an #

5, R

ound

#1)

Irre

leva

nt o

r of l

ess

valu

eCo

nten

t unr

ealis

tic: s

tatin

exa

mpl

e irr

elev

ant f

or p

eopl

e at

low

risk

of c

ardi

ovas

cula

r dis

ease

s, th

e fil

m d

ispl

ays

a si

mul

atio

n, n

ot

real

ity“In

real

ity, I

’m n

ot s

ure

peop

le w

ould

be

incl

ined

to ta

lk a

bout

tak-

ing

stat

ins

with

a p

atie

nt w

ho’s

low

risk

. I u

nder

stan

d; I’

ve s

een

the

stud

ies

show

ing

ther

e m

ay b

e so

me

bene

fits,

but a

t the

sa

me

time,

with

figu

res

like

that

, it’s

not

nec

essa

rily

a ca

se w

here

I w

ould

use

sha

red

deci

sion

-mak

ing.

” (Ph

ysic

ian

#14,

Rou

nd #

3)

Irrel

evan

t for

spe

cific

aud

ienc

es: c

linic

al in

form

atio

n no

t app

licab

le to

all

prof

essi

ons,

info

rmat

ion

mor

e re

leva

nt fo

r old

er H

CPs

, in

form

atio

n le

s us

eful

to e

xper

ienc

ed/le

ss e

xper

ienc

ed p

hysi

cian

s“T

his

part

is a

bit

mor

e ab

out t

he m

edic

al s

ide,

and

that

one

cou

ld

be m

ore

for s

ocia

l wor

kers

or o

ther

s. Su

re, t

here

are

thin

gs th

at

are

a bi

t les

s re

leva

nt fo

r me

that

I ca

n st

ill e

xplo

re fu

rthe

r, bu

t yo

u kn

ow, w

hen

I see

cer

tain

thin

gs, I

’m m

ore

likel

y to

just

refe

r th

em…

“ (S

ocia

l wor

ker #

9, R

ound

#2)

Inap

prop

riat

e le

arni

ng s

trat

egie

sVi

gnet

te w

ith a

vata

rs d

ispl

ayin

g pa

tient

cou

nsel

ing

stra

tegi

es: n

ot re

alis

tic e

noug

h, ro

bot-

like,

chi

ldis

h, in

form

atio

n is

too

theo

reti-

cal,

optio

nal c

onte

nt“W

hen

you’

re a

clin

icia

n an

d yo

u w

atch

that

, you

see

inte

rvie

w

tech

niqu

es w

ith th

e pa

tient

. The

pro

blem

with

the

vide

o is

that

th

e av

atar

s do

n’t h

ave

any

into

natio

n. W

hen

we’

re ta

ught

how

to

com

mun

icat

e w

ith o

ur p

atie

nts,

we’

re ta

ught

wha

t int

onat

ions

to

use

. But

in th

is c

ase,

ther

e is

no

into

natio

n. T

hey

alw

ays

spea

k in

exa

ctly

the

sam

e to

ne o

f voi

ce.” (

Phys

icia

n #5

, Rou

nd #

1)


Tabl

e 3

(con

tinu

ed)

Them

es a

nd S

ubth

emes

Illus

trat

ive

cita

tion

Crit

ical

app

rais

al e

xerc

ise

(Coc

hran

e re

view

on

the

impa

cts

of p

atie

nt d

ecis

ion

aids

): in

form

atio

n la

yout

sho

uld

be im

prov

ed, b

or-

ing,

read

ing

is le

ss a

ppre

ciat

ed a

s le

arni

ng s

trat

egy

“I ha

te re

adin

g st

udie

s, es

peci

ally

stu

dies

in E

nglis

h! I

get c

onfu

sed

with

the

wor

ds […

]. Ev

en in

Fre

nch,

I do

n’t l

ike

it, b

ut in

Eng

lish

it’s

even

wor

se! I

’m ju

st n

ot in

tere

sted

. Esp

ecia

lly w

ith th

e w

ay

it’s

pres

ente

d he

re. T

here

are

too

man

y fig

ures

and

, in

any

case

, it

real

ly d

oesn

’t in

tere

st m

e.” (P

hysi

cian

#2,

Rou

nd #

1)

Film

: unr

ealis

tic. c

omm

unic

atio

n of

sta

tistic

stil

l con

fusi

ng“T

he fa

ct re

mai

ns th

at it

’s a

sim

ulat

ed in

terv

iew

. You

kno

w, i

t’s n

ot

real

ity. I

t loo

ks n

ice,

but

in re

al li

fe, i

t’s n

ot o

ften

like

that

.” (Ph

ysi-

cian

#6,

Rou

nd #

2)

Too

long

: the

who

le p

rogr

am is

too

long

, som

e se

ctio

ns a

re to

o lo

ng, t

he fi

lm is

too

long

, som

e ex

erci

ses

are

too

long

“I th

ink

it’s

a bi

t lon

g in

pla

ces.

The

cont

ent o

n de

cisi

on a

id to

ols

was

per

haps

a b

it lo

ng. T

here

wer

e se

vera

l slid

es p

rese

ntin

g th

e to

ols,

and

I figu

re p

eopl

e w

ill b

e ab

le to

und

erst

and

it ea

sily

en

ough

. Aft

er a

ll, it

’s ai

med

at H

CPs

.” (Ph

ysic

ian

#7, R

ound

#2)

Dry

: rel

evan

t but

dry

(crit

ical

app

rais

al e

xerc

ise,

and

con

tent

on

evid

ence

app

rais

al)

“Whe

n yo

u ge

t to

this

par

t, it

shift

s fro

m v

isua

l mod

e, w

hich

is

easi

er to

follo

w, t

o a

mor

e pu

rely

info

rmat

iona

l mod

e, w

ith

wor

ds in

Eng

lish

and

all t

hat,

and

lots

of t

ext.

[…]T

he in

form

a-tio

n is

cle

ar e

noug

h, b

ut it

’s pe

rhap

s a

little

har

der t

o fin

d it.

It’s

not a

s si

mpl

e as

with

the

vide

os.” (

Phys

icia

n #5

, Rou

nd #

1)

Tech

nica

l iss

ues:

vid

eo d

oes

not w

ork,

diffi

culti

es m

ovin

g to

the

next

slid

es, f

eedb

ack

does

not

sho

w, l

oosi

ng th

e In

tern

et c

onne

c-tio

n“T

he v

ideo

feed

back

doe

sn’t

show

up,

onl

y te

xt.” (

Soci

al w

orke

r #1

5, R

ound

#3)

Bori

ng: fi

rst p

art i

s bo

ring,

read

ing

is b

orin

g, n

arra

ted

slid

e sh

ows

are

borin

g, la

ck o

f ani

mat

ion

“I’m

a v

ery

visu

al p

erso

n. W

hen

ther

e ar

e lo

ng s

tret

ches

of n

arra

-tio

n on

ly, I

just

sw

itch

off.” (

Phys

icia

n #1

3, R

ound

#3)

Term

inol

ogy

issu

es: a

cron

yms

shou

ld b

e de

fined

, som

e te

rms

that

are

too

stro

ng, u

ncle

ar te

rmin

olog

y, w

hat d

o “o

ptio

n” a

nd

“num

erac

y” m

ean?

, avo

id th

e te

rm “c

hoos

ing

the

optio

n of

doi

ng n

othi

ng”, s

ome

term

s ar

e di

fficu

lt to

und

erst

and

“A li

st o

f ava

ilabl

e he

alth

opt

ions

… I

can’

t pic

ture

exa

ctly

wha

t tha

t m

eans

.” (Ph

ysic

ian

#3, R

ound

#1)

Risk

com

mun

icat

ion

seem

s ch

alle

ngin

g“I

don’

t alw

ays

reca

ll al

l the

pro

babi

lity

perc

enta

ges.

In a

sin

gle

day.

I m

ight

see

fift

een

patie

nts,

all w

ith d

iffer

ent p

robl

ems.

I can

’t al

way

s re

mem

ber o

ff th

e to

p of

my

head

wha

t the

pro

babi

litie

s ar

e.” (P

hysi

cian

#2,

Rou

nd #

1)

Opt

iona

l con

tent

Ove

rall

desc

riptio

n of

the

prog

ram

, pro

gram

des

ign

team

, “Y

ou k

now

, we’

re s

o pu

shed

for t

ime

that

we

real

ly w

ant t

o ge

t st

raig

ht to

the

poin

t whi

ch, i

n th

is c

ase,

is th

e tr

aini

ng. I

get

it

that

it’s

real

ly w

ell d

one

and

all t

hat,

but I

wou

ld s

till t

ry to

con

-de

nse

it a

bit m

ore.”

(Phy

sici

an #

5, R

ound

#1)

GRA

DE

qual

ity o

f evi

denc

e as

sess

men

t: ou

tsid

e th

e pr

ogra

m’s

scop

e, in

form

atio

n th

at is

alre

ady

know

n, c

over

ed in

oth

er p

rogr

ams

“I fo

und

it le

ss re

leva

nt fo

r sha

red

deci

sion

-mak

ing,

whi

ch m

ade

it le

ss in

tere

stin

g.. [

…].

If I w

ante

d to

wat

ch a

web

inar

on

shar

ed

deci

sion

-mak

ing,

I w

ould

n’t w

ant t

o w

atch

that

.” (Ph

ysic

ian

#8,

Roun

d #2

)

Inco

mpl

ete,

mis

sing

info

rmat

ion:

mis

sing

sou

rces

, spe

cific

det

ails

mis

sing

, mis

sing

feed

back

on

som

e ex

erci

ses,

abbr

evia

tions

or

acro

nym

s ar

e no

t defi

ned

“I do

n’t k

now

if it

’s fe

asib

le, b

ut it

wou

ld h

ave

been

fun

to h

ave

a D

B in

han

d to

follo

w a

long

at t

he s

ame

time

as th

e tr

aini

ng s

es-

sion

.” (Ph

ysic

ian

#8, R

ound

#2)

Redu

ndan

t con

tent

: cou

ld b

e sh

orte

ned,

slig

htly

too

repe

titiv

e“A

t one

poi

nt th

ey g

ive

a lo

t of e

xam

ples

. May

be th

ere

are

som

e th

ings

that

cou

ld b

e re

mov

ed.” (

Phys

icia

n #7

, Rou

nd #

2)


Tabl

e 3

(con

tinu

ed)

Them

es a

nd S

ubth

emes

Illus

trat

ive

cita

tion

Info

rmat

iona

l or t

ypog

raph

ic e

rror

“’Are

you

sure

abo

ut w

hich

cho

ice

is be

st fo

r you

?’ Kn

owin

g so

me

of

my

elde

rly p

atie

nts,

I thi

nk th

is q

uest

ion

coul

d de

stab

ilize

them

or

mak

e th

em fe

el le

ss c

onfid

ent i

n th

eir d

ecis

ion.

I w

ould

n’t

have

wor

ded

it th

at w

ay. I

wou

ld h

ave

valid

ated

that

that

is

the

deci

sion

they

wan

t to

mak

e, b

ut I

find

it a

bit s

tron

g to

use

w

ords

like

‘cer

tain

’ or ‘

best

.’ Per

sona

lly, I

wou

ld h

ave

take

n a

gen-

tler a

ppro

ach

in th

at s

ense

.” (Ph

ysic

ian

#11,

Rou

nd #

3)

Patie

nt P

refe

renc

es s

ectio

n to

o sh

ort:

mor

e co

mm

unic

atio

n tip

s sh

ould

be

offer

ed“N

ot e

very

one

in th

e m

edic

al fi

eld

has

good

pat

ient

com

mun

ica-

tion

skill

s, so

I th

ink

you

coul

d ex

pand

this

sec

tion

a bi

t.” (S

ocia

l w

orke

r #15

, Rou

nd #

3)


non-pharmacological treatment to manage agitation, aggression, or psychotic symptoms (88% ± SD 11%). Participants mentioned that they liked the visual design of the DBs, because it facilitates their use in practice, especially the tabular format presenting risks and ben-efits/harms (Table 4). Several participants also expressed their satisfaction with the informational content of the DBs, especially the information about the options. Some mentioned that the DBs helped make them aware of the options, or found that the options were relevant. One person appreciated the fact that the DB was available to support older adults in realizing, on their own, that their driving might be dangerous. They thought this might help maintain their relationship with patients.

The limitations reported by study participants on the decision boxes allowed enhancing them to improve user experiences. Some of the modifications made were quite extensive. For example, several participants reported lower beliefs about their capabilities to use the DB to explain the pros and cons of health options to patients, because of the lack of accessibility to the services described in the DB (Table 5). We judged this a critical flaw, as if it remained unresolved, HCPs would not use the DB and adopt SDM. Therefore, to resolve this aspect, we added a section with a list of contact information for professional and community services available to imple-ment the options offered in the DB, such as massage ther-apy, music therapy, and physical activity. Another critical flaw was that several participants perceived that they might not have enough time to use the DB. We there-fore added some content describing the situations where SDM should be prioritized. We also added information about the possibility to delay decision-making to a subse-quent consultation, and thus limit the time needed to go through the complete SDM process.

In some cases, we chose not to attempt to resolve the issues raised. For example, some participants felt the statistics were too hard for patients and their family caregivers to understand. Since probabilities in numeri-cal formats are required to understand risks, we chose not to change the risks presentation in the DBs. Instead, we modified the e-learning activity by adding a module describing best practices to communicate risks to people with lower numeracy skills.

Similarly to the e-learning activity, many of the par-ticipants’ comments were specific and easily addressed. For example, participants mentioned that the informa-tion was too dense, the terminology challenging, or some usability issues. We therefore adjusted the content of the DBs to reduce their length and complexity, and thereby limit the time needed to understand them, without com-promising their meaning. We kept the use of jargon to a minimum, and added a glossary where we were unable to

find simplified terminology. We also synthesized the sci-entific information on the pros and cons of the options in summary tables where possible. When there were more than two options for a given clinical situation, we added a table setting out the potential options for the decision at hand on the first page, including the estimates of the probabilities of impacts for each option, as well as the corresponding page detailing the impacts.

A few physicians reported that the topic covered by DB #5 (Power of Attorney) was irrelevant to their pro-fessional role. In an earlier Delphi study [41], we identi-fied a need in primary care practices for decision support regarding this topic. We consequently attempted to improve DB #5 by making some of the legal aspects of the power of attorney easier to understand so that HCPs, especially physicians, can take ownership of the content and become more comfortable discussing it with their patients.

Tailoring content based on participants perceptions of SDMWe explored participants’ beliefs about consequences, or usefulness of SDM process after completing the e-learn-ing activity. Participants’ descriptions of the benefits and inconveniences of SDM (Table 6), were very useful to appraise participants knowledge after training, and tailor the content to improve knowledge. Several of these com-ments pointed to known barriers to adopting SDM. We added specific content to the existing modules to address each of these concerns. Overall, these comments led us to describe several strategies for adopting SDM in diverse clinical situations, for example, where time is limited, when there is an emergency and a decision cannot be delayed, when the patients’ preferences go against those of the professional, when risk is low, or when there are several decisions to be made. We also clarified the role of HCPs in situations where the patient’s choice appears contrary to public health recommendations.

Some of the participants’ comments after reading a decision box also point to a lack of knowledge about SDM, for example that DBs are of little use when stating their opinion or making recommendations (Table 6). To improve understanding of the SDM approach, we added an introductory paragraph to all DBs, entitled “What’s this document for?” which described the gen-eral SDM approach. We also added patient stories to most of the DBs, usually demonstrating an encounter between a patient and a clinician, to demonstrate the value of seeking patient priorities. The stories were created from testimonies gathered online and were validated by the expert panel. These strategies proved effective, as we received no more comments suggest-ing that SDM might not be well understood after these changes.


Changes in the level of intention as the rounds progressedE‑learning activityVisual examination of the quantitative descriptive results suggests that there was no change in participants’ intention to adopt SDM after their participation in the e-learning activity. Intention was relatively high and

stable across the three rounds, with a mean level of 6.8, on a scale ranging from 1 (low intention) to 7 (high inten-tion) (Additional file 1). Mean levels of potential factors influencing intention were also relatively high, ranging from 5.6 to 7.0, on a scale ranging from 1 to 7.

Table 4 HCPs’ perceptions of the strengths of the Decision Boxes

*DB #1 = Choosing a support option to decrease caregiver burden; DB #2 = Choosing a non-pharmacological treatment to manage agitation, aggression, or psychotic symptoms; DB #3 = Deciding whether or not to stop driving following diagnosis; DB #4 = Choosing an option to improve quality of life; DB #5 = Deciding whether or not to prepare a power of attorney.

Themes and Subthemes Illustrative citation*

Visual designGood visual design “Very nice tool with an excellent visual pres-

entation.” (Physician #22, Round #1, DB #3) ; “Well-designed tool. Easy to use.” (Physician #31, Round #2, DB #3)

Tabular format: tables are very clear and visual “Very clear, visually appealing tables. The Confi-dence in these results pictograms could be a bit more visible (black dots rather than a cross? Bigger circles?). The presentation page (page 1) is a bit dry to read, but essential for explaining the goal.” Physician #12, Round #1, DB #1)

Balance between benefits and harms is useful“Nice layout of benefits vs harms.” (Physician #74, Round #4, DB #2)

Informational contentValue of the information about the options “The box presents some very interesting options.”

(Physician #32, Round #3, DB #1)

Raises awareness about certain options “The role of case manager no longer exists in many CLSCs. Highly relevant and appropriate for our family caregivers who are unsure or unaware of which resources to turn to. I will definitely use it.” (Social worker #12b, Round #4, DB #1) ; “Great idea for improving our client service.” (Social worker #48, Round #4, DB #4)

Information allows HCPs to keep up-to-date and to empower patients “Nice tool that allows us to be more professional and access up-to-date knowledge. Also enables us to show that we respect the client’s values. Helps empower them.” (Social worker #48, Round #4, DB #1)

A tool to help older adults realize themselves their own risks “Very interesting toolbox for guiding and helping patients realize on their own that their driving may not be safe, instead of having the impres-sion, as a doctor, that you are taking away their license and their autonomy. It helps maintain the quality of the therapeutic relationship.” (Physician #36b, Round #4, DB #3)

Useful to remind me of something I already know “The information in the box will be helpful for refreshing my memory on the various power of attorney options.” (Physician #31, Round #1, DB #5)

Implementation of SDMUseful to adopt a shared decision-making approach in their practice “I have never (or rarely) discussed stopping driving

with a patient based on the risks and benefits to the patient. Rather, I tried to test the patient’s skills through tests without necessarily dwelling on his understanding of the risks of driving. Participation in this study will make me more likely to approach the risk-benefit aspect with the patient in the future.” (Physician #12, Round #3, DB #3)


Tabl

e 5

HCP

s’ pe

rcep

tion

s of

the

wea

knes

ses

of th

e D

ecis

ion

Boxe

s by

theo

reti

cal d

omai

n.

Theo

retic

al D

omai

n, W

eakn

ess

Illus

trat

ive

cita

tion*

Inte

ntio

nI h

ave

no in

tent

ion

of c

hang

ing

my

day-

to-d

ay a

ppro

ach.

“The

info

rmat

ion

in th

e de

cisi

on b

ox w

ill b

e us

eful

to m

e to

re

fresh

my

mem

ory

on th

e di

ffere

nt p

rote

ctio

n re

gim

es b

ut I

do

not b

elie

ve th

at I

will

cha

nge

my

way

of d

oing

thin

gs fr

om d

ay

to d

ay.” (

Phys

icia

n #3

1, R

ound

#1,

DB

#5)

Belie

f abo

ut c

onse

quen

ces

of u

sing

the

DB;

Use

fuln

ess

of th

e D

BTh

e D

B is

not

wel

l ada

pted

to e

very

pat

ient

, nor

is it

ada

pted

to e

very

situ

atio

n“T

he fa

cts

wer

e ge

nera

lly k

now

n to

me,

eve

n th

ough

I di

d no

t ha

ve p

reci

se s

tatis

tics.

In a

dditi

on, e

ach

case

is d

iffer

ent,

and

I do

not b

elie

ve th

at a

pply

ing

this

box

will

allo

w m

e to

bet

ter t

arge

t th

e ne

cess

ary

inte

rven

tions

.” (Ph

ysic

ian

#19,

Rou

nd #

2, D

B #3

)

DBs

do

not a

dd a

ny v

alue

to c

linic

al p

ract

ice

“We

unde

rsta

nd th

at q

ualit

y of

life

is th

e m

ain

obje

ctiv

e, b

ut th

e to

olbo

x, a

lthou

gh in

tere

stin

g, is

hea

vy a

nd b

rings

not

hing

mor

e to

the

clin

ical

leve

l.” (P

hysi

cian

#31

, V3,

DB

#5)

DBs

are

not

hel

pful

to a

nnou

nce

my

own

opin

ion/

reco

mm

enda

tion

"Wha

t is

mos

t diffi

cult

is to

ann

ounc

e ou

r opi

nion

s w

hen

they

ar

e ve

ry d

iver

gent

from

thos

e of

the

patie

nt o

r the

fam

ily, a

nd

I do

not b

elie

ve th

at th

e de

cisi

on b

ox h

elps

us."

(Phy

sici

an #

19,

Roun

d #2

, DB

#3)

Stat

istic

s ar

e us

eles

s"T

he D

B, w

hile

inte

rest

ing,

is c

umbe

rsom

e an

d br

ings

not

hing

m

ore

to c

linic

al p

ract

ice."

(Doc

tor #

31, R

ound

#3,

DB

#4)

The

sam

e in

form

atio

n ca

n be

offe

red

info

rmal

ly w

ithou

t pre

sent

ing

the

DB

“The

re a

re m

any

tool

s fo

r diff

eren

t asp

ects

of m

edic

ine,

and

the

use

of c

oncr

ete

tool

s is

diffi

cult,

but

the

idea

con

veye

d by

thes

e to

ols

can

be tr

ansm

itted

ver

bally

to p

atie

nts

info

rmal

ly th

roug

h ot

her i

nfor

mat

ion.

” (Ph

ysic

ian

#9, R

ound

#1,

DB

#5)

Info

rmat

ion

is h

arm

ful t

o in

terp

rofe

ssio

nal c

olla

bora

tion

"I w

as s

urpr

ised

by

the

stat

istic

s th

at 1

% to

3%

of t

hera

pist

s co

m-

mit

sexu

al a

cts

that

cou

ld h

inde

r the

pro

cess

of c

are.

Con

side

r-in

g th

e lo

w p

ropo

rtio

n of

men

, the

per

cent

age

of th

erap

ists

w

ith d

evia

nt b

ehav

iour

s se

ems

to m

e to

be

high

. I v

ery

muc

h do

ubt t

his

stat

istic

. As

I am

a m

an, I

find

that

this

sta

tistic

mig

ht

affec

t ref

erra

l and

the

confi

denc

e of

the

doct

or to

war

ds th

e th

erap

ists

." (S

ocia

l wor

ker #

69, R

ound

#4,

DB

#1)

Alre

ady

awar

e of

this

info

rmat

ion

“I w

as a

war

e of

the

fact

s, bu

t not

of t

he e

xact

sta

tistic

s.“ (P

hysi

cian

#1

9, R

ound

#2,

DB

#3)

Belie

f abo

ut c

apab

ilitie

s: I

mig

ht n

ot b

e ab

le to

use

the

DB

to p

rese

nt th

e pr

os a

nd c

ons

of h

ealth

opt

ions

to p

atie

nts

beca

use…

… it

is c

halle

ngin

g to

acc

ess

the

serv

ices

offe

ring

the

heal

th o

ptio

ns d

escr

ibed

in th

e D

B “A

cces

sibi

lity

rem

ains

a p

robl

em in

man

y re

gion

s of

Que

bec.

The

se

data

hav

e be

en c

olle

cted

to fa

cilit

ate

disc

ussi

on, b

ut th

e bu

lk

of th

e w

ork

that

will

ulti

mat

ely

incr

ease

the

patie

nt’s

qual

ity o

f lif

e is

not

the

DB,

but

the

long

-ter

m a

cces

sibi

lity

to th

is ty

pe o

f se

rvic

e.” (P

hysi

cian

#32

, Rou

nd #

2, D

B #4

).

…it

is c

halle

ngin

g to

pre

sent

sta

tistic

s"W

hen

patie

nts

and

thei

r fam

ily c

areg

iver

s ar

e in

our

offi

ce, t

alki

ng

abou

t sta

tistic

s is

unt

hink

able

. It i

s al

read

y ve

ry d

ifficu

lt to

onl

y ta

lk a

bout

the

real

ity o

f eve

ryda

y lif

e." (N

urse

#14

, Rou

nd #

2, D

B #1

)


*DB

#1=

Cho

osin

g a

supp

ort o

ptio

n to

dec

reas

e ca

regi

ver b

urde

n; D

B #2

= C

hoos

ing

a no

n-ph

arm

acol

ogic

al tr

eatm

ent t

o m

anag

e ag

itatio

n, a

ggre

ssio

n, o

r psy

chot

ic s

ympt

oms;

DB

#3=

Dec

idin

g w

heth

er o

r not

to s

top

driv

ing

follo

win

g di

agno

sis;

DB

#4=

Cho

osin

g an

opt

ion

to im

prov

e qu

ality

of l

ife; D

B #5

= D

ecid

ing

whe

ther

or n

ot to

pre

pare

a p

ower

of a

ttor

ney.

Tabl

e 5

(con

tinu

ed)

Theo

retic

al D

omai

n, W

eakn

ess

Illus

trat

ive

cita

tion*

…I d

on’t

have

tim

e‘’O

ffice

day

s ar

e be

com

ing

heav

ier a

nd h

eavi

er a

nd it

is n

ow p

os-

sibl

e to

use

the

serv

ices

of o

ur p

aram

edic

al s

taff

to c

onve

y m

ore

com

plet

e in

form

atio

n so

we

can

focu

s m

ore

on c

linic

al ta

sks.”

(P

hysi

cian

#31

, Rou

nd #

1, D

B #5

).

...I d

on’t

know

how

to a

cces

s th

e D

Bs.

“Acc

ess

to th

e D

B sh

ould

be

faci

litat

ed.” (

Nur

se #

15, R

ound

#2,

DB

#4)

Ease

of U

seTh

e D

B us

es u

nfam

iliar

jarg

on o

r ter

min

olog

y"T

he te

rms

used

are

lega

l ter

ms

and

it’s

a to

ugh

jarg

on fo

r me."

(P

hysi

cian

#20

, Rou

nd #

2, D

B #5

)

The

info

rmat

ion

is to

o de

nse

and

shou

ld b

e sy

nthe

size

d"T

he p

rese

ntat

ion

is to

o de

nse

and

too

com

plex

." (P

hysi

cian

#2,

Ro

und

#1, D

B #1

)

The

info

rmat

ion

is d

ifficu

lt to

und

erst

and

“I fo

und

the

late

st d

ata

on u

sing

vs

stop

ping

med

icat

ion

conf

us-

ing.

In th

e H

arm

s se

ctio

n, it

is h

ard

to in

terp

ret w

hat y

ou’re

tr

ying

to s

how

.” (Ph

ysic

ian

#32,

Rou

nd #

1, D

B #2

)

Usa

bilit

y of

the

DBs

cou

ld b

e im

prov

ed"T

he P

icto

gram

s fo

r the

Con

fiden

ce in

the

resu

lts s

ectio

n co

uld

be a

litt

le m

ore

visi

ble.

Cou

ld b

lack

dot

s be

use

d ra

ther

than

cro

sses

? Co

uld

the

circ

les

be e

nlar

ged?

" (Ph

ysic

ian

#12,

Rou

nd #

1, D

B #1

)

Soci

al in

fluen

ce: M

y co

lleag

ues

mig

ht n

ot u

se th

e D

B to

pre

sent

the

pros

and

user-centered and theory-based design of a professional ......user-centered and theory-based design...

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