影响癌症护理中常规实施共享决策的主要因素：一项递进式整群随机试验的定性过程评价。
Major influencing factors on routine implementation of shared decision-making in cancer care: qualitative process evaluation of a stepped-wedge cluster randomized trial.
机构信息
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
Center of Health Care Research, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
出版信息
BMC Health Serv Res. 2023 Aug 8;23(1):840. doi: 10.1186/s12913-023-09778-w.
BACKGROUND
Shared decision-making (SDM) is highly relevant in oncology but rarely implemented in routine care. In a stepped-wedge cluster randomized implementation trial, the outcome evaluation of a theoretically and empirically based multi-component SDM implementation program did not show a statistically significant effect on patient-reported SDM uptake. Within this SDM implementation trial, a thorough a priori planned process evaluation was conducted. Thus, the aim of this study was to investigate factors influencing SDM implementation in the context of a multi-component SDM implementation program.
METHODS
We conducted qualitative process evaluation of a stepped-wedge SDM implementation trial. Qualitative data included interviews with nurses and physicians of participating departments, field notes by the study team, and meeting minutes. Data were analyzed via deductive and inductive qualitative content analysis on basis of the Consolidated Framework for Implementation Research (CFIR).
RESULTS
Transcripts of 107 interviews with 126 nurses and physicians, 304 pages of field note documentation, and 125 pages of meeting minutes were analyzed. Major factors influencing SDM implementation were found for all domains of the CFIR: a) four regarding characteristics of the individuals involved (e.g., perceived personal relevance, individual motivation to change), b) eleven regarding the inner setting (e.g., leadership engagement, networks and communication, available resources, compatibility with clinical practice), c) two regarding the outer setting (e.g., culture of health care delivery), d) eight regarding characteristics of the intervention (e.g., relative advantage, adaptability), and e) three regarding the implementation process (e.g., integration into existing structures). Furthermore, we found strong interrelations between several of the influencing factors within and between domains.
CONCLUSIONS
This comprehensive process evaluation complements the outcome evaluation of the SDM implementation trial and adds to its interpretation. The identified influencing factors can be used for planning, conducting, and evaluating SDM implementation in the future.
TRIAL REGISTRATION
clinicaltrials.gov, NCT03393351, registered 8 January 2018, https://clinicaltrials.gov/ct2/show/NCT03393351.
背景
在肿瘤学中，共同决策（SDM）非常重要，但在常规护理中很少实施。在一项阶梯式楔形集群随机实施试验中，基于理论和实证的多组件 SDM 实施计划的结果评估并未显示对患者报告的 SDM 采用率有统计学意义的影响。在这项 SDM 实施试验中，进行了彻底的事先计划的过程评估。因此，本研究的目的是调查在多组件 SDM 实施计划背景下影响 SDM 实施的因素。
方法
我们对阶梯式 SDM 实施试验进行了定性过程评估。定性数据包括参与部门的护士和医生的访谈、研究团队的现场记录和会议记录。根据实施研究综合框架（CFIR），对数据进行了演绎和归纳定性内容分析。
结果
对 126 名护士和医生的 107 次访谈、304 页现场记录文档和 125 页会议记录进行了分析。在 CFIR 的所有领域都发现了影响 SDM 实施的主要因素：a）四个涉及参与个体的特征（例如，感知到的个人相关性、个人改变的动机），b）十一个涉及内部环境（例如，领导参与、网络和沟通、可用资源、与临床实践的兼容性），c）两个涉及外部环境（例如，医疗保健交付文化），d）八个涉及干预措施的特征（例如，相对优势、适应性），以及 e）三个涉及实施过程（例如，融入现有结构）。此外，我们还发现了几个领域内和领域之间相互关联的影响因素。
结论
这项全面的过程评估补充了 SDM 实施试验的结果评估，并增加了对其的解释。确定的影响因素可用于未来的 SDM 实施规划、实施和评估。
试验注册
clinicaltrials.gov，NCT03393351，于 2018 年 1 月 8 日注册，https://clinicaltrials.gov/ct2/show/NCT03393351。
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