Discussion
SECONDARY, POSITIVE
We performed a comprehensive qualitative process evaluation of a theoretically and empirically based SDM implementation program with six strategies within a cluster-randomized SDM implementation trial. Data collection integrated various stakeholders’ perspectives through qualitative process interviews with nurses and physicians of participating departments, field notes by the study team, and meeting minutes. Qualitative data analysis was based on the CFIR, a conceptual framework for implementation research. Major influencing factors on SDM implementation were found for all domains of the CFIR and amended by inductively derived influencing factors where necessary. Major themes regarded e.g., relative priority and relevance of SDM and its implementation, leadership support, coordination and communication, applicability and compatibility, and available resources. In addition, strong interrelations between different major influencing factors were identified.The influencing factors found in this trial align with previously reported influencing factors on SDM implementation [Furthermore, our comprehensive assessment of influencing factors guided by the CFIR as a theoretical foundation added to existing literature by highlighting the interrelations between influencing factors on different levels (i.e. regarding different CFIR domains) that likely need to be addressed simultaneously. A successful implementation program might need to take into account many if not all of the influencing factors in order to lead to a relevant change in SDM implementation. Barriers on different levels might stabilize the current lack of SDM uptake. Implementation efforts that manage to tackle some, but not enough of the influencing factors are likely not finding significant effects. This might explain, why the outcome evaluation of this trial did not show significant differences in patient-reported SDM uptake and most secondary outcomes before and after implementation of the multi-component SDM implementation program [In addition, the influencing factors differ in who has the power to modify them and how. Positive attitudes and motivation to change on the individual level, as found in this trial, did not suffice to foster SDM uptake on the department level. This aligns with recent literature that points to the necessity to consider barriers on the organizational and health system level in order to successfully implement SDM [Participatory research could be a way out of limited implementation success due to influencing factors on the individual, organizational, and intervention level [