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Faculty of Health Sciences, Department of Health and Caring Sciences, UiT -The Arctic University of Norway, Alta, NorwayThe South-Eastern Norway Regional Health Authority, Department of Medicine and Healthcare, Hamar, Norway
In Norway, shared decision-making (SDM) is on the top of the priorities announced by the health authorities. Accountability for implementing this priority has been delegated to the four health regions, and from there into particular departments, hospital trusts, working groups or SDM coordinators. Using abundant public funding, different approaches to producing and implementing patient decision aids have been developed. However, none of these is implemented by any Norwegian services on a regular basis, while the accessible decision aids on the national health platform are not quality approved and in very little use. An ongoing new project is aimed to resolve this dilemma. Health professional training has been developed as a meta-curriculum with multiple modules, adaptive to setting and user group, and designed as an open-source learning platform, based upon the experience of “SDM Ambassadors” delivering the training. Most of the modules are already implemented on a regular basis in the South-Eastern Health Region, and 5000 health care professionals have already graduated from the training modules. However, in the standard patient pathways, and in most of the national medical guidelines, the patient is still considered to be a passive receiver of directives or recommendations, rather than an active participant in their own health decisions. Considerable structural implementation has been done in the education guidelines of all health professions on all levels to embed SDM principles. Teaching in SDM skills, quality of information and evidence-based nursing has become standard in most of the programs at Norwegian universities. Nevertheless, we currently still have no reliable estimate on the degree to which patients are actually involved in their own health decision-making. Further efforts in the process of implementing the patient’s choice in the health system should involve the municipal services, follow a research-based strategy, include monitoring and consider the quality level of the informational environment of health-related decisions.
Zusammenfassung
In Norwegen steht die partizipative Entscheidungsfindung (PEF) an oberster Stelle auf den Strategieplänen der Regierung. Die Verantwortung für dieses Ziel wurde an die Verwaltungen der Gesundheitsregionen und innerhalb dieser Regionen an Krankenhäuser, Arbeitsgruppen und PEF-Koordinatoren delegiert. In riesigen Förderprojekten wurden unabhängig voneinander drei Methoden entwickelt, wie Entscheidungshilfen in großer Zahl produziert und implementiert werden können. Keine dieser Methoden ist implementiert, während die auf der norwegischen Gesundheitsplattform publizierten Entscheidungshilfen nicht qualitätsgesichert sind und fast nicht benutzt werden. Ein neues Projekt soll dieses Problem nun lösen. Für das Kommunikationstraining von Gesundheitsberufen wurde ein Meta-Curriculum mit zahlreichen Modulen entwickelt, das an Settings und Nutzergruppen angepasst werden kann und als lernendes System designt ist, in das Erfahrungen der Trainer eingespeist werden. Die meisten Module sind in der Praxis implementiert, und 5000 Gesundheitsfachkräfte wurden bereits geschult. Allerdings wird der Patient in den Behandlungsstandards und den meisten klinischen Leitlinien immer noch als Weisungsempfänger betrachtet, und nicht als aktiver Teilnehmer in den eigenen Gesundheitsentscheidungen. Erhebliche strukturelle Implementierung wurde im Bereich der Ausbildungsrichtlinien für alle Gesundheitsberufe geleistet. Unterricht in PEF-Fertigkeiten, Informationsqualität und evidenzbasierte Pflege sind in der Mehrzahl der Studienprogramme inzwischen Standard. Bis heute haben wir keine Anhaltspunkte, um einschätzen zu können, ob oder in welchem Maße Patienten tatsächlich an ihren Entscheidungen beteiligt werden. Zukünftige Anstrengungen in Sachen Patientenentscheidung sollten die kommunalen Gesundheitsdienste einbeziehen, einer wissenschaftlich begründeten Strategie folgen, für ein Benchmarking sorgen und die Qualität der Informationen berücksichtigen, die den Kontext der Entscheidungen darstellen.
] was influenced by the euphoric mood of a small group of people (including the authors), who felt capable of improving the health system of a whole country. The SDM movement was just about to rise, and in a very short time our proposals captured the attention, at the policy level of the Norwegian health system. We had also obtained funding for a range of implementation projects, and even established a national commission to implement a new culture of health communication which aimed to embrace already existing interventions and technologies within a SDM framework [
]. At that time, it seemed a realistic goal to achieve, at least partial implementation of SMD within many of the main patient pathways within a few years. Today, five years later, the Norwegian health system is still in a dynamic process of shifting towards this new paradigm. We have learned much more about the dimensions and complexity of this endeavour, however, SDM is still far from being fully implemented in the Norwegian health system.
The national health care system
Healthcare in Norway is a constitutional right – ideally it is expected to provide services equitably across all phases of life, regardless of socioeconomic status, ethnicity, or area of residence [
]. This ambition is challenged by the country’s geography; about 5 million citizens are unevenly spread over 2000 kilometres from south to north, with a 25,000 kilometres coastline and thousands of islands and mountains, implying difficulties in the delivery of the entire spectrum of health services to everybody. This, of course, also causes a barrier to the equitable implementation of SDM. Another barrier is caused by the semi-decentralized organization of the Norwegian health system. That is, primary and specialist care services are administered separately. Collaboration between health care providers is, however, intended to be improved by the “One Citizen – One Record” objective, which has been designed to reform the electronic medical records in Norway [
], and hence communication between health providers, as it rolls out.
Policy and legislative efforts
Strategies and priorities of health care in Norway are widely steered by political values conveyed by the National Health and Hospital Plans. The 2020-2023 plan lists the importance of the patients ‘preferences, development of health literacy, and informed patient choices as the main priorities of the national strategies [
“In the encounter with health service the patient shall experience openness, respect and participation in choices about treatment. SDM and the use of decision aids shall be facilitated.” [
The focus on SDM has even been strengthened during recent years, and the four regional health authorities have been commissioned to make efforts to operationalize this task. In particular, this task is being tackled by the South-Eastern Health Authority (S-EHA), which is responsible for more than half of the Norwegian population. The hospital trusts of this region have been instructed to make use of a couple of specific interventions and methods, which have been selected because of their proven ability to facilitate SDM. Moreover, the clear and strong focus on patient involvement has impacted upon multiple developments at a national level, such as guidelines for education of health care professions, as reported below.
User involvement in the change process
Both patients and health care providers are normally involved when implementing new policies in health care in Norway. In regards to SDM specifically, this has been achieved firstly by developing SDM-methods as recommended for complex interventions, through stepwise approaches including qualitative and quantitative evidence and considering the needs of the user groups [
Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the Medical Research Council (MRC) Framework.
]. Secondly, health care professionals are (e.g. in their role as ambassadors) involved in activities related to implementation and further development of methods used to support SDM. Thirdly, the user representative board has advocated strongly over many years, in their meetings with the Ministry of Health and Care Services, for including SDM in the national assignment documents, to ensure that this happens. Fourthly, user representatives regularly participate in all decision-making processes at the regional health authorities.
The knowledge to action translation framework
Our report of activities and achievements regarding implementation of SDM is structured along the knowledge to action translation framework [
] (Figure 1). The framework defines the necessary steps in a research-based implementation process following a method that has been proven to be effective. However, it also indicates the need for new research to be conducted on new problems discovered in the implementation process, such as on how to overcome barriers to implementation.
Figure 1The knowledge to action translation framework. (Rosarot Design, Norway)
As an important player in Norway, the MAGIC Evidence Ecosystem Foundation is developing a platform (MagicApp) for authoring and publishing digitally structured guidelines, evidence summaries, and decision aids. The SHARE-IT project within MAGIC (SHARing Evidence to Inform Treatment decisions) is a framework guiding production of generic encounter decision aids from recommendations in the GRADE guidelines. It includes a set of interactive and adaptable presentation formats to be used by clinicians and patients in the clinical encounter to facilitate SDM [
]. The decision aids include numbers for likely benefit related to the different treatment alternatives as well as a systematic presentation of practical issues and likely burden of treatment related to the options. Development of the underlying framework linking guidelines, evidence summaries, and recommendations to decision aids have been tested with users in Norway, UK and Canada [
]. MAGIC also cooperates with The BMJ to develop Rapid Recommendations with corresponding decision aids with strong emphasis on methods related to Evidence-based Medicine, patient and caregiver involvement, and conflicts of interests.
The DECISION AID FACTORY (DAfactory), funded by the Northern Norway Regional Health Authority, provides an approach for producing multiple decision aids in a generic template, and for implementing patient involvement in the respective clinical domains through and during the development process [
Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making.
]. This method was initially used in developing decision aids by the University Hospital of North Norway (UNN). It was considered compelling by the Norwegian Directorate of Health, leading to the decision to publish these decision aids on helsenorge.no (the national digital health services platform in Norway). Later, however, UNN withdrew from the DAfactory cooperation.
“DECIDE treatment” provides a software system that offers another approach to generic decision aids. This extensive system does not only address one-off decisions but is also designed to meet the needs of people with chronic diseases and multiple decisions. The development was funded in two stages: first it was launched as an open-source project within a consortium of public and private partners, and then it was further developed as proprietary software by the Norwegian electronic journal vendor Dips ASA. The system is decision-centric, and integrates tools and information for management of specific diseases. Its theoretical framework is mostly based on multi-criteria decision analysis and single subject research designs. The system personalises all of the main components of decisions, and applies several panels integrating and visualising the data [
Leitlinie evidenzbasierte Gesundheitsinformation: Einblick in die Methodik der Entwicklung und Implementierung [Guideline for the Development of Evidence-based Patient Information: Insights into the methods and implementation of evidence-based health information].
], an instrument has been developed and validated to assess the quality of health information materials (Mapping the quality of health information, MAPPinfo) [
]. MAPPinfo is the first instrument to use evidence-based quality criteria. To generate an estimate of the extent to which information is facilitating informed patient choices, MAPPinfo considers only the most easily accessible information amongst the total of all evidence-based criteria in the guideline. The checklist presents in German, English and Norwegian languages, allowing readers in these language groups to systematically assess, compare, and develop patient information, which is essential in SDM.
As a part of the DAfactory project and supported by Norway’s S-EHA a meta curriculum (according to the Greek prefix “meta”: a comprehensive, or overarching, framework going beyond the level of single measures) for training of health care providers in SDM, communication standards have been developed and evaluated. “Ready for SDM” (original Norwegian title: “klar for samvalg”) uses evidence-based behaviour change techniques (BCT) [
The behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behaviour change interventions.
] and provides seven classroom-based modules and an e-tutorial addressing different professions and settings. A generic didactic approach is applied to various target groups, including SDM trainers. On the website samvalg.no, a list of available courses is presented. In addition, certified graduates of the courses are provided with materials such as education videos, PowerPoint presentations, or exercises, and the trainers are encouraged to upload their own training materials following approval of these by the Ready for SDM authors. Thereby, the meta curriculum is working as an adaptive learning system, which incorporates the need for ongoing user involvement as a requirement of implementation.
Knowledge adaption to health domains or user groups
Decision aids for the Norwegian users are published with other kinds of health information on the national platform, helsenorge.no. Users of the health system also find selected parts of their medical record, examination results, and physician appointments on this website. Using a generic template, decision aids on 15 conditions are accessible: Aortic stenosis, breast cancer surgery, pancreatic cyst, not operable pancreatic cancer, Graves disease, hip- and gonarthrosis, idiopathic hydrocephalus, end-stage renal disease, myoma, prostate cancer, psychosis and obesity.
There are over 300 guidelines in MAGICapp, developed by over 60 different organizations, in different languages, most with corresponding decision aids. These decision aids can easily be adapted to local circumstances, and a number of these decision aids are in Norwegian. Decision aids produced by MAGIC are not published on helsenorge.no, but instead are available through the platform www.magicapp.com, or as widgets used on webpages.
The DECIDE approach to developing decision aids has been applied for several diagnoses (e.g., bipolar disorder and lung cancer). They are in the process of being extensively tested via several projects, including simulation, but are not openly accessible yet [
Several modules of the “Ready for SDM” curriculum have been developed addressing the needs of different health professions in particular settings (Figure 2). Using a stepped research approach, each module has been adjusted to the needs of the target group, and equipped with specific exercises, training videos, and didactic features, all tailored for each of the specific professional contexts [
Figure 2Shared decision-making training modules offered in Norway. The figure illustrates the existing modules in the meta-curriculum “Ready for SDM”. Six of eight modules are already implemented on a regular basis in the target settings.
It is the nature of this kind of implementation processes that knowledge about typical barriers from other contexts is not sufficient in and of itself, and thus needs to be supplemented by information gleaned from studies in that particular context, and with the particular target group specifically in mind. Within the guide for developing generic decision aids in the DAfactory, an assessment method has been tested which has been used to identify specific needs and barriers to SDM in a given target groups. In addition to the many general barriers that are relevant for more or less all patients, application of this method has also revealed barriers that are quite specific for each of the given target group [
Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making.
]. To give an example, patients in a consultation with a surgeon making decisions about hip replacement felt disempowered regarding their ability to obtain balanced information about all (included nonsurgical) possibilities, at least partly because the consultation comprised (and mixed up) two agendas, one of which was to determine the indication for surgery per se. This barrier was found to be context specific, and was not present in consultations about surgery for breast cancer. However, the observer guide led to identification of other specific barriers in this context, instead.
Another approach to identifying preferences of patients for this purpose has been used by MAGIC in the BMJ Rapid Recommendation collaboration. Systematic reviews of patients’ values and preferences were explored for particular indications, and those results were integrated into the body of evidence when developing the clinical practice guidelines. Practical issues relevant for decision making were also included and presented in the corresponding decision aids [
Some of the modules developed within the “Ready for SDM” meta curriculum also passed through a survey of barriers, which informed the revision of the training modules. As an example, this was done with SDM Ambassadors related to a training to certify them as trainers of HCPs using “Ready for SDM” [
]. As a measure accompanying the ongoing implementation work through ambassadors in the hospital trusts, the S-EHA is inviting HCPs involved in SDM implementation (e.g., certificated graduates from train the trainer courses) to become involved in workshops, together with user representatives from the patient side, in order to collect feedback on the usefulness of the materials and methods taught, and to identify barriers to implementation. It turned out that ambassadors need a high degree of freedom regarding the format and style of presentation to feel self-confident when recruiting health care providers at their hospital trust for SDM trainings. This implies that rigorous standardisation of the trainings is perceived as a barrier rather than a facilitator to implementation
Using qualitative methods, experiences related to patient participation were studied from different perspectives for several Norwegian patient groups, including those with renal disease and cancer [
]. It was shown how characteristics on both system- and individual levels, as well as those related to the dynamic of the disease, can impede patient involvement. Moreover, the opportunities and limitations of anchoring SDM in standardized patient pathways were elucidated in several patient groups with cancer diagnoses [
To the best of our knowledge, no systematic work has been done to identify barriers which are typical for the Norwegian health system. However, as an obvious challenge, the uneven distribution of the citizens across the country, and the subsequent difficulty in delivering equitable health services to everybody regardless of their place of residence also poses barriers to the delivery of SDM, which is reliant upon the availability of a range of medical options for successful application.
Implementation of SDM
Here we report on the current status of implementation of SDM in Norway, the interventions in regular use, and the arrangements made to secure implementation. At this point in time, we do not know exactly the extent to which patients are involved in their own health decisions, and how patient involvement varies between the different health services. However, we have some preliminary information, and will present data from the first survey conducted during the ISDM 2022 conference.
Despite of the existence of three ambitious approaches for development and implementation of decision aids in Norway, SHARE-IT, DECIDE treatment and DAfactory, none of these approaches is implemented in the Norwegian health care services yet. According to the numbers from the traffic checker of helsenorge.no, the 15 decision aids already published on helsenorge.no are not used to an extent that would indicate they are being implemented in general clinical practice or the standard patient pathways. A national working group with participants from all four health authorities commissioned with coordinating quality assurance and the implementation of decision aids, has delivered recommendations for the prioritization of certain conditions requiring decision aids, and is working on methods for certification with the IPDAS (International Patient Decision Aid Standards) criteria. However, hitherto quality assurance of the available decision aids is conducted and permission to publication given based on self-declaration only.
Responding to the lack of available and implemented high end decision aids, the S-EHA is engaged in an extensive project to plan the acquisition of a patient-facing decision support system. According to the plan, this system consists of an author suite for creating patient decision aids facing both patients and clinicians, and a way for individual patients to access and use personalised patient decision aids. The decision aids will be populated with data from the patient, the clinician, and research, and will be suitable for facilitating SDM along the entire patient journey. The system is supposed to be integrated within the vast national information architecture. To secure the system’s compliance with the IPDAS criteria and extensive technologic requirements, a multidisciplinary expert team is involved. The acquisition of a patient-facing decision support system forms part of the overall initiative to embed shared decision-making within all the health services in Norway. However, this project is now put on hold.
Securing patient involvement through prescribing SDM as a procedure in the standard patient pathways, such as for cancer diseases, is an aspirational goal of the Directory of Health. However, a study exploring patients‘ actual experiences related to SDM in standard cancer patient pathways showed that patient involvement varied depending on preference sensitivity of the choices [
]. So, to the best of our knowledge, at this point in time SDM is only implemented in an appropriate manner in some of the patient standard pathways, mostly those related to mental health conditions.
Six of eight modules from the “ready for SDM” meta curriculum (Figure 2) are already implemented on a regular basis, at least, in the south eastern health region, and 5000 HCPs have been trained with “Ready for SDM”. The trainings are rolled out over the health region through ambassadors graduated through the train the trainer module. Until today, 100 ambassadors have been certified by the S-EHA. The other modules will soon be implemented, and new modules are already being developed to respond to upcoming needs.
Interested HCPs, ambassadors, and the authors of the training approach and administrators of the training activities, use samvalg.no as meeting point and for obtaining and sharing information. Accessible through a login, the learning materials, exercises and example videos are shared, and the ambassadors are invited to share their individual adaptations of the materials (e.g., their presentation slides). This communication strengthens the motivation of the ambassadors, gives the “Ready for SDM” curriculum flexibility, and allows for further learning and development among all involved.
Most universities have now adopted training in SDM as a topic in primary academic training (in their bachelor and master’s degree courses) for various health professions, such as nurse specialist, physiotherapists, midwifes, radiographers, public health nurses, and physicians. Some use modules from the meta curriculum. To make this course available for even more students and programs, a digital version of the Ready for SDM module is now under development at the Metropolitan University of Oslo. Moreover, a master course module for health professions related to CLAIM, the international project on informed health choices [
], has been validated and implemented at the health science faculty of the Metropolitan university.
SDM coordinators have been employed by the regional health authorities, such as in S-EHA and in Northern Norway, to facilitate use of the existing interventions by the specialist health services in the hospital trusts.
Monitoring of knowledge use and evaluation
Here we report on how the use of SDM and its components are monitored, and what has been done in terms of evaluating efforts of implementation regarding patient-relevant outcomes.
There is little monitoring of SDM use within the Norwegian health care system, but it is clear that this must be established as an essential part of a comprehensive implementation strategy. As a first attempt at installing a monitoring and benchmarking process, the MAPPIN’SDM patient questionnaire [
] were recently added to a regular patient satisfaction survey at Akershus University Hospital, conducted by the Norwegian Institute for Public health. Both instruments are validated, and generally accepted, measures of SDM. This survey should provide estimates on whether, how, and to what extent, patients are currently involved in making decisions about their own health. Over two months, all inpatients have been contacted after their hospital stay. Data will be reported at the ISDM 2022 conference.
Quality of health information is now about to be systematically mapped over the whole country and for most health topics. Several master projects have already been conducted in the field of midwifery and public health nursing. Recently, a three-year project (2022–2025) was approved which will apply MAPPinfo to the screening of information quality in 30 health topics. MAPPinfo is easy to administer without special training or need for further reading of the scientific literature. Because this instrument is the only existing measure based on evidence-based criteria alone, it is expected that MAPPinfo will become a quality standard for evaluating the quality of public health information, including decision aids.
Most of the SDM-related interventions and methods recommended for use and considered in the implementation plan are thoroughly evaluated. This applies to the MAPPIN‘SDM, used for benchmarking and the “Ready for SDM” training modules. The latter have proven feasible and acceptable, and, importantly, have been shown to facilitate health behaviour change. Moreover, they can improve SDM-specific communication competencies [
]. However, further research is needed to follow these outcomes over time, and especially under implementation conditions.
Sustain knowledge use
To achieve maintenance of the quality standards and continuation of the behaviour changes, the SDM implementation strategy needs additional support. We believe that any training concept for SDM will soon become obsolete if it is not capable of adapting to new ideas and allowing for individualised application in its use. Therefore, designing “Ready for SDM” as a learning system, and encouraging ambassadors to co-design and further develop the platform, is a fundamental component, essential as an investment in the sustainability of the movement. Our experiences so far seem to support this strategy, however, we also need to limit the degrees of freedom to prevent degradation of the core elements of this training approach.
Importantly, the government‘s focus on patient involvement and informed health choices has, in recent years, been operationalized in the development of new overarching education guidelines for health and social professions [
]. Many subsidiary guidelines have further substantiated the goals related to training of patient involvement skills and facilitation of health choices. Moreover, SDM has been included in the learning goals of many professional curricula at particular academic institutes. As an appreciable change, these guidelines and learning goals are now legally binding for those planning the teaching and training of health professionals.
As the primary academic entity in Norway accountable for addressing questions relating to evidence-based patient information and shared decision making, the Health Communication Research Group has recently been formally established at the Metropolitan University Oslo. Moreover, the Faculty of Health Sciences has now instituted a new priority area on the topic of health literacy, and a professorship was recently established, demonstrating the University’s commitment to providing high-level support and resources in health communication research. This will be advantageous to the implementation of SDM throughout Norway, as this new position will support the expansion of further activities and ensures that the overarching plans will be founded upon a solid, research-based implementation strategy.
Discussion
Our report provides a narrative and critical review of how, and to what extent, SDM is currently being implemented in Norway. Due to limitations of space, we have not mentioned every single activity, and might even have overlooked certain individual initiatives. Instead, we have provided an overview of the most important activities, achievements, and issues.
We consider it advantageous to be encouraged and challenged by our government to translate our knowledge about patient involvement directly into the encounters with the patient, and to carry out a sustainable shift of the communication paradigm within our health system. Norway has three strong resources related to this goal: firstly, Norway already demonstrates exemplary standards regarding the translation of evidence into understandable language for the patient. Secondly, Norway already has an adaptive, broadly modularized curriculum for the training of SDM related communication skills, making it easy to provide training to various groups of HCPs for various settings and competence levels. Thirdly, Norway already has, from the beginning, used an interdisciplinary approach, and is thereby more likely to overcome barriers related to traditional hierarchy or discipline-silo-work dynamics within its health system.
On the other hand, as a weakness that is noted through our report, Norway shows a suboptimal relationship between the size of projects in the health care sector and the extent to which the knowledge obtained from these projects is fully implemented within general clinical practice. In the context of SDM, a better balance might be achieved if projects were more strongly informed, and structured, by research, such that they were founded upon a theory-based focus of implementation. In this regard, the establishment of the Health Communication Research Group at the university might be purposive. Another barrier appears to be the Norwegian organization of health services into two separate health systems (municipal and specialist). Most of the developments regarding SDM have taken place in the specialist sector, which according to the health structure might seem more receptive to these sorts of innovative activities. Many of the decisions relating to patient health, however, are made with, or at least initiated by, GPs at the municipal part of the health system. Further efforts are therefore needed to translate this knowledge within the municipal health care services as well.
Importantly, SDM is not just an interactive approach for guiding face-to-face communication between HCP and patient. Access to good quality health information, developed and designed according to valid quality criteria, is one of the minimal prerequisites of SDM [
Leitlinie evidenzbasierte Gesundheitsinformation: Einblick in die Methodik der Entwicklung und Implementierung [Guideline for the Development of Evidence-based Patient Information: Insights into the methods and implementation of evidence-based health information].
]. Therefore, an implementation plan needs to include the establishment of a high quality health information environment. Trustworthiness of a strategy to induce a sustainable change in communication patterns between HCPs and patients will rely on whether its components – HCP communication training, decision aids, medical guidelines and patient standard pathways – are harmonized across all health settings.
Conclusion
Currently, we do not know enough about the extent to which patients are involved in making their own health care decisions in Norway. However, the country has, in a relatively short space of time, achieved an impressive level of knowledge and competence in SDM, which has provided us with a solid foundation, upon which we can build a more comprehensive and rigorous implementation process in the coming years. The next steps of implementation will include rolling out “ready for SDM” in both the South-Eastern Health region and beyond, developing a central platform for certified decision aids accessible to all Norwegian citizens, including efforts of implementation on the GP-level, and completing a theory- based overarching implementation plan. The latter should include consideration of the decision-making context, such as improving the quality of health information materials available for use, and embedding SDM principles in guidelines and standard patient pathways.
Acknowledgement
The authors would like to acknowledge all the healthcare providers, health service users, user-representatives, policymakers and researchers which have contributed to strengthen the patient’s role. We are also grateful for funding of research by various institutions facilitating developments in this regard. Thanks to Dr Wendy Longley, who kindly and thoroughly edited our English manuscript.
Conflict of interest
The authors declare that there is no conflict of interest.
CRediT author statement
All authors contributed to writing the manuscript and agreed to its final version.
References
Kasper J.
Lager A.R.
Rumpsfeld M.
Kienlin S.
Smestad K.H.
Bråthen T.
Ankell H.
Knutsen T.
Kløvtveit R.
Gulbrandsen P.
Vandvik P.O.
Heen A.F.
Flottorp S.
Tollåli G.
Eiring Ø.
Status report from Norway: Implementation of patient involvement in Norwegian health care.
Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the Medical Research Council (MRC) Framework.
Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making.
Leitlinie evidenzbasierte Gesundheitsinformation: Einblick in die Methodik der Entwicklung und Implementierung [Guideline for the Development of Evidence-based Patient Information: Insights into the methods and implementation of evidence-based health information].
The behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behaviour change interventions.
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