105 Applying a DOI theory-based framework In our additional interviews, the adjective “realistic” was chosen seven times, and most participants believed that SDM aligned with their current practice. However, according to the interviewees, not all patients desire SDM, and team policies or strong advice can override it. A few clinicians expressed that SDM was unsuitable for certain patients who find it burdensome or are unable to make choices, suggesting that a paternalistic approach might be more suitable in such cases. Some admitted to being more controlling in specific situations, such as when there is a superior medical option, when patients explicitly request the doctor to decide, or when patients face difficulties in decision-making. Emergencies were also perceived as less suitable for SDM, and time constraints were mentioned as a reason to be more controlling: “Well, in my experience, if you have a hectic consultation schedule and end up running forty-five minutes behind at the end of the day, that [SDM] becomes constrained by time pressures. You think: Well, [a particular treatment option] would suit this woman. Consequently, you start steering towards a specific course of action more rapidly, rather than calmly engaging with the decision aid, discussing the options, and allowing the patient to leave and revisit the matter in the following week.” Source: additional interviews, gynecologist #3 We observed several limitations concerning time constraints: short consultation times, swift treatment protocols, and a fast-paced discussion of individual patient cases during meetings. As a result, there was limited space for SDM. Persuasion – Complexity Our interviews showed that levels of experience in gynecology care provision impacted the perceived difficulty of SDM, as residents more frequently mentioned finding SDM challenging compared to senior clinicians. The perceived complexity of executing SDM was situationally determined and aligned with the compatibility issues mentioned earlier. Factors such as patient intelligence and their ability to understand the SDM process and content, influenced by language barriers and cultural differences as well, played a significant role in determining the difficulty for healthcare professionals. Difficulties arose when options were unequal, patient preferences were unclear, unrealistic patient wishes existed, or clinicians were biased due to their opinions. “If you feel that a patient makes a choice that is very remote from you, which you do not support yourself, then it gets difficult. Because then, as a doctor, I might not want to participate in this treatment because that is not good for this patient. Is that shared decision-making? To me, it is not shared decision-making because we did not do it together.” Source: additional interviews, junior doctor #2 Sometimes, colleagues complicate the SDM process as well. Some participants expressed a lack of appreciation and felt the need to justify their decisions to colleagues when their decision-making deviated from the usual or medically preferred practice. As one resident puts it: 6
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