The aim of this study was to identify potential implementation interventions to increase the uptake of shared decision making (SDM) in clinical practice in New South Wales (NSW) Health. The Agency for Clinical Innovation hosted a full-day SDM masterclass in May 2017 and 53 attendees completed a survey to identify barriers to implementing SDM. The Theoretical Domains Framework, COM-B ('capability', 'opportunity', motivation' and 'behaviour') Model and Behaviour Change Wheel were used to conduct a theoretical analysis of the barriers and identify potential interventions to increase the uptake of SDM. This was supplemented by a purposive review of articles about current international efforts to facilitate SDM. From the theoretical analysis, 9 of the 14 theoretical domains were considered relevant to implementing SDM in the NSW Health context. Multi-faceted interventions including education, training, enablement, modelling, incentivisation, persuasion and environmental restructuring were identified as potential ways to increase SDM. The review of international articles identified communication and marketing, patient and public involvement, research, training, legislation, patient decision aids, service provision, clinical champions, financial incentives and policy as interventions being used to increase the uptake of SDM internationally. Based on current perceptions about barriers for SDM implementation in NSW Health, initial efforts should focus on workforce skills development, motivation, communication and marketing, service provision and creating receptive work environments. Investments into facilitating SDM will require an ongoing commitment to enhancing patient experience, evidence translation and reducing unwarranted variations in care.
Objective: Despite much effort and goodwill, the gap in health status between Aboriginal and non‐Aboriginal Australians persists. Bringing Aboriginal cultural protocols and teaching strategies into healthcare could improve the fit between healthcare services provided and Aboriginal peoples. This approach to making healthcare more accessible has not been tested in mainstream health settings. This study aimed to introduce ‘8 Aboriginal Ways of Learning’ to a mainstream health organisation and observe how learning about Aboriginal perspectives and processes shaped work‐related project or program design. Methods: Program and network coordinators (n=18) employed in a state‐wide health organisation joined in‐person workshops and virtual sessions. Participatory Action Research methods guided the process and framework analysis transformed data. Results: Introducing ‘8 Ways’ generated conversations which went beyond deficits in Aboriginal health. Learning about cultural processes provided scaffolding to show how services and models of care can change. Conclusions: This strategy demonstrated potential to improve approachability, acceptability and appropriateness of mainstream healthcare for Aboriginal peoples. Implications for public health: Introduction of Aboriginal pedagogies were welcomed by mainstream healthcare workers as they provided scaffolding and support to plan and work in new ways. Future studies could examine outcomes on program design and access to services for Aboriginal peoples.
Definitions of health literacy have tended to focus on the abilities of patients and communities, rather than on the ability of the health system and its services to respond to patients' different levels of health literacy. However, health literacy is increasingly being recognised as part of a dynamic, two-way relationship, affected by both organisational factors (e.g. tailoring of communication and care to patients' needs) and community factors (e.g. individuals' ability to perceive and seek care). Developing a more comprehensive understanding of health literacy is an important step towards improving health literacy. Most health literacy interventions described in the literature tend to be small and focused on either organisational or community aspects of health literacy rather than addressing both sides. However, some good examples can be found in Local Health Districts and Primary Health Networks in New South Wales (NSW), Australia, of health literacy interventions that are multidimensional and address both organisational and community health literacy. Although progress is being made, gaps in knowledge remain. A deeper understanding of the intersection between health literacy, culture and language is needed, as well as identification of effective communication strategies after patient comprehension has been assessed using strategies such as 'teach-back'. The teach-back method can be used to check patient understanding, but it is not a communication strategy in itself. If teach-back shows that the patient has not understood, clinicians can employ communication strategies such as limiting discussion to two or three points, or using visual aids. If these are not effective, extended family networks and the use of patient navigators may be required. These health literacy interventions address both organisational and community aspects. More work is needed to evaluate such interventions, in particular their impact on health literacy and appropriate and timely access to healthcare.
BackgroundDespite the development of theory-driven frameworks to guide implementation strategies, their application thus far has largely been limited to evaluating effectiveness within specific contexts. This study describes the use of these frameworks to inform a scale-up strategy for shared decision making (SDM) implementation across a state-wide government-funded health program. MethodsTailored SDM strategies were implemented in three multidisciplinary osteoarthritis care teams over a 3-6 month period during 2019-20 in New South Wales, Australia. Staff interviews occurred across 3 timepoints based on the Organisational Readiness for Change Scale, the Theoretical Domains Framework and the Preparation for Decision-Making (PreP-DM) Scales. Patient interviews based on the PreP-DM were also completed. A hybrid inductive-deductive thematic analysis was followed by mapping the results to the Consolidated Framework for Implementation Research (CFIR) and the OMERACT core domains for SDM. Finally, a ranked list of Expert Recommendations for Implementing Change (ERIC) was derived using a published tool.Results47 interviews were conducted with 18 staff along with 20 interviews with patients. We identified 39 themes for SDM implementation across the five CFIR domains: 1) Interventions need to be flexible to align with different clinical workflows and busy clinics; 2) Outer Settings such as senior managers should formally endorse SDM and clinical protocols and standards need to better align with an SDM approach; 3) Inner Setting teams need early engagement, role clarification and communities of practice in SDM; 4) Individuals are strongly motivated by better patient outcomes and need SDM training and support; and 5) Processes such as patient-reported measures and feedback along with adequate resourcing were key. Recommended strategies therefore focussed on Stakeholder Engagement, Evaluative and Iterative Strategies, Education and Training and Adaptation/Tailoring to the Context. Skills in the identification of decision points, values clarification and deliberation were particularly challenging for staff.ConclusionsTheory-driven scale-up strategies can be developed using qualitative research within demonstration sites. By combining the CFIR and TDF frameworks and prior mapping to the ERIC strategies, health system and program planners can obtain a relevant and evidence-informed roadmap for implementation across complex health systems.
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