Comparison with the literature
The ambassadors' satisfaction with their learning outcomes from the Ambassador course is in line with the international literature, which shows that even short-term SDM training programmes have a positive effect on MDs’ learning outcomes (13, 19–21). However, our results are not strictly comparable with the results of these studies as they are primarily collected from MDs within one medical specialism. Thus, our study contributes to a broader picture of the effects of training programmes on MDs' satisfaction with their learning outcomes. Also, our results showed that fewer ambassadors were satisfied with their competencies compared with their knowledge and communication skills within SDM. This finding was explained and nuanced in our interviews, in which several ambassadors said that it was difficult for them to apply their learning outcomes in their clinical practice, although they did have sufficient knowledge and materials about SDM. This indicates that short-term training programmes in SDM are not sufficient if MDs are to be equipped to use and disseminate SDM routinely in their clinical practice with patients and among colleagues.
This study showed that most of the ambassadors used (79%) and disseminated (59%) SDM following the Ambassador course. To our knowledge, only a few studies have examined whether and how MDs use and disseminate SDM, with patients and among colleagues respectively, after an SDM training programme. Studies have shown varied results which can be attributed to differences in study designs and methods of measurement (19, 22, 23). Unlike our study, Körner et al. (2012) found that daily interaction with colleagues in relation to a train-the-trainer programme in SDM, for providers in executive positions, affected the number of healthcare professionals using SDM in clinical practice (23). Our results also indicate that there is not one shared understanding of what SDM is among MDs. Further, it is likely that the ambassadors are not aware that dissemination of SDM is a practice that can be carried out unintentionally when the ambassadors use SDM themselves, as they may inspire their colleagues to use it too. Overall, SDM is an ambiguous concept, which makes it difficult for MDs to assess the learning outcomes, use, and dissemination of SDM following a training programme.
Different conditions in the clinical context shaped the ambassadors' use and dissemination of SDM, including lack of time, the clinical situation, the medical hierarchy, and lack of clinical experience. These contextual conditions are known in the literature (12, 19, 22, 24). Thus, this study does make a contribution by confirming that these conditions also influence the ambassadors' usefulness and dissemination of SDM in the context of the Danish healthcare system. A short SDM training programme cannot alter these contextual conditions.
Strengths and limitations
This study should be considered within the context of its methodological strengths and limitations. We used mixed methods to carry out an in-depth evaluation of the Ambassador course. Our quantitative results provided a broad knowledge of the ambassadors' satisfaction with their learning outcomes, as well as the extent to which the ambassadors used and disseminated SDM in their clinical practice. These results were nuanced and contextualised by the interviews, which drew attention to several contextual conditions that shaped the ambassadors' perception of their learning outcomes, as well as their experiences with using and disseminating SDM. This comprehensive knowledge, gained from triangulating quantitative and qualitative data, underlines the strength of our mixed methods design.
Our data collection approach has led to a relatively high response rate (61%), which reduces the risk of selection bias in our results. However, the Ambassador course is a voluntary training programme, from which it can be assumed that the ambassadors had a positive attitude towards SDM in advance. Thus, our results cannot be generalised to every member of Junior Doctors Denmark. Further, the cross-sectional design does not permit an assessment of causality within our results. It is likely that the ambassadors' satisfaction with their learning outcomes, use, and dissemination of SDM are not solely a result of their participation in the Ambassador course. However, we consider our use of maximum variation sampling as a strength, regarding the study's applicability. By ensuring as much variation as possible among the interviewed ambassadors, in terms of their learning outcomes, use and dissemination of SDM, we have achieved a more representative evaluation of the Ambassador course than if we had only interviewed those who, for example, were the most satisfied with the ambassador course.
Our study focuses on JMDs’ experiences with SDM training. Future studies should therefore investigate whether the patients feel more included in health-related decisions and experience better treatment because of SDM training programmes. In the long run interventions and evaluations should target multiple health professional, including MDs; as well as patients and their relatives. However, the interventions need to take place in a context where the cultural and structural conditions that work as barriers for SDM are addressed. Thus, interventions need to be accompanied by organisational and political support so that the clinical context facilitates both the use and dissemination of SDM.
Based on this study’s results, future short-term SDM training programmes should supplement SDM teaching with regular refresher courses that can be taken online, to accommodate MDs’ busy and changeable professional and everyday lives. Further, it is relevant to discuss whether it is appropriate for relatively young and newly-qualified MDs to be agents of change in the Ambassador course, as this study has shown that this group of MDs lacks impact in their clinical environments, especially among their older and more experienced colleagues. Thus, future SDM programmes should focus on targeting MDs with different levels of medical experience and impact in their clinical environments. Following on from this, it would be beneficial if SDM was introduced at medical school so that future MDs will be introduced to SDM earlier in their medical careers. Thus, SDM education will not be limited to those who participate in a voluntary SDM training programme. In addition, an interdisciplinary effort is required if SDM training programmes such as the Ambassador course are to fulfil their potential. This is because a patient’s pathway involves contact with various health professions in the healthcare system, not only MDs. Therefore, it will be appropriate that healthcare providers in executive positions introduce SDM training programmes to their entire departments, based on their local structures and contact with patients.
Finally, there is a need for a clear definition of SDM among MDs, as well as other healthcare professionals engaging with patients, if SDM is to be implemented routinely in MDs’ clinical practice.