
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

39269215
10.7812/TPP/23.152
TPJ-23-152
Original Research
A Qualitative Study on the Impact and Feasibility of a Simulation-Based Program for Shared Decision-Making in Non–Small Cell Lung Cancer Care
http://orcid.org/0000-0002-8931-0843
Hakim Hasna DNP, RN, MPH, CCRN 1 2
http://orcid.org/0009-0003-3532-1875
Alexander Catherine C DNP, MPH, RN 2
Rudell Elaine MHA 3
Ingram Michele BS 3
Agrawal Tarjani PhD 3
Peterson Patty BS 3
Davies Marianne DNP, ACNP, AOCNP 4
Adelson Kerin MD 4
http://orcid.org/0000-0002-7399-622X
Oliver Brant J PhD, MS, MPH, FNP-BC, PMHNP-BC 5 6 7
1 Brigham and Women’s Hospital, Boston, MA, USA
2 Nightingale Consulting, Portsmouth, RI, USA
3 Projects In Knowledge Powered by Kaplan, Ft Lauderdale, FL, USA
4 Chronic Health Improvement Research Program (CHIRP) at Dartmouth Health, Lebanon, NH, USA
5 Division of Care Experience, Value Institute, Dartmouth Health, Lebanon, NH, USA
6 Departments of Community & Family Medicine, Psychiatry, and the Dartmouth, Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
7 Smilow Cancer Hospital at Yale New Haven Health/Yale Cancer Center, New Haven, CT, USA
Hasna Hakim, DNP, RN, MPH, CCRN hhakim@bwh.harvard.edu
2024
13 9 2024
28 3 212222
03 11 2023
01 2 2024
10 7 2024
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Background

In the pursuit of improved clinical outcomes and patient experience in health care, shared decision-making (SDM) stands as a pivotal concept garnering increasing attention, but SDM utilization varies widely, often leading to confusion regarding team members’ roles. This study explores knowledge, skills, and attitudes of oncology clinicians engaged in a pioneering educational initiative at a comprehensive cancer care center, aimed at enhancing frontline SDM capabilities.

Methods

Utilizing a prospective cohort qualitative approach, the team conducted interviews with 6 clinicians in a multidisciplinary oncology program who were engaged in an SDM continuing education program. In the program, participants were immersed in experiential learning activities including standardized didactic sessions and simulation-based SDM case role-play activities.

Results

Thematic analysis of interview data revealed 5 major categories: 1) perceptions of SDM; 2) training; 3) patient-centered care; 4) challenges and constraints; and 5) leadership buy-in. Participants perceived benefits, including adopting a better approach to integrate SDM into their practice, heightened engagement, emphasizing team collaboration, and embracing a patient-centric care model.

Conclusions

This study underscores the transformative impact of education and training on enhancing SDM capabilities among oncology clinicians and is not intended for generalizability. By promoting a basic understanding and application of SDM principles, practicing clinicians can be better empowered to improve health care outcomes and experience. Our findings contribute to the broader endeavor of embedding practical SDM principles within clinical practice, thereby fostering a more patient-centered and effective health care environment.

Keywords:

leadership
oncology
quality improvement
simulation
educational intervention
role-play
semistructured interview
education
collaboration
patient-centered care
Funding and Financial Disclosures This study was supported by an educational grant from Genentech, a Member of the Roche Group, grant number 2361. Projects In Knowledge was one of the groups involved in the collaboration creating the educational program and provided technology and program development contributions to the program including collaboration with other authors on the paper to develop and facilitate it.

Drs Adelson, Alexander, Hakim, and Ms Davies received personal fees, and Dr Oliver received limited consulting fees from Projects In Knowledge Powered by Kaplan during the study. The work, developed using data from Projects In Knowledge Powered by Kaplan, reflects the authors' independent findings without influence.
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pmcIntroduction

Lung cancer patients are faced with many treatment choices that involve complex decisions, and they need to coordinate care among multiple clinicians on their cancer care team as well as other care teams.1 When more than 1 clinically indicated treatment option is available, and in the absence of evidence or guidelines recommending a single best treatment option, decisions become preference-sensitive, indicating the use of shared decision-making (SDM). SDM focuses on patient-centered care and incorporates patient preferences and values in the determination of health care choices.2 In the past, patients have traditionally deferred to clinicians in making their treatment and health care management decisions. However, a patient participation study review found that in 71% of studies conducted after 2000, a majority of patients wanted to participate more actively in their health care, and a growing body of evidence suggests that patients want an active partnership with their clinicians and are seeking to coproduce their health care experience together.3

The American Society of Clinical Oncology, in their 2017 State of Cancer Care Report, proposed a “framework for patient-centered, evidence-based, high quality cancer care” that included patient engagement in making informed medical decisions that align with patients’ needs, values, and preferences through communication and SDM with their clinicians.4 The Centers for Medicare & Medicaid Services includes patient engagement in their new performance category for the merit-based incentive payment system, and in 2017 the National Quality Forum initiated a “Call to Action” to integrate SDM processes into practice in which clinicians and patients work together to make health care decisions that align with what matters most to patients.5,6 SDM can reduce complexity and decisional conflict and improve decision quality, satisfaction, and treatment adherence.7–12

Shared Decision-Making (SDM)

SDM is often applicable in cancer care, given the complexity of disease states and treatment options that exist in oncology settings. This is particularly true in non–small cell lung cancer (NSCLC), where many treatment options exist that are clinically reasonable, creating preference-sensitive decision situations and also increasing the stress on patients and clinicians to make complex decisions in busy health care environments. SDM can help clinicians better communicate information about NSCLC and its treatment in easily understandable language throughout the care and treatment process, and help patients make better-informed decisions that are aligned with their preferences. However, many oncology centers do not have experience or training in SDM even though they are clinical experts in oncology.

The Practical Approach program

Clinical case vignettes were developed by invited oncologist faculty to provide clinical content for the case scenarios. Authors ER and BJO integrated these with comprehensive scripting and SDM content to accompany the case study for training videos and case role-plays, and they also provided training to the standardized patients. Participants watched education videos prior to doing role-plays, which included training on the management of non–small cell lung cancer and on the practical method for SDM, and a recorded example of a case role-play, and then they participated in a virtual online synchronous case role-play session themselves with the standardized patient, which was observed by ER and BJO, who provided real-time feedback based on observed performance compared to the practical method model domains. Constructive feedback was provided and discussion entertained with the participant and the standardized patient to process the simulation experience together.

Methods

The authors developed a partnership of 3 key stakeholders to qualitatively evaluate a new SDM continuing education program created for busy oncology clinicians, the Practical Approach for SDM.13 This program was modified specifically for multidisciplinary specialists caring for people with NSCLC by a design team that included: 1) an accredited continuing education provider with experience in oncology and SDM professional health care education; 2) an academic consultant with experience in SDM, health professions education, and health care improvement science; and 3) a leading academic oncology center.12,14,15 The result was the “Yale Model” program, which was designed to increase SDM capability in a way that was specific to their care delivery system and practice approach.

The “Yale Model” Practical Approach program

The SDM training program for frontline clinicians consisted of the following components: 1) didactic (standardized, brief, and practical curriculum on SDM and NSCLC); 2) simulation (hybrid video [webinar] and on-site case-based learning scenarios, including professional patient actors); 3) feedback (immediate feedback to learners’ postsimulation from faculty and professional patients); and reflection (interactive discussions between learners and faculty postsimulation about implications of what they learned, including practice changes). The didactic component on SDM is based on core SDM principles and the oncology-specific didactic with collaboration from oncologists.8 Simulation videos were developed from structured case scenarios that were practiced and optimized prior to recording. Feedback to learners was provided in “real time” and organized by SDM domains, identifying areas of strength and opportunities for improvement (Figure 1). Below the authors describe themes of learner experience in a sample of oncology clinicians at Smilow/Yale caring for patients with NSCLC who participated in this SDM education program.

Figure 1: Flow chart, training process. SDM = shared decision-making.

Qualitative interviews and data analysis

We studied a convenience sample of 6 health professionals from a single oncology clinic in a large academic ambulatory care center, including 2 physicians, 2 nurse practitioners, 1 nurse coordinator, and 1 social worker. We used a prospective cohort, pre-/post-, qualitative, descriptive design. Interviews were conducted over Zoom using a set of semistructured interview questions posed by a single interviewer for approximately 60 minutes. Pre- and posteducational intervention interviews were conducted to understand experience before and after the intervention.

NVivo qualitative data analysis software was used to analyze interview data.16 A total of 12 transcripts were used for analysis (6 pre- and 6 postintervention). Transcripts were coded independently by 2 researchers using rigorous thematic analyses on the qualitative data to draw interpretations from the data. The researchers closely examined the data to identify common themes that come up repeatedly, such as a topic or pattern of ideas or meaning.17 The transcripts were read through in their entirety, and then codes were generated that corresponded to the interview questions. Codes were then sorted into categories and each was examined to identify themes within each category (Figure 2). Two researchers then compared codes, categories, and themes to ensure they were representative and inclusive of data. Discrepancies were resolved through a consensus process.

Figure 2: Thematic analysis. Thematic analysis graphs show comparison of code frequency between pre- and postintervention. The arrows in the graphs indicate the collection of codes for “pre” (left blue bubble) and “post” (right blue bubble). (A) Comparison of code frequency for perception of SDM shows lower postintervention frequency resulting from clearer understanding of SDM among participants. (B) Comparison of code frequency for challenges shows lower postintervention frequency resulting from less inhibition to face barriers. (C) Comparison of code frequency for leadership was found to be very similar. SDM = shared decision-making.

The qualitative approach for our pilot study sought to assess perceived knowledge, skills, and attitudes of clinician experience using SDM. A qualitative approach was selected because our small sample size was insufficient for quantitative approaches, and our specific purpose was to describe learner experience and perceptions.

Patient and public involvement

This study focused on health care professionals as study participants. Patients were not directly involved in the study design or the design of the research questions or outcome measures and were not participants in the study itself. Professional patients (actors) were involved in the role-play scenarios discussed in this article but were not actual oncology patients. This was not a randomized controlled trial and did not have a control group.

Ethics review

This study meets Yale Institutional Review Board criteria for a health care quality improvement (educational program) activity and was not considered to be human subjects research.

Results

Six health care professionals completed the Yale Model program and completed qualitative interviews. Five major themes were identified from the qualitative analysis1: perception of shared decision-making2; training3; patient-centered care4; challenges and constraints; and leadership buy-in5 (Table and Figure 3).

Table: Selected participant quotes pre- and postintervention

Theme	Preintervention	Postintervention	
Perception of SDM	“Providing them with a balanced perspective on what those treatment options are.” “My perception of what SDM is, I think sometimes people will think they are practicing it, and if they ask me what I thought if they were actually practicing it I would say absolutely not.”	“Definitely has changed in terms of what is involved. Initially thought it was more about like end-of-life decision-making and we talk a lot about that in oncology care. It's more comprehensive than I initially thought.” “It should be an interdisciplinary effort.” “It certainly has shifted; we involve our patients and make decisions after going through the training.” “Need a team approach. No one provider is able to do it. Is just too much and too complex for one provider.”	
Training	“Is it the right thing to have shared decision-making? I don’t know; you haven’t proven that to me.” “A combination of in-person and also like a webinar would be good.”	“A group session where you can do role-plays and you have a live program is always very nice.” “I have a much better understanding . . . it's really crystallized after the role-play. So glad I did it.” “Having that immediate feedback as opposed to a pre- and posttest was great.”	
Patient-centered care	“Helpful to talk about when shared decision-making is useful.” “When there’s more than one option that is clinically reasonable.” “It should be used especially for big decisions like end of life.” “Help the patient understand this is the approach we want to take.” “When multiple treatment options are available.”	“Build it into everyday practice.” “Helps to involve the patient right from the start.” “I really see how it's trying to put the decision back into the patient’s hands now but, with guidance; you know, it's got to be a structured type thing.”	
Challenges and constraints	“A key factor in all of this is going to be time.” “Is it possible to incorporate something like this in daily practice? I don't know. Maybe sometimes for some people on some days but it depends.”	“Time is the biggest barrier.” “A new patient checked in for their visit, they can potentially be given an iPad or something to look at with the shared decision-making things on it while they're in the waiting room. If it was something that stayed in clinic and said, this is something for you to review, or, you know, for people who aren't but I don't know who has that in their budget.”	
Leadership buy-in	“It’s a better experience for patients when use SDM.” “It would be nice to figure out the monetary value. You need to show it improves outcomes in some way like keeping patients out of the hospital.”	“It would definitely be in the data. Genuine struggle, you know, quantity (vs) quality.” “I think all the money was going to take .take more time; need metrics.. “The idea of there being value in reputation and satisfaction.”	
SDM, shared decision-making.

Figure 3: Frequency counts of codes per theme pre- and postintervention. Five major themes resulted from qualitative analysis of data: perception of SDM, training, patient-centered care, challenges and constraints, and leadership buy-In. SDM = shared decision-making.

Perception of SDM

We observed substantial pre-/postprogram changes in basic knowledge about and attitudes toward SDM, including how they defined SDM and how they perceived its application in health care.

Preintervention

We observed substantial variation in participant responses when they were asked to define SDM. Some participants believed that SDM was only appropriate for major health decisions, whereas others expressed skepticism about its usefulness in daily practice.

“It’s informed consent, I guess at its most basic level, making sure the patients understand the information provided to them.”

“It’s coming to a consensus or conclusion with someone’s health care.”

Some participants wondered whether SDM was an efficient tool to guide practice.

“Is it the right thing to have shared decision-making? I don’t know; you haven’t proven that to me.”

Postintervention

After the intervention, participants began to view SDM as a patient-centered process of care delivery whereby patients are actively involved in most of their health care decisions and especially in preference-sensitive decisions.

“I think there’s many more facets to it than I initially realized in terms of understanding a patient’s perspective.”

Training

We observed a general aversion to simulation-based experiential learning at the outset of the program, despite its strong evidence base, in program participants. However, attitudes toward this shifted postprogram exposure.

Preintervention

Participants agreed that they would need multiple educational training options to make sure they are competent to use SDM. Although providers shared their dislike for simulation case role-play, many understood that it was an important tool for learning and acquiring SDM skills through “hands-on” experience.

“I hate simulation; I hate role-play; I hate being watched.”

“Some sort of simulation might be the best approach.”

Participants wondered how they would begin to integrate the SDM skills into practice and began to brainstorm strategies to help guide the process and then sustain the process.

“It is a way of practice, but you know, certainly some reminders, like bullet points or some sort of reminders that people can access, would help.”

“Use an app to learn the program [SDM]. I would go for a little more technology if it is really well-done technology.”

Participants discussed the challenges of implementing SDM, indicating that they had no idea how to sustain its usability. One participant asked for a roadmap or some sort of infrastructure for engendering patient engagement in decision-making.

“I have no idea how you could actually make something like this sustainable.”

“A guideline to follow and recommendations to put in place could be implemented across the board.”

Postintervention

A shift in focus occurred after the intervention. Participants started to creatively explore training options. Most agreed that simulation case role-play was a necessary teaching intervention.

“I think there is no substitute for doing it in real time. Everyone needs to do 1 role-play every once in a while.”

Participants also asked for cues, a framework, or prompt to execute SDM. They began to see SDM as something that adds value to patient care. Participants saw that the process would add consistency to patient care.

“SDM provides a basic approach that everyone can follow.”

“It builds a shared understanding so the team can use the same approach.”

Patient-Centered Care

We observed preexposure that most participants felt that they understood the concept of SDM and generally practiced it in their work. Postprogram, many participants expressed that they may have had a limited view of the concept initially and that their understanding of it had developed further during the program.

Preintervention

Participants defined SDM as being episodic rather than uniform, stating that patients generally preferred collaborative roles with their oncologists during major treatment decisions when multiple treatment options are presented.

“I think it should be used especially for big decisions like end of life.”

Postintervention

The understanding of SDM began to expand with the use of words like “patient-centric,” acknowledging that patients should always be involved in their care and should have an active voice in the process. Two participants spoke about it this way:

“Let’s build it into everyday practice . . . and involve the patient right from the start.”

Others defined patient-centered care this way:

“Know where the patient stands. Understand their learning needs.”

“Find out what is important to them.”

Challenges and constraints

Most participants cited typical barriers to SDM, including time, space, and workflow constraints preprogram, but postprogram expressed that they felt more knowledgeable about how to practice SDM, and that this enabled them to work past barriers that they previously perceived to be too difficult to overcome.

Preintervention

Time was viewed as the biggest challenge for the implementation and sustainment of SDM for all participants.

“Time is such a big one. I don't know, I can’t even think of another one.” Although participants preferred a collaborative SDM approach, they did not know how to overcome this barrier.

“Is it feasible to incorporate something like this in daily practice? I don't know, maybe for some people on some days but it depends.”

Postintervention

Although time and space continued to be described as “the biggest barriers” for the integration of SDM, participants moved beyond this hurdle and began to discuss other strategies, like the use of technology.

“Using an online tool allows team members to address alternative approaches to patient care. Using a tool helps to ‘fine tune’ the patient visit.”

Leadership Buy-In

Many participants identified leadership support as a critical factor for successful SDM practice and felt challenged to “make the case for SDM” with their leadership. However, postprogram, they shared that they had developed new ideas and more optimism about how to advocate for SDM to leaders and better partner with them.

Preintervention

Although participants believed SDM was a good concept, they were skeptical that it could be sustained in daily practice. Participants emphasized the importance of collecting data to gain leadership support. Using SDM could potentially improve a patient’s understanding of their treatment plan, and this in turn would help decrease readmissions, which is an important organizational benchmark for health care reimbursement.

“When you practice SDM you are going to have greater patient satisfaction and a more positive view of the treating team. If you start there you have a higher chance of being able to come up with a plan that could be cost-effective and efficient for the hospital system.”

“When patients feel empowered to be part of the decision-making process, it’s a better experience for them. This would result in higher scores on patient satisfaction surveys, which in turn would result in higher compensation for the hospital.”

“You have to prove that it’s really the right thing, then people will do it even if it takes some extra energy and time.”

Postintervention

After the intervention participants continued to hold firm on the need for data to make their case to leaders, eg, “it would definitely be in the data,” and then went on to brainstorm more efficient ways to collect data by saying “we need the metrics.” Further, participants saw the need to justify extra time spent with patients and saw the link between positive patient experiences and increases in referrals. They viewed “word of mouth” as a powerful mechanism and recognized that if patients had a positive patient experience, referrals could potentially expand and generate additional revenue for the organization.

“If there’s a little less volume but a lot more quality, your referral rate might go up.”

“You have to collect the data to show that by implementing more of the shared decision-making, you show a correlation with increased patient satisfaction. I guess the hope would be that word-of-mouth patient referrals based on their own positive experiences might bring new patients into the system”

“Word of mouth is a powerful mechanism for expanding clinic visits.”

Related to leadership buy-in, participants discussed issues around sustainment. Although the participants were not directly asked about sustainability, they discussed opportunities to improve clinic efficiencies, such as the scheduling of patients and the better use of technology. Others believed ongoing access to online educational materials was critical to sustain the SDM effect.

“Address structure of our settings.”

“I would use a little more technology.”

“Continual refresher course . . . or enduring materials and have different modules online.”

Discussion

In their study the authors identified key shifts in participant knowledge and attitudes in 5 key areas as they progressed through the “Yale Model” Practical Approach program in each of the 5 major thematic areas we identified. They discuss below how each of these links meaningfully to important evidence and developing areas in the field.

SDM as a method of coproduction

During the preintervention interviews, participants expressed varying perceptions of SDM. Some believed SDM was appropriate for “big” patient-care decisions like end-of-life care, while others believed that SDM might be as simple as asking a patient their preference for treatment. However, a shift in thinking occurred after the intervention as participants began to view SDM as a patient-centered experience. In other words, patients were now viewed as active partners in their care decisions. In addition to an expanded view of a patient-centric model of care, participants also better understood that SDM was a collaborative team approach to care, meaning care decisions are shared and owned collectively by a team; the burden of responsibility no longer rested solely on the shoulders of the prescribing clinician. This created new possibilities for the team to consider team-based facilitation of SDM.

The shift in thinking that occurred is described in the literature as a patient-centered approach to care that leverages professional and end-user collaboration that allows patients to contribute to the management of their illness. Batalden and colleagues refer to this concept as “coproduction,” which is described as something similar to the experiences and efforts of businesses who engage consumers in designing and marketing products.18 Coproduction relies on a process and/or technology that leverages an end user’s time and skills for improving the convenience, cost, and efficiency of the end product.19 The coproduction model in health care is further specified as the cocreation of a health care service. This relies on open communication between the patient and practitioner, allowing the patient to understand their diagnosis and therefore better engage in communication about treatment options.20 In this manner, SDM can be viewed as 1 of many methods that can be employed to coproduce health care services.

Experiential learning

Preintervention, participants understood that training was necessary but struggled with what would be the best strategies for learning SDM concepts. Many participants expressed their discomfort with simulation training both pre- and postintervention, but recognized that role-play was a key learning strategy to fully understand the SDM concept and develop “hands-on” skills. During pos-training interviews, participants suggested creative ways to provide ongoing SDM training to improve engagement and usability. As 1 participant noted, “Creating a roadmap for successful integration would require a variety of opportunities for engagement in learning.” Participants understood that ongoing educational opportunities were critical for integration into practice but an elusive goal in a busy oncology clinic. Rocque and colleagues stated that designing a flexible training model will require new approaches and new implementation strategies outside of the clinical setting.21 A design-thinking model can support effective interventions to drive new SDM practices.22 Design thinking uses human thought processes, emotions, and behaviors to guide new methods of training. User-centered design starts with the assumption that all users have basic needs and limitations and that it is the designer’s responsibility to understand, anticipate, and design in accordance with these needs and limitations.23

Rocque and colleagues outlined 3 best practices to design and test tools used to promote SDM: “(1) engage a diverse set of stakeholders who have interest in SDM ; (2) develop and validate an evidence-based SDM tool supported with a conceptual framework; and (3) create the roadmap needed for implementation.”21 Several studies offer suggested pathways for SDM training. Bieber et al suggested building training programs that teach physicians SDM and preference assessment skills.24 Müller and colleagues found that SDM performance improved when SDM communication skills training was included.25 In a recent systematic review focused on SDM education for medical students and fellows, researchers concluded that future SDM programs should be interactive, include multiple teaching strategies, accessibility to resources, and reminders for application in the practice setting.26

From barriers to facilitators

Preintervention participants actively discussed the challenges of integrating SDM into the practice setting, but this was less of a concern postintervention. The most common barrier mentioned pre- and postintervention was time, but posttraining participants began talking more about the challenges of SDM sustainability in daily clinical practice. Although having enough time to engage in SDM is critical during a patient visit, there was a heightened sense of engagement posttraining as participants viewed SDM not as an add-on responsibility but an opportunity to engage patients in their health care. SDM was also viewed as a collaborative team approach where the burden of time no longer rested only with a physician but was shared across team members. This suggests that the current incentives and operational structures in place were not aligned with patient-centered coproduction and SDM. The core question then became, “How do you prove its value?” Participants knew that SDM would require additional resources, and this led to discussions about leadership buy-in. Participants identified leaders as key collaborators for SDM integration. They understood that a financial case for SDM integration would need to be made to leadership and explored ways to use data to measure outcomes (eg, patient experience scores, cost, and patient referrals).27 These offer several metrics to measure success, including continuous performance monitoring and feedback on SDM performance, decision aid distribution rates, decision quality, and patient satisfaction rates. SDM integration at the organizational level could improve patient experience, reduce complaints and legal challenges, and lead to cost savings.28

Given the complexity of the current health care system, SDM integration into clinical practice faces myriad challenges that have yet to be studied. At the systems level, health care organizations have yet to view SDM as the standard of care.29 Much of the literature to date has been focused on implementing SDM at the individual level, with few studies investigating system-level characteristics.27 In a study by Hahlweg and colleagues, individuals as well as organizational factors were found to influence the degree of SDM integration.30 Most studies targeted knowledge, skills, attitudes, and behaviors of individual providers, and the barriers and facilitators for using SDM in the practice setting versus at the organizational level.27,31 At the systems level, Lin and colleagues highlighted the importance of culture, leadership support, and changes in workflow structure for improved implementation of SDM in cancer care.27,30 However, few studies have provided an in-depth synthesis of organizational/systems-level characteristics that would influence the implementation of SDM in routine care. In a scoping review, Scholl and colleagues described leadership characteristics such as providing feedback and articulating the mission and values of the organization as important, but these characteristics are vague and will require more research to fully understand their impact.27 Future research will need to focus on system-level approaches, such as learning health systems, which have the potential to simultaneously monitor, improve, and study patient-centered coproduction of health care services.32,33

Strengths and limitations

This qualitative study aimed to explore knowledge, skills, and attitudes regarding SDM in a small sample, making traditional quantitative measurement approaches impractical for assessing outcomes. The study was conducted in a practical clinical setting focused on feasibility, acceptability, utility, and rich information extraction from a small group in a complex organization. However, it was not designed as a quantitative comparative outcomes study, and the authors’ design does not provide inferences about the longitudinal sustainability of effects or generalizability. Rather, their focus was on obtaining a rich and detailed description of learner experience and perceptions, which was appropriate for a qualitative approach.

Another limitation of this manuscript is the absence of details on patient feedback regarding their experiences with clinicians who have completed the SDM training.

Despite these limitations, participants perceived great effects, including a more focused approach to SDM practice, increased engagement, enhanced team collaboration, and a belief in SDM as a patient-centric practice. The practical need for virtual training, highlighted by the COVID-19 pandemic, underscored the program’s perceived effectiveness as a low-burden, high-impact, flexible, meaningful, and adaptable training activity.

Conclusion

The team’s results suggest initial perceived feasibility, acceptability, and utility of the Practical Approach program, and these results align with observed improvements in simulation-based assessments of SDM skills performance in the same “Yale Model” pilot, as reported by Alexander et al.34 Participants perceived having a more focused problem-solving approach, increased engagement and ownership, more collaborative teamwork perspective, and a more patient-centric view of health care practice. This Practical Approach program shows initial promise for increasing perceived practical capability to practice SDM effectively in busy clinical settings. These initial findings set the groundwork for further development of the program and longitudinal studies of program implementation, experience, and outcomes.

Author Contributions, Continued

HK was lead author, completed the analysis of the qualitative interviews, participated in manuscript preparation, and revisions. CCA participated in the analysis of the qualitative interviews and manuscript development and revisions. ER guided and participated in the design of the pilot, contributed to the development of the SDM role-play simulations and NSCLC didactic treatment content, contributed to the facilitation of the qualitative interviews (along with BJO), participated in the data analysis review (along with TA), and developed, wrote, and revised the manuscript. MI guided and participated in the study design, reviewed the content, and participated in manuscript reviews and revisions. TA participated in pilot design, facilitated database development for data collection and storage, developed data analysis protocol, and participated in review. PP guided and participated in the study design, reviewed the content, and participated in reviews and revisions. MD contributed to the development of NSCLC content, participated in the pilot case role-play interview assessments and SDM educational interventions, and participated in manuscript reviews and revisions. KA contributed to the development of NSCLC content, participated in the pilot case role-play/interview assessments and SDM educational interventions, and participated in manuscript reviews and revisions. BJO guided and participated in the methodological design and facilitation of the pilot, the development of SDM didactic content and role-play simulations for the study intervention, facilitation of the qualitative interviews (along with ER), and participated in reviews of the data analysis and reviews and revisions of the manuscript.

Author Contributions: Please see the full author contributions paragraph at the end of the text.

Conflicts of Interest: None declared

Funding: None declared

Data-Sharing Statement: Qualitative data and results from this study are held in secure databases by Projects In Knowledge Powered by Kaplan per study protocol and data custodianship regulatory requirements. This data has been deidentified and is not publicly available. Data inquiries can be addressed to the corresponding author.
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