Step 3: Identify barriers and explore ways to overcome them
Explore ways to improve decision aid use and provision of decision support while overcoming barriers.

What is likely to get in the way of using decision aids and/or providing decision support? Who will use the decision aids and include them in the process of care? What can be done to make it easier for decision aids/decision support to be provided? What are barriers and facilitators to using decision aids and/or providing decision support within the setting?

3.1 Ask patients and health professionals

1. What is likely to get in the way of using decision aids and/or providing decision support?
   • Are the barriers specific to the decision aid (e.g., requires computer access, literacy too high, too difficult to use, not accessible)?
   • Are the barriers specific to the patients or health professionals (e.g. lack of awareness, limited knowledge/skills, poor attitudes, concerns, incompatible with current practice, lack of confidence)?
2. Who will use the decision aids and include them in the process of care?
3. What can be done to make it easier for decision aids or decision support to be provided?

3.2 Explore barriers and facilitators within the setting?
What are barriers and facilitators to implementing decision aids and/or providing decision support within the healthcare setting (e.g., organizational structures, cultural issues, patient expectations, economic concerns)?

• Are there health policy or organization documents to justify implementation of decision aids or decision support?
• Who needs to approve the decision aid? Who could facilitate (or block) implementation of decision aids or decision support?

3.3 More formal measures of factors influencing implementation of decision aids and decision support

1. Survey health professionals to identify barriers and facilitators influencing their use of decision aids and provision of decision support. There is a measurement tool based on the Ottawa Model of Research Use.
2. Survey health professionals to identify their attitudes, subjective norms, perceived control and intentions to use decision aids and provide decision support. There is a measurement tool based on the Theory of Planned Behavior.
3. Qualitative interviews or focus groups can be used to explore factors influencing use of decision aids and decision support and obtain feedback on decision aids or decision support tools (positive features, changes needed, relevance, timing for use).

Examples of additional resources

Légaré F, O'Connor AM, Graham ID, Saucier D, Côté L, Blais J, Cauchon M, Paré L. (2006). Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice. Patient Educ Couns. 63(3):380-90.

Légaré F, Ratté S, Gravel K, Graham ID. (2008). Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals' perceptions. Patient Educ Couns. 73(3):526-535.

Logan J, Harrison MB, Graham ID, Dunn K, Bissonnette J. (1999). Evidence-based pressure-ulcer practice: The Ottawa Model of Research Use. Can J Nurs Res. 31(1):37-52.

Stacey D, Graham ID, O'Connor AM, Pomey MP. (2005). Barriers and facilitators influencing call center nurses' decision support for callers facing values-sensitive decisions: a mixed methods study. Worldviews Evid Based Nurs. 2(4):184-95.

Stacey D, Chambers SK, Jacobsen MJ, Dunn J. (2008). Overcoming barriers to cancer helpline professionals providing decision support for callers: An implementation study. Oncol Nurs Forum. 35(6):961-9.