99 Applying a DOI theory-based framework its coverage in earlier interviews was insufficient. Therefore, additional data were gathered through focused interviews with clinicians working in the department and not interviewed before. Modification – Additional data collection A semi-structured interview guide was developed, incorporating elements from the DOI model, and exploring physician attitudes towards SDM in-depth. Second, to gain deeper insights into physician attitudes towards SDM, the same interviewees were asked to complete the ADOPT adjective checklist. The ADOPT list of adjectives is specifically designed to explore attitudes towards SDM. [24] The complete interview guide can be found in Appendix A. Two interviewers (KR, IJ), under the supervision of an experienced researcher (LS), conducted the interviews between June and July 2020. All interviews were recorded and subsequently transcribed verbatim. We obtained informed consent from all participants to use interview data for research purposes. Data saturation was achieved after conducting twenty additional interviews, indicating that further interviews were unnecessary to obtain new insights. Eight interviewees (40%) were fully trained gynecologists, with an average age of 40.2 years (ranging from 35 to 50). Ten (50%) were residents, with an average age of 33.0 years (ranging from 27 to 37). Two (10%) were junior doctors who had completed medical school but had yet to start their specialty training, a common occurrence in the Dutch medical training system. The first junior doctor was 27 years old, and the second was 30. Phase 2 – Identifying and establishing a thematic framework The framework used in this study is based on the first two stages of the innovation-decision process, ‘knowledge’ and ‘persuasion,’ as described by E.M. Rogers. [11] Consequently, the framework was named the Innovation-Decision framework. During the familiarization phase and drawing on Rogers’ manuscript, important subthemes were identified within the broader themes ‘knowledge’ and ‘persuasion’. A third theme, ‘prior conditions,’ was added to the framework, referring to the circumstances and factors preceding the introduction of an innovation. According to Rogers, prior conditions are crucial in adoption and diffusion dynamics within a social system. [11] Table 1 shows more details on themes and subthemes from our framework. Appendix B explains the rationale for including each theme in our DOI-based framework. Phase 3 – Indexing The additional focused interviews were initially open-coded by two interviewers (KR, IJ) using the Atlas.ti software program. [25] Collaborative discussions with LS led to the development of a comprehensive codebook, ensuring consensus on specific coding decisions. This iterative process involved alternating between interviews, transcription, and coding. Phase 4 – Charting and Mapping Following the coding phase, the codes were organized into subthemes aligned with the Innovation-Decision framework. Next, data from the previous research projects were integrated into these subthemes where applicable. The results section provides a narrative description of the findings. 6
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