Normalization of a conversation tool to promote shared decision making about anticoagulation in patients with atrial fibrillation within a practical randomized trial of its effectiveness: A cross-sectional study

Gabriela Spencer-Bonilla, Anjali Thota, Paige Organick, Oscar J. Ponce, Marleen Kunneman, Rachel Giblon, Megan E. Branda, Angela L. Sivly, Emma Behnken, Carl R. May, Victor M. Montori, Megan E. Branda, Juan Pablo Brito, Marleen Kunneman, Ian Hargraves, Angela L. Sivly, Kirsten Fleming, Bruce Burnett, Mark Linzer, Haeshik GorrElizabeth Jackson, Erik Hess, Takeki Suzuki, James Hamilton, Peter A. Noseworthy, Haeshik Gorr, Alexander Haffke, Mark Linzer, Jule Muegge, Sara Poplau, Benjamin Simpson, Miamoua Vang, Mike Wambua, Joel Anderson, Emma Behnken, Fernanda Bellolio, Renee Cabalka, Michael Ferrara, Rachel Giblon, Jonathan Inselman, Annie Leblanc, Peter Noseworthy, Marc Olive, Paige Organick, Nilay Shah, Gabriela Spencer-Bonilla, Amy Stier, Anjali Thota, Henry Ting, Derek Vanmeter, Claudia Zeballos-Palacios, Park Nicollet-Healthpartners, Carol Abullarde, Lisa Harvey, Shelly Keune, Timothy Smith, Shannon Stephens, Bryan Barksdale, Theresa Hickey, Roma Peters, Memrie Price, Connie Watson, Douglas Wolfe, Gordon Guyatt, Brian Haynes, George Tomlinson, Paul Daniels, Bernard Gersh, Thomas Jaeger, Robert McBane

Research output: Contribution to journalArticlepeer-review

9 Scopus citations


Background: Shared decision making (SDM) implementation remains challenging. The factors that promote or hinder implementation of SDM tools for use during the consultation, including contextual factors such as clinician burnout and organizational support, remain unclear. We explored these factors in the context of a practical multicenter randomized trial evaluating the effectiveness of an SDM conversation tool for patients with atrial fibrillation considering anticoagulation therapy. Methods: In this cross-sectional study, we recruited clinicians who were regularly involved in conversations with patients regarding anticoagulation for atrial fibrillation. Clinicians reported their characteristics and burnout symptoms using the two-item Maslach Burnout Inventory. Clinicians were trained in using the SDM tool, and they recorded their perceptions of the tool's normalization potential using the Normalization MeAsure Development (NoMAD) survey instrument and verbally reflected on their answers to these survey questions. When possible, the training sessions and clinicians' verbal responses to the conversation tool were recorded. Results: Our study comprised 183 clinicians recruited into the trial (168 with survey responses and 112 with recordings). Overall, clinicians gave high scores to the normalization potential of the intervention; they endorsed all domains of normalization to the same extent, regardless of site, clinician characteristics, or burnout ratings. In interviews, clinicians paid significant attention to making sense of the tool. Tool buy-in seemed to depend heavily on their ability to see the tool as accurate and "evidence-based" and their perceptions of having time in the consultation to use it. Conclusions: While time in the consultation remains a barrier, we did not find a significant association between burnout symptoms and normalization of an SDM conversation tool. Possible areas for improving the normalization of SDM conversation tools in clinical practice include enabling collaboration among clinicians to implement the tool and reporting how clinicians elsewhere use the tool. Direct measures of normalization (i.e., observing how often clinicians access the tool in practice outside of the clinical trial) may further elucidate the role that contextual factors, such as clinician burnout, play in the implementation of SDM. Trial registration:, NCT02905032. Registered on 9 September 2016.

Original languageEnglish
Article number395
Issue number1
StatePublished - May 12 2020


  • Anticoagulation
  • Atrial fibrillation
  • Burnout
  • Conversation aid
  • Normalization process theory
  • Shared decision making
  • Trial procedures
  • Trials


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