Background Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives. Methods The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM. Results Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations. Conclusions SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs. Trial Registration The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645.

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Background Shared decision-making (SDM) has been shown to improve healthcare outcomes and is a recognized right of patients. Policy requires health services to implement SDM. However, there is limited research into what interventions work and for what reasons. The aim of the study was to develop a series of interventions to increase the use of SDM in maternity care with stakeholders. Methods Interventions to increase the use of SDM in the setting of pregnancy care were developed using Behaviour Change Wheel and Theoretical Domains Framework and building on findings of an in-depth qualitative study which were inductively analysed. Intervention development workshops involved co-design, with patients, clinicians, health service administrators and decision-makers, and government policy makers. Workshops focused on identifying viable SDM opportunities and tailoring interventions to the local context (the Royal Women’s Hospital) and salient qualitative themes. Results Pain management options during labour were identified by participants as a high priority for application of SDM, and three interventions were developed including patient and clinician access to the Victorian Government’s maternity record via the patient portal and electronic medical records (EMR); a multi-layered persuasive communications campaign designed; and clinical champions and SDM simulation training. Factors identified by participants for successful implementation included having alignment with strategic direction of the service, support of leaders, using pre-standing resources and workflows, using clinical champions, and ensuring equity. Conclusion Three interventions co-designed to increase the use of SDM for pain management during labour address key barriers and facilitators to SDM in maternity care. This study exemplifies how health services can use behavioural science and co-design principles to increase the use of SDM. Insights into the co-design of interventions to implement SDM in routine practice provide a framework for other health services, policy makers and researchers.

Purpose The purpose of this paper is to explore whether people’s intuitions regarding the social consequences of word of mouth (WOM) match the actual consequences. The authors investigate the expectations people have about how sharing WOM (positive or negative) will change others’ perceptions of them and then compare these expectations to the actual impact of WOM. Design/methodology/approach Six studies were conducted. Study 1 predicted how sharing their experiences with various products or services would change others’ opinion of them. Studies 2a/2b contrasted participants’ intuitions about the potential social consequences of sharing WOM with the consequences. Studies 3a/3b and 4a/4b tested for the hypothesized mediating mechanism. Studies 5a/5b focused on negative WOM and used participants’ own reviews to compare intuitions with impact. Study 6 explored whether considering one’s own consumption experience mitigates the negative social impact of WOM. Findings Consumers expect positive WOM to improve perceptions as it conveys only positive cues about the communicator (i.e. helping intentions and a positive personality). Negative WOM is expected to have neutral impact, as it conveys mixed cues (i.e. helping intentions but a negative personality). In contrast, the authors show that sharing negative WOM tends to be quite detrimental, whereas sharing positive WOM has little impact. People are largely unaware of these effects. Research limitations/implications The research contributes to the literature on WOM and social transmission by comparing people’s intuitions about the social consequences of WOM with its actual consequences. The authors acknowledge that they used mostly WOM messages that were pre-written (vs spontaneously generated by participants). This may have constrained the generalizability of the results. Several potential moderators remain to be investigated, such as the role of message extremity, the interpersonal closeness between communicator and receiver, whether the WOM was solicited vs spontaneous, online vs offline, etc. Practical implications Greater effort is needed to raise consumers’ awareness about the gap between their expectations and the actual social consequences of WOM. Furthermore, marketers responsible for designing product review opportunities should be encouraged to provide consumers with more flexible options, such as the ability to easily remove an online review. Finally, consumers transmitting negative WOM in particular should be aware that their negative tone may compromise the persuasiveness of their message by making the receiver more vigilant and thus less receptive. Originality/value The authors are the first to directly contrast people’s intuitions about the social consequences of WOM with its consequences. Unlike the previous literature, the authors investigate people’s intuitions directly, and investigate the consequences of positive and negative WOM by comparing them to a neutral no-WOM condition. They also shed light on the specific personality traits people infer from WOM.

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