64 Chapter 4 physician behavior in SDM practice. It focused especially on those elements that could explain the incorrect execution of SDM. The study was executed in a gynecological oncology department. Oncology care is considered challenging in implementing SDM since this field is particularly regulated and guideline-driven. [13] New insights from this study could potentially be useful to redesign SDM implementation processes and further improve decision-making in healthcare. Methodology Setting In contrast to other countries, the Dutch healthcare system is not divided into private and public healthcare. All Dutch citizens have mandatory health insurance, and the insurance pays for essential healthcare. [14] This makes oncological care easily accessible for everyone. The government has played a crucial role in how healthcare is currently shaped. Over the past decades, the Dutch government has designed laws and regulations to make healthcare more patient-oriented and demand-driven (p.284). [3] Consumer experiences are highly valued, and several government initiatives are employed to encourage patients to engage in their medical treatment decision process. [15] The study at hand was conducted within the gynecological oncology department of an academic center in the Netherlands, where gynecologists dedicate their work solely to treating gynecological cancer. Neighboring hospitals refer a large part of patients to receive specialized care. Research methods: Hospital ethnography For this study, hospital ethnography was used to collect data. [16] Ethnography is a qualitative research method specifically aimed at studying culture and has its origin in anthropology. It is characterized by often longer periods of so-called participant observation in a natural setting, combined with other ways of qualitative data collection. [17] In participant observation, one aims to gain close contact with a group in their cultural environment. Participant observation is crucial in ethnography because it “provides access to what people do and say about it, instead of only listening to what people say that they or others do” (p.32). [18] Observations were performed by two researchers (LS, SV). The first had experience in gynecological oncology as a resident in obstetrics and gynecology. The second was a student in medical anthropology. In the initial phase of observations and data processing, they received strict supervision from the medical anthropologist (TG), who has extended experience in hospital ethnography. [18] The level of supervision decreased with each sequential phase. Observations took place over a period of ten weeks, from March through May 2018. Both researchers were each approximately two to three full working days per week present performing participant observations. An exploratory approach was used, where observations were combined with interviews. All interviews were held by the second researcher in the last four weeks of the study period and included both formal and informal interviews.
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