This study found that with a tailored implementation strategy to promote PDA use, there was a relatively high degree of reach and adoption among doctors, although patient adoption of the insulin PDA was only moderate. At the end of the study period, a high proportion of doctors indicated a willingness to continue using the insulin PDA. Qualitative findings shed light on the interplay between selected strategies and implementation outcomes. While some barriers and facilitators to PDA implementation were common (e.g. too busy, finding the PDA useful and beneficial [29, 30], patient desire for more information), we found that factors unique to the Malaysian health setting (HCPs’ roles and responsibilities) and culture (social hierarchy) influenced the implementation outcomes in unexpected ways.
In this study, the insulin PDA implementation was promoted to clinic staff by the Head of Department through an announcement in a unit meeting as well as provision of official letters to all the doctors and nurses. ‘Reach’ to HCPs was found to be relatively high as indicated by the high attendance rate (89%) in the insulin PDA workshops among the doctors. This finding is comparable to the Group Health SDM demonstration project whereby a high attendance rate was also observed where 90% of their clinicians attended the SDM training provided. This was attributed to the high priority placed on the training by the institution and specialty-service-line chiefs [31]. In another study, a nurse coordinator was appointed at each implementation site, and was responsible for approaching physicians and nurses personally to get them to participate in the SDM programmes, which resulted in 97.1% of the HCPs participating [32]. However, one study which appointed a research assistant (rather than an influential physician) to help with recruitment of community primary care practices to implement cancer screening PDAs only has a recruitment rate of 6% [33]. These findings together with the findings of this current study indicated that using an organisational leader or influential HCP to make personal invitations (i.e. individualised letters, personal face-to-face meeting) is an important facilitator to promote PDA implementation among HCPs. This facilitator may also be more important to implementation of PDAs given the lack of awareness and knowledge of the concept of SDM and PDA in Malaysia, which necessitates push from an authority person. Unlike the implementation of clinical practice guideline, which HCPs are more familiar with, the need for an organisational leader to promote guideline uptake is not necessary as it was not reported as a common strategy for guideline implementation [34].
The strategy mandate change is reported elsewhere as a facilitator for PDA implementation studies as it leads HCPs to believe that PDA implementation is an organizational priority [35, 36]. However, this study found that while this strategy can influence PDA adoption, it was tied to more negative punitive beliefs as doctors reported fear of implications for not following orders from their higher authority. Malaysia has a hierarchical society, and in healthcare settings, junior HCPs tend to obey senior HCPs or the higher authorities. Hence this may be another reason why this strategy was effective to facilitate the insulin PDA implementation. Nevertheless, there is a need for better understanding on the mechanism of how the strategy mandate change exerts its effect, for example, would negative influence (i.e.: mandate result in the feeling of coercion to be involve in the implementation) or positive influence (i.e.: mandate result in positive belief that the implementation is important and useful) of mandate has a better effect in facilitating implementation as such is lacking in the literature.
This study found that some nurses did not perform their task for the insulin PDA implementation despite aligning the nurses’ insulin PDA implementation task with their existing duty in this current study (i.e., refilling supplies). Social hierarchy, organisational work culture, and the clear role and responsibilities of different HCPs in Malaysia might have contributed to nurses’ lack of motivation to carry out their task. In Malaysia, doctors are perceived to be more knowledgeable, have more authority, and they are the only HCP who can prescribe medication such as insulin to patients. Nurses are given limited roles such as administering medications and treatments according to doctor’s orders. Some studies have reported nurses in Malaysia to be dissatisfied, stress, and felt that their their job as a nurse was under-respected [37–40]. In the Western countries, nurses have reported to perform tasks without physician oversight such as physical examinations, order and interpret diagnostic tests, and write prescriptions [41, 42]. Teamwork is an essential key determinant of implementation outcomes. In order to promote teamwork for PDA implementation, there is a need for a paradigm shift on the way of thinking about nurses’ roles in patient care, and this needs to start from recognising nurses’ abilities and giving them more responsibility for clinical decision making in patient care so that they would feel empowered in carrying out their duties. Interprofessional approach has been promoted to facilitate PDA implementation [43] as different HCPs can play different roles in the implementation hence disperse the workload that is needed to implement SDM and PDA. For example, nurses can take the responsibilities to familiarise patients with the PDA [44], or provide decision coaching before patients meet with clinicians [45, 46], while clinicians can carry out the SDM discussions with patients. This will help to alleviate the burden of operationalising PDA delivery by physicians, which have consistently being reported to be not effective [6, 33, 47–50].
This study highlighted that doctors were demotivated to continue using the insulin PDA when many of their patients who were given the PDA did not read it. This can affect sustainability of PDA implementation as doctors lose motivation over time as they could not see the positive impact of the PDA. Conversely, one of the facilitators for PDA adoption among doctors found in this study was the personal positive experience and perceived usefulness of the insulin PDA. This indicates that if doctors experienced the value and benefits of delivering the PDA to patients, this could overcome barrier such as “HCPs are busy” as they may find ways to integrate PDA use in their busy consultation. Perceived positive contribution of PDA to patients and practice have been shown to be factors associated with the sustainability of PDA implementation [8, 44]. Future implementation effort should leverage on the strategy of making HCPs to understand the value and benefits of PDA. One way that can be done is through continuous feedback provision focusing on patient positive feedback, satisfaction, knowledge and decision quality [31, 36, 51–54].Notwithstanding, efforts are also needed to promote PDA use among patients. In this study, patients did not read the insulin PDA because they have psychological resistance to insulin therapy. Future PDA implementation may need to include initially assessment of patients acceptance of the treatment options and counsel accordingly before the PDA is offered to the patient.
Study strengths and limitations
The strengths of this study are that this is one of the few PDA implementation studies that assessed implementation outcomes, and that were conducted in the Asian settings. Secondly, this study was conducted in routine clinical practice with minimal interference. Hence the findings have considerable external validity and may be applicable to other settings. Thirdly, this study utilised various sources of data (literature review, administrative data (EMR), questionnaire, interviews), and adopted perspectives from a wide range of stakeholders (healthcare policymakers, doctors, pharmacists, nurses, patients), which enhances the credibility of the findings of this study.
This study has a few limitations. First, there is a possibility of underreporting of the number of PDAs given to patients using the insulin PDA tracking log (Reach-patient, Adoption-doctor), notes made in the EMR, and notes made on patients’ appointment books among the doctors, as well as reporting on follow-up with patients by the doctor (Implementation) as these findings relied on doctors self-reported data. Secondly, the number of patients who were eligible to use the insulin PDA could not be determined (Reach-patient). This limits the understanding of the true extent to which the insulin PDA reached the patients. Thirdly, the definition of the RE-AIM “implementation” dimension in this study referred to HCPs’ fidelity to the various implementation tasks as set in the insulin PDA implementation protocol, and not HCPs’ fidelity to how they use the PDA with patients using the SDM approach. It would be of greater value, if HCPs fidelity to SDM approach can also be measured to ensure that SDM are truly being practised, and not mere handing out PDAs to patients.
Study implications and recommendations
The findings of this study are useful for PDA implementers who may want to target specific implementation outcome (‘reach’, ‘adoption’, ‘implementation’, and ‘maintenance’), and adopt or improvise the strategies reported in this study to facilitate PDA implementation efforts. Some of the recommendations for future PDA implementers are, to attract HCPs in engaging in PDA implementation, an organisation leader or influential physician should show visible support for the PDA implementation and send personal invitations to the staff who would be involved in the implementation particularly for settings where the concept of SDM and PDA are not well known. As perceived usefulness and benefits of PDAs are crucial for sustainability of PDA use among HCPs, continuous feedback provision particularly on patient outcomes are important. The Malaysian healthcare work culture should shift towards more empowered nurses roles in order to promote true interprofessional collaboration to PDA implementation.
This current study did not evaluate the ‘effectiveness’ of the insulin PDA implementation specifically the impact of the insulin PDA implementation on SDM and PDA-related outcomes such as patients’ decisional conflict, patients’ involvement in the SDM process, clinicians’ satisfaction with PDA use, and clinicians’ discussions with patients. These outcomes are useful as feedback to doctors to motivate them to use the PDA with their patients. Future studies can consider adopting the hybrid effectiveness-implementation study design whereby both implementation and effectiveness outcomes are measured [55].