Table 3.

Summary of review findings for dominant themes

Summary of review findings Studies contributing to the review finding Illustrative quote	CERQual assessment of confidence in the evidence
Knowledge:
Clinician-related factors: Not knowing what SDM is, a number of clinicians have either no knowledge of or an incorrect working definition of what SDM is [52] [55] [46] [57] “[Some clinicians] understood SDM as the professional collaboration between care providers prior to discussing the options with the patient. We make the decision as a team whether or not the patient should go for a cath. I don’t frequently give patients—if I’m sending a patient, if I make the decision that this is appropriate, then we go through the risks and benefits.” [52]	High confidence
Patient-related factors: Patients who are well informed prior to the SDM conversation, report feeling able to engage in SDM conversations with their clinician, (especially those who are able to understand the risks and benefits of their options) [45, 47, 50–54, 57] [45, 47, 51–53] “Additional patient behaviours that take place outside the consultation, including gathering medical information and preparing for the consultation were also identified as important.” [54]	High Confidence
Patient-related factors: Lack of knowledge of risk of different treatment options is seen as a barrier for both clinicians in trying to explain options and patients trying to understand their different treatment options [44, 45, 50, 52, 53, 56] “I had no knowledge and I still don’t have much knowledge about what the complications could have been.” [52] I think after the procedure the nurse or some knowledgeable person should have walked me through what was done, how, when, why, and where. I really wasn’t informed” [52]	High confidence
Skills:
Clinician-related factors: Communication skills were identified by clinicians as necessary to elicit patient preferences and enable SDM conversations [45–48, 50–53, 56, 57] “Yeah, I mean. I think any sort of training in communication and helping with choices and that sort of thing is probably helpful.” [51]	High confidence
Clinician-related factors: Formal training was identified as a facilitator (lack of a barrier), with clinicians noting training would provide them with confidence to know they were doing SDM correctly. [44, 48–51, 55, 56] “I’ve not had any formal training in it… I’m very comfortable in it but I don’t know if it matches with the techniques that others use.’ ‘I’ve done it more than most and therefore am comfortable, not that I’m doing it right or anything” [56]	Moderate confidence
Clinician-related factors: Trust in one’s own clinical expertise and past experience were facilitators for clinicians, who felt past experience helped them increase their clinical skills, confidence and awareness of their own limitations [47, 48, 55–57] “I think I do that [SDM] a lot more now than I did when I started. When I started it was kind of like . . . you follow protocols and evidence-based medicine and all these things, and [back] then I just didn’t feel comfortable swaying from some of those things, and now I feel like my instincts are a piece of that puzzle, of using the evidence-based medicine and things like that. If that’s getting me to a point where it’s 50/50 or 60/40 in that range, then I just start talking to [the] patient and figure out ‘What are you trying to get?”’ [48]	Moderate confidence
Patient-related factors: Patients’ informational capacity is both a barrier and facilitator of SDM with those lacking informational capacity less likely to be engaged in SDM and those with informational capacity being included in informed decisions (for some this was due to past experience within the healthcare system) [45, 47, 50–52, 54, 56] ( [45, 47, 54]) “Their ability to understand that they really, really need to come back if something different happens, is really important for me to involve them in the decision making process.” [56]	High confidence
Organisation- and system-related factors: Lack of formal training for SDM is seen as a system-level barrier by clinicians who believe there should be formal training provided to clinicians [46, 48, 50, 51, 56] “Participants stressed that training will be vital in order to overcome the belief among clinicians that applying SDM does not differ much from their current practice.” [46]	Moderate confidence
Environmental Context and Resources:
Clinician-related factors: Lack of time was a major barrier due to numerous interruptions, overall workload (including administrative tasks), and competing priorities including acuity of other patients [44, 45, 47–50, 53, 56, 57] “I think everyone recognizes that we as physicians and extenders and team members don’t have the time to really spend to help patients make decisions that are good for them” [57]	High confidence
Clinician-related factors: Busy and noisy ward environments also make it difficult for clinicians and patients to engage in SDM [47, 48, 51, 53, 56] “What I’m seeing recently is that the patients want to be listened to, but the environment on the ward is so difficult and so chaotic. We are there trying to listen to their expectations, the way they feel so we can try to change something but if the environment remains the same is very difficult to do’” [52]	Moderate confidence
Clinician-related factors: Lack of private spaces to conduct SDM conversations is a barrier for clinicians and patients, especially those placed in hallways when there are not enough available beds in emergency departments [47, 48, 50, 51, 56]“Having a real conversation in the hallway, it’s not private…can’t sit down…” [56]	Moderate confidence
Clinician-related factors: Presence of family members is seen as both a barrier and facilitator for clinicians. Some clinicians report additional complexity, while others see family members as a resource for patients that enables SDM conversations. [49, 51, 56] (barrier) [45, 47, 49, 50, 52, 53] (facilitator) “Obviously the more people are involved, the more points of conflict there are and the more there is to be negotiated you know but by not involving them, you don’t take that complexity away necessarily” [51] “Sometimes, doctors will give you information and just like the tip of the iceberg. I like to have my daughter along when we’re talking to a doctor because she has some very pointed questions that she puts to them. I get a lot of information through my daughter’s questioning.” [52]	Moderate confidence
Patient-related factors: Patient characteristics barriers reported include low socio-economic status, multiple comorbidities, English (or countries most popular language) as a second language, and past negative healthcare experiences. Whereas patients who had higher socio-economic status, higher education level, and past positive experiences with healthcare report being more likely to engage in and be engaged in SDM [45–51, 55, 56] “If there’re huge language barriers, unfortunately even with a translator, sometimes those nuances are lost.’ ‘They think it’s because of who they are, that they don’t have insurance, that’s why we’re not admitting them… I think (with) that specific population I have a very hard time doing (shared) decision making with” [56]	Moderate confidence
Patient-related factors: Presence of carer or family members provide support for patients going during decision-making and treatment, patients report feeling they can rely on their carer/family to encourage SDM with their clinician [45, 47, 49–51, 53] “One patient asked her daughter accompanying her during an inpatient consultation, ‘Isn‘t that good [treatment]?’ in order to reassure herself.” [53] “It’s hard to be an advocate for yourself when you’re by yourself. It would be easier if you had someone here for you.” [47]	Moderate confidence
Organisation- and system-related factors: Changing clinical guidelines to promoted SDM is reported by clinicians and other stakeholders as being one way in which the system could be changed to facilitated SDM [44, 46, 55, 57] “I really like hospital guidelines, especially if they’re done well where they don’t limit me, yet they give me kind of a something to stand on ... give me protection for what I think is right even though there is a small amount of risk involved in doing it.” [55]	High confidence
Organisation- and system-related factors: Noisy or busy ward environment also makes it difficult for clinicians and patients to engage in SDM [47, 48, 50, 51, 53, 56] “A number of clinicians mentioned that due to the ward being so busy, they were sometimes unable to find a space to sit down with the patient and have a conversation” [51]	Moderate confidence
Organisation- and system-related factors: Lack of private spaces to conduct SDM conversations is a barrier for clinicians and patients, especially those placed in hallways when there are not enough available beds in emergency departments [47, 48, 50, 51, 56] “This is not a hallway thing” [56]	Moderate confidence
Social/Professional Role and Identity
Clinician-related factors: Clinician’s perceived role as educator. Clinicians who saw their role as educators (and/or collaborators) reported being more likely to engage in SDM with their patients, proving information to patients before helping them through the decision-making process [46, 47, 49, 50, 53–55] “making sure that they have information on the available treatment alternatives…within drug treatment, there are a number of different options available. Giving them those options and that independence of making a choice, that’s helpful as well.” [50]	High confidence
Clinician-related factors: Clinicians perceived role as decision maker is a barrier for clinicians who feel it is their responsibility to make decisions for their patients, with a number citing concerns over looking indecisive to their patients. [48, 50, 52, 56, 57] “I think that people want to know that the doctor that they talked to had found something or was confident in this is what’s going on, and so I think that if I don’t do a good job, of that or come in too shared decision-making-oriented, where ‘maybe it’s this, maybe it’s that,’ …I don’t want to sound too wishy-washy” [56]	High confidence
Clinician-related factors: Interprofessional collaboration is seen as a key facilitator of SDM, clinicians feel it is crucial that all members of the care team are communicating the same message to the patient to enable ongoing SDM across multiple conversations with members of the team [45, 49–51, 57] “... you’ve got multiple doctors or multiple specialists involved who have vying opinions in relation to what’s occurring ... what can happen is it can lead to medications being changed quite rapidly .. . which in a patient’s mind creates this lack of confidence ... ” [50]	Moderate confidence
Patient-related factors: Patients having a trusting relationship with their clinician was seen to facilitate SDM [47, 50, 51, 54, 55] “patients emphasized that being patient, having some trust in advance and giving doctors and therapies a try might be helpful” [54]	High confidence
Beliefs about capabilities:
Clinician-related factors: Belief that the patient does not want to be involved in decision-making is a barrier for clinicians who assume their patient does not want to engage is SDM. [45, 50, 54, 56, 57] (barrier) “suggesting that clinicians presume that many patients will not benefit from SDM or do not wish to take part.” [45] “‘Sometimes patients just want to be told what to do. “Others have clearly expressed to me that they don’t want to have any part in that decision, ‘(You’re) the goddamn doctor, why don’t you make a decision?’” [56] Conversely a number of clinicians hold the belief that patients should be involved in decisions about their care and actively work to engage them [47, 50, 52, 55](facilitator) “I think it’s super important some of the questions that you pose for patients to think about, like is this congruent with quality of life. I’ve been there at the eleventh hour and people have to make decisions about what they want and don’t want, and my hope is for them to have a decision aid going into this.” [57]	High confidence
Patient-related factors: Patients belief that they should not disagree with their clinician is a barrier to SDM [45, 47, 56, 57] “How can you make a decision when you’re not an expert?...The bottom line is I am not a doctor.” [47]	High confidence
Patient-related factors: Patients beliefs that they should be included in decisions about their own care, either due to past experience in the healthcare system and/or confidence in their own knowledge of their lived experience [45, 47, 53, 54] “This is my life, and I need to be able to make that decision because they are not the one who is suffering. I am the one that is suffering.” [47]	Moderate confidence