Step 4: Implement decision aids/decision support with training
Implement decision aids and decision support using strategies tailored to overcome barriers in the setting and provide training for health professionals.

How can decision aids/decision support be implemented? Are strategies needed to overcome barriers likely to interfere with the use of decision aids/decision support? Is there motivation from managers and/or leaders within the setting; if not how can they be motivated? Do health professionals recognize a need to better support patients when making decisions? Is there a need for training in shared decision making and/or decision coaching?

4.1 Patient's view

1. By focusing on patients and health professionals
   
   How can decision aids and decision support be implemented? Are strategies needed to overcome barriers likely to interfere with the use of decision aids or provision of decision support? Do health professionals recognize a need to better support patients when making decisions?
   
   Choose strategies that are evidence-based and likely to overcome known barriers. For example:
   • Use information gained in Steps 1 to 3
   • Highlight the gap between patient(s)' identified decision making needs and current practice
   • Increase patient and family awareness of decision aids and decision support tools
   • Choose effective interventions to change health professional behaviours based on the findings reported in the Cochrane Effective Practice and Organizational of Care Group (e.g. printed materials, audit and feedback, educational meetings, educational outreach, reminders local opinion leaders)
   • Provide training for health professionals (see 4.2) and reinforce learning with use of continuing education, self-appraisal, and/or case-based discussions
2. By focusing on the setting to ensure sustained changes
   
   Is there motivation from managers and/or leaders within the organization; if not, how can they be motivated? What are the current care pathways and can decision aids/decision support be implemented into the pathway?
   
   Choose strategies that are evidence-based, more embedded within organizational structures, and likely to overcome known barriers. For example:
   • Identify modifiable and non-modifiable barriers interfering with implementation of decision aids/decision support and determine ways to overcome these barriers
   • Focus on potential early adopters and environments ready to change
   • Find resources to support patients' decision making
   • Use information gained in Steps 1 to 3
   • Add patient decision aids to the care pathways and identify who is most responsible for providing patients with decision aids
   • Link health information resources to electronic health records to ease documentation and flag relevant resources "just in time".
   • Choose effective interventions targeting the health care setting based on the Cochrane Effective Practice and Organizational of Care Group
   • Ensure clear mandate to use patient decision aids and provide decision support

4.2 Provide training for health professionals
The Cochrane Review of Interventions to Increase Adoption of Shared Decision Making and another systematic review of patients' perception of shared decision making both found that when health professionals participated in education, they were more likely to use patient decision aids and share decision making with patients. The following are evidence and theory-based educational programs developed and evaluated by our research program.

1. Ottawa Decision Support Tutorial (ODST)
   The ODST is an online tutorial based on the Ottawa Decision Support Framework and designed to help health professionals further develop their knowledge and skills in providing decision support. The ODST features:
   • Self-paced learning
   • Self-assessment quizzes with tailored feedback at the end of each section
   • Criterion-referenced final test
   • Certificate of Completion (for scores of 75% or more on the final test)
   • Downloadable PDF version of online reading
   Login requires selection of your own user name and password. There is no fee for the ODST. Findings from multiple studies show that health professionals and students who use the tutorial have improved knowledge (compared to baseline scores and when compared to control groups).
2. Decision Support Workshops
   There are two workshops for health professionals on topics related to decision support. If you are interested in any of the workshops please contact us at decisionaid@ohri.ca for information on availability and cost.

   Decision Support/Coaching Skill-Building Workshop
   Based on the Ottawa Decision Support Framework, this 3-hour workshop to build skills in assessing patients' decisional needs, coaching patients through a process of decision making, self-assessing the quality of decision support provided, and exploring ways to implement decision support.

   Interprofessional Shared Decision Making (IP-SDM) Skill-Building Workshop
   Based on the key elements of the IP-SDM conceptual model, this 3-hour workshop aims to build skills in considering team-based approach to involving patients in the decision making process, assessing patients' decisional needs, using evidence- and theory-based interventions to support patients making decisions, self-appraising the quality of decision support, and exploring ways to implement decision support.

3. Credit Courses in Decision Making
   • University of Ottawa: NSG 6133 - Decision Making in Clinical Practice
4. Curriculum-Based Tools

   Integrating Patient Decision Support in Curriculum
   Stepwise series of lectures, problem-based case scenarios, and assignments that can be embedded as a thread across a curriculum for health professionals.

Examples of additional resources

Institute of Health Economics. (2008). Effective dissemination of findings from research. Alberta, Canada.

Légaré F, Turcotte S, Stacey D, Ratté S, Kryworuchko J, Graham ID. (2012) Patients' perceptions of sharing in decisions: A systematic review of interventions to enhance shared decision making in routine clinical practice. Patient. 5(1):1-19. doi: 10.2165/11592180-000000000-00000.

Légaré F, Ratté S, Stacey D, Kryworuchko J, Gravel K, Graham ID, Turcotte S. (2010). Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev. (5):CD006732.

Légaré F, Graham I, O'Connor A, Aubin M, Baillargeon L, Leduc Y, Maziade J. (2007). Prediction of health professionals' intention to screen for decisional conflict in clinical practice. Health Expect. 10(4):364-79.

Murray MA, Stacey D, Wilson KG, O'Connor AM. (2010). Skills training to support patients considering place of end-of-life care: a randomized control trial. J Palliat Care. 26(2):112-21.

O'Connor AM, Tugwell P, Wells G, Elmslie T, Jolly E, & Hollingworth G. (1998) A decision aid for women considering hormone therapy after menopause: Decision support framework and evaluation. Patient Education & Counseling. 33(3):267-279.

Stacey D, Higuchi KA, Menard P, Davies B, Graham ID, O'Connor AM. (2009). Integrating patient decision support in an undergraduate nursing curriculum: An implementation project. Int J Nurs Educ Scholarsh. 6(1):Article10.

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.

Stacey D, O'Connor AM, Graham ID, Pomey MP. (2006). Randomized controlled trial of the effectiveness of an intervention to implement evidence-based patient decision support in a nursing call centre. J Telemed Telecare. 12(8):410-5.