Table 3.

All identified barriers and facilitators to SDM*, grouped according to six levels of the healthcare system¹²

Levels	Barriers	Facilitators
The innovation itself	SDM takes too much time There are not always two or more equivalent treatment options available Sometimes decisions are urgent and have to be made right away SDM causes patients to question the expertise of healthcare professionals (nurses only) SDM causes patients distress or discomfort	SDM saves time in the long run (physicians only) SDM fulfils the ethical imperative of respecting patient autonomy SDM is appropriate regardless of the type of rheumatic disease or decision SDM benefits the professional relationship with patients (physicians only) SDM improves patients’ treatment adherence Ultimately, SDM improves health outcomes
The individual professional	Healthcare professionals lack knowledge of what SDM entails Healthcare professionals do not exactly know how to apply SDM Healthcare professionals fall back into routines (ie, they forget to apply SDM) There is a lack of motivation among healthcare professionals to change routines Healthcare professionals lack knowledge of treatment options Healthcare professionals lack communication skills Healthcare professionals do not want to stray away from what they believe is the best decision There are many other things demanding the attention of healthcare professionals	Healthcare professionals have a (very) positive attitude toward SDM Healthcare professionals feel confident to apply SDM Healthcare professionals have hands-on experience with SDM Healthcare professionals try to imagine themselves in their patients’ shoes There are education programme on SDM available There are communication skills training programme available
The patient	Patients do not prefer to be involved in decision making SDM is often too complex for patients (ie, patients are not able to take an active role) Patients lack knowledge of treatment options Patients’ treatment preferences are at odds with those of healthcare professionals Sometimes there are communication issues (eg, language barriers)	Patients are well-prepared for consultations There is patient information on treatment options available (eg, leaflets, booklets and websites)
The social context	The inter-professional collaboration is inadequate (eg, poor communication between physicians and nurses) (nurses only) Colleagues are not supportive (nurses only)	Physicians and nurses collaborate successfully with each other There is a supportive team culture
The organisational context	SDM is incompatible with clinical practice guidelines There is not enough time to apply SDM (ie, consultation times are too short) The workflow does not allow SDM to be easily implemented (eg, poor logistics) (nurses only) There is a lack of tools that support the application of SDM (eg, decision aids)	Consultation times are long enough to apply SDM
The economic and political context	There is a lack of reimbursement for SDM (physicians only) Some treatment options are expensive (physicians only)	SDM is an important topic in the Dutch healthcare system

*Barriers and facilitators were experienbed by both physicians and nurses, unless indicated otherwise.

SDM, shared decision making.