114 Chapter 7 Shared decision-making (SDM) is a collaborative healthcare approach in which healthcare providers and patients work together to make informed, mutually agreed-upon decisions regarding the patient’s care, considering the patient’s preferences, values, and the best available evidence. [1] Despite previous dedicated efforts, realizing the full potential of SDM in routine patient care remains challenging. Practitioners frequently grapple with inconsistencies or shortcomings in integrating SDM into their practice, and critical treatment decisions still lack comprehensive, collaborative discussions and preference formation. This concluding chapter addresses the over-arching research questions introduced in Chapter 1, the general introduction, regarding (1) the effectiveness of SDM training initiatives for residents and (2) the critical determinants that influence clinician (dis-)engagement in SDM. It starts by highlighting and interpreting the main findings of the previous chapters in light of these primary research questions. Subsequently, it critically reflects how SDM is taught and used, establishing connections between research findings and existing knowledge. Strengths and limitations are discussed, and research and practice recommendations are provided. 1. Effective approaches to teaching SDM to residents Previous research has emphasized the critical importance of high-quality training programs rooted in experiential and reflective learning, as discussed in the general introduction of this thesis. In order to assess the educational quality of current training interventions aimed at enhancing SDM skills among residents, we conducted a systematic review (Chapter 2). Our innovative evaluation framework was specifically tailored to assess educational quality, focusing on training characteristics rather than solely measuring outcomes. This novel approach was chosen because it leveraged the most reliable evidence for evaluating intervention characteristics. The framework we designed in Chapter 2 drew from a previously published overview of systematic reviews concerning effective communication skills transfer. [2] It was constructed to assess whether SDM training initiatives incorporated elements that effectively facilitate the transfer of similar complex communication skills. [2] The incorporated effective training characteristics all revolved around the principles of workplace learning and reflection discussed in Chapter 1. These included ‘learner-centeredness’ and ‘role-play’, which relate to experiential learning, as well as ‘feedback’ and ‘small-group discussion’, which align with the principles of reflective learning. [3] Additionally, we included elements related to training content. We integrated relevant SDM components described in the current literature into our framework to assess whether training interventions adequately addressed these elements. [4, 5] We did consider training outcomes. However, given the significant heterogeneity in the design of training programs within our review and the variability in the criteria used to assess outcomes in individual studies, we refrained from reporting them. It is worth noting that previous studies had already reported poor outcomes after training. [6] This thesis provides possible reasons for these poor outcomes. As explained in Chapter 1, training outcomes could have been influenced by mechanisms associated with informal learning or the hidden curriculum, as interactions
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