98 Chapter 6 The obstetrics and gynecology department in the Netherlands serves as an illustrative case, as it has been previously examined in SDM studies, resulting in a wealth of qualitative data. [19, 20] By leveraging the first stages from the DOI theory in our framework studying SDM adoption in this particular case, our study aims to deepen the understanding of implementation challenges. When viewed in light of relevant theoretical frameworks, this study’s findings can potentially inform policy and practice. They can guide efforts towards promoting enhanced and patientcentered decision-making approaches. Methodology Study design This study uses a modified framework analysis approach, [21-23] drawing upon two sources of data: ethnographic and interview data from two previous studies, [19, 20] and separate data obtained through additional interviews. The framework approach provides a systematic and transparent methodology for analyzing qualitative data. It comprises five distinct research phases: ‘familiarization’, ‘identifying a thematic framework’, ‘indexing’, ‘charting and mapping’ and ‘interpretation’. The modification consisted of conducting supplementary interviews and using those as an important additional data source after the process of data familiarization with the previously existing data. This alteration was necessary because it became evident that the existing ethnographic and interview data did not adequately address all components outlined within the DOI framework. Setting This study took place in the obstetrics and gynecology department of a tertiary teaching hospital in the Eastern region of the Netherlands. The participants comprised both experienced gynecologists and less experienced clinicians, including residents in obstetrics and gynecology. Framework Analysis Phase 1 – Familiarization In this phase, a team of three researchers (LS, JA, FS), all providing gynecological care and familiar with ethnographic research, reviewed data from two prior research projects on SDM in the same department. [19, 20] The data were collected in 2018 and 2019, respectively. They included written observations and field notes from witnessing consultations and multidisciplinary meetings, as well as twenty interview transcripts from interviews focusing on clinicians’ and nurses’ attitudes and behaviors regarding SDM. No patients were interviewed in these research projects. Our research team discussed these data in light of the Diffusion of Innovations (DOI) theory to feed the subsequent phase in our framework analysis. It became apparent that more than existing data was needed to fill a potential DOI theory-based framework. The way clinicians interpret the attributes of SDM was not consistently apparent in the previous on-site observations, and
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