103 Applying a DOI theory-based framework Knowledge – Socioeconomic characteristics The group of clinicians, both gynecologists and residents, were very homogeneous. Specifically, they exhibited similarities regarding their higher socioeconomic status and cultural backgrounds. Knowledge – Personality variables Certain clinicians demonstrated higher interest and engagement in SDM than others. Through our observations, we noticed distinct personality differences among physicians, with some individuals displaying more assertiveness and expressing their opinions more firmly than others. The doctors themselves also acknowledged these differences. Knowledge – Communication behavior We identified a notable absence of emphasis on SDM in local protocols and national guidelines. Moreover, during meetings and handovers, patients’ preferences were lacking in discussion, meaning SDM was hardly integrated. Additionally, we observed variations in engagement and assertiveness among participants during group discussions. It became evident that more proactive and assertive individuals often assumed leadership roles when shaping policies and making decisions. Persuasion – Relative advantage The use of decision aids offered specific advantages, benefiting both clinicians and patients in the process of making treatment decisions. They provided valuable structure, assisting in clarifying the patient’s preferences and desires. They were crucial in presenting a comprehensive and realistic understanding of treatment options and their potential outcomes to the patient. As one participant highlighted: “Well, for example, I use the decision aid for heavy menstrual blood loss (…). That also gives me structure. One uses it as a handle to have that conversation.” Source: previous interview data, [20] resident #7 Participants considered it advantageous that SDM allowed patient interests to be visible, leading to better understanding and insight into the patient’s thoughts and feelings. It led to a stronger doctor-patient relationship, with patients appreciating the shared responsibility between clinicians and patients in the decision-making process, as well as improved health outcomes, better quality of care, and providing patients with better explanations and informed decision-making. SDM involved patients more consciously in the decision-making process, making them aware of disadvantages and reducing regret or blame in case of adverse outcomes: “You also create clear expectations with the patient by explaining which treatment option has risks and what success rates comprise. So, I also think that, ultimately, if a treatment does not work, patients will at least appreciate being included in the process.” Source: additional interviews, gynecologist #3 6
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