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Abstract

Objective. This qualitative study explores the barriers and facilitators to implementing shared decision making (SDM) for breast reconstruction (BR) from multistakeholder perspectives in the Chinese health care context. Methods. A qualitative study was conducted from November 2021 to January 2022, involving 36 participants, including patients, doctors, nurses, and hospital administrators from 3 tertiary hospitals in Beijing, Hebei, and Guangzhou. Purposeful and snowball sampling was used until data saturation. In-depth semi-structured interviews were analyzed using thematic analysis. Results. Findings from 36 stakeholders (20 patients, 16 health care providers/administrators) revealed 5 key dimensions influencing SDM implementation: decision making, patient, health care professional (HCP), organizational, and societal levels. Notable factors include patient self-efficacy, information needs, HCPs’ role recognition and SDM competencies, team coordination, SDM convenience, availability of support tools, and cultural influences. Limitations. The limitations of this study primarily stem from the narrow sample source, which includes only 3 regions in mainland China. Conclusion. Successful SDM implementation in China requires optimizing clinical workflows, utilizing technological tools, providing professional training, and integrating SDM with traditional Chinese medicine philosophies. These strategies enhance decision-making quality and align SDM practices with Chinese cultural values. Practice Implications. Integrating culturally sensitive SDM into clinical workflows, supported by decision tools, training, and robust policies, is essential for BR SDM in China.

Highlights

Identified barriers and facilitators on shared decision making for breast reconstruction from multistakeholder perspectives in China’s health care context.

Explored cultural influences on shared decision making for breast reconstruction in Chinese patients.

Emphasized the importance of integrating shared decision making into existing clinical workflows.

Proposed integrating traditional Chinese medicine diagnostics with shared decision making for culturally sensitive care.

Keywords

breast reconstruction China organizational context qualitative study shared decision making

Breast cancer is the most common malignant tumor among women worldwide and the leading cause of cancer-related mortality in women, posing a significant threat to women’s health.¹ Mastectomy is a common surgical treatment for breast cancer,² but it often has a profound impact on patients’ body image and psychosocial health.^3,4 To mitigate the adverse effects of mastectomy, patients can opt for immediate or delayed breast reconstruction (BR).⁵ Studies have shown that BR can improve body image and psychological health, reduce stigma, and enhance quality of life.^4,6,7 However, the decision-making process for BR is complex,^8–10 often involving decision conflicts and regret.^11–13 This complexity arises partly because patients must navigate decisions about the type and timing of surgery, choice of implants, and factors such as surgical risks, postoperative complications, prognostic uncertainties, and costs. In addition, the surgery involves an organ that symbolizes femininity, closely tied to body image and social integration.¹⁴ Therefore, it is crucial to support patients in making decisions that align with their personal values and preferences.^11–13

Shared decision making (SDM) is a process that promotes active collaboration among patients, their family members, and health care providers (HCPs) in making health decisions where multiple medically appropriate treatment options exist.^15,16 This process ensures that patients make the most suitable decisions for themselves. SDM can enhance the quality of preference-sensitive decisions, especially when facilitated by patient decision aids (PtDAs).^16,17 This model is well developed and widely applied in the field of BR in Western countries.¹⁸ However, the practical implementation of SDM and PtDAs remains challenging.¹⁹ Several scoping reviews on SDM in the breast cancer field have highlighted that, despite increasing evidence of the effectiveness of SDM interventions, there is still limited knowledge supporting its sustained implementation in routine care.^19,20 There is a notable lack of exploration into the various factors influencing breast cancer patients’ participation in SDM for BR, particularly at the HCP and organizational system levels.

In China, sociocultural and health care context factors significantly influence patients’ decision making by affecting social expectations related to female roles and family responsibilities.²¹ These norms often lead women to prioritize family health over their own, hindering SDM.^22,23 Critical yet underexplored factors such as cognitive understanding of decision makers, communication styles, and trust also affect SDM implementation.^24–27 For instance, family dominance in decision making and reluctance to question doctors further limit SDM.^25,26 In addition, despite increased patient education resources, a lack of decision support tools such as PtDAs impedes effective patient engagement in SDM.²⁴

Qualitative research enables an in-depth exploration of complexities, providing insights into stakeholders’ experiences and attitudes during the SDM process. Therefore, as part of the development and application research of BR PtDA, this study aims to explore the factors influencing SDM implementation for BR decisions among breast cancer patients from multistakeholder perspectives in the Chinese context. The findings will contribute to addressing barriers and promoting SDM in BR, informing subsequent studies.

Methods

Study Design

This study is part of a larger project that uses literature review, qualitative interviews, and surveys to explore and develop SDM models and corresponding PtDAs for BR in breast cancer patients within the context of China. This article specifically focuses on a qualitative exploration of stakeholders’ perspectives regarding the factors influencing the implementation of SDM in clinical practice for BR decision making among breast cancer patients in China. Previous related studies^18,24,28 have been published elsewhere. The study design and analysis adhered to the standards for reporting qualitative research.²⁹

Study Population and Recruitment

The study was conducted in 3 tertiary hospitals in Beijing, Hebei, and Guangzhou from November 2021 to January 2022. The interviewees included stakeholders involved in the BR SDM process, including patients who face BR decisions after breast mastectomy, breast surgeons or plastic surgeons who perform BR procedures, perioperative nursing staff who care for surgically treated breast cancer patients, and relevant hospital administrators. Specific inclusion and exclusion criteria for participants can be found in Appendix A.

Purposeful and snowball sampling methods³⁰ were employed to recruit potential subjects with diverse characteristics, including gender, age, occupation, education level, and decision-making experience, ensuring a range of experiences. In addition, recruited participants were invited to recommend other potential participants for the study. Researchers then contacted potential subjects individually, offering options for face-to-face or telephone interviews (due to the impact of the COVID-19 pandemic, face-to-face interviews were not possible for all participants) and coordinating interview times and locations. The sample size for this qualitative study was determined by data saturation.³⁰

Procedures

In-depth semi-structured individual interviews were conducted either face to face or via telephone. Before the interviews, separate interview guides were developed for patients and HCPs based on a prior literature review by our research team.¹⁸ The patient guide focused on decision-making experiences, information needs, and influencing factors, while the HCP guide addressed roles in SDM, perceived barriers/facilitators, and implementation challenges (see Online Appendix B for detailed questions). Both guides were piloted with 2 participants (data excluded from final analysis).

Each interview lasted 40 to 50 min and was audio-recorded with the participants’ consent prior to transcription. During the interviews, notes were taken to document new concepts or areas needing further clarification or discussion with the participants. Additional notes were made after the interview to reflect on the interview process and the interviewer’s overall impressions.

Given that the primary subjects of this study were breast cancer patients, to ensure the data encompassed a wide range of perspectives and phenomena, HCPs and hospital administrators who frequently engage in SDM for BR were also included as stakeholders and supplementary data sources. The criterion for data saturation in this study was the point at which no new themes emerged across all groups of participants.

Data Analysis

To ensure confidentiality, the participating institutions were labeled as A, B, and C, while patients were designated as P and HCPs/hospital administrators as H. Interviewees were uniquely identified using combinations of these letters and Arabic numerals (e.g., AP1, AH1).

After transcription, 3 researchers (YY, SC, and ZW) reviewed the transcripts to ensure accuracy and consistency with the interview recordings. Following this, thematic analysis³¹ was conducted to identify key themes and patterns in the data. Initially, the interviews, conducted by the researcher (Xuejing L), were transcribed verbatim and imported into NVivo 12.0 software for analysis. Two researchers (MM and DY), both adept in qualitative methods and with backgrounds in breast surgery and SDM, independently reviewed and coded the interview transcripts. They applied initial codes to text segments reflecting participants’ narratives, followed by in-depth discussions to categorize the data into emerging themes and collaboratively refine the codes. In cases of differing interpretations, a third researcher (JZ) was consulted to reach a consensus.

Participants were invited to provide feedback on the research findings, and there was no disagreement with the analysis. All analyses were conducted in Chinese, and the final results were translated into English by researcher JZ.

Results

Demographic Information of Participants

A total of 36 participants from different institutions across 3 regions were interviewed. This group included 20 patients and 16 HCPs, which comprised 6 doctors and 10 nurses. Among the HCPs, 8 also held clinical management positions. All participants who provided consent completed the interviews, with no dropouts reported during the study. Detailed information about the patients is provided in Table 1, and information about the HCPs and administrators is presented in Table 2.

Table 1

Characteristics of the 20 Interviewed Breast Cancer Patients

Characteristic	Patient Interview, n (%)
Age, y
≤30	3 (15)
31–40	3 (15)
41–50	6 (30)
51–60	8 (30)
Education level
Primary school and below	0 (0)
Middle school	2 (10)
High school or technical secondary school	7 (35)
College	6 (30)
Undergraduate	4 (20)
Master’s and above	1 (5)
Occupation
Worker	4 (20)
Farmer	4 (20)
Civil servant	2 (10)
Self-employed	4 (20)
Professional technician	0 (0)
Company staff	2 (10)
Teacher	1 (5)
Medical staff	1 (5)
Others	2 (10)
Disease stage
Had undergone mastectomy but did not undergo BR	18 (90)
Had undergone BR	2 (10)

BR, breast reconstruction.

Table 2

Characteristics of the 16 Interviewed HCPs and Administrators

Number	Age, y	Highest Level of Education	Work Experience, y	Professional Position
AH1	42	Master	20	Associate professor of nursing
AH2	34	Master	10	Nurse-in-charge
AH3	35	Master	10	Nurse-in-charge
AH4	31	PhD	5	Attending physician
AH5	52	PhD	26	Chief physician
BH1	33	Master	7	Nurse-in-charge
BH2	49	Master	27	Professor of nursing
BH3	51	PhD	22	Chief physician
BH4	47	PhD	19	Associate chief physician
BH5	32	Master	7	Nurse-in-charge
BH6	33	Master	7	Nurse-in-charge
CH1	34	Master	9	Nurse-in-charge
CH2	41	Master	18	Associate professor of nursing
CH3	52	Master	29	Associate professor of nursing
CH4	35	PhD	8	Attending physician
CH5	38	PhD	13	Attending physician

Multilevel Barriers and Facilitators of SDM for BR among Chinese Breast Cancer Patients

Through qualitative analysis of interviews with 36 stakeholders, this study identifies complex interactions across 5 interconnected dimensions: decision-making level, patient level, HCP level, organizational level, and societal level. The following contextualized narrative integrates participant quotes and data patterns to elaborate on these findings.

Decision-making level: Dual challenges of time pressure and complexity

The urgency and unpredictability of decisions posed core barriers. Patients often faced abrupt decision making due to acute illness presentation, as described by “Everything happened so suddenly. After diagnosis, I had to undergo surgery immediately with no time to deliberate” (AP5). Objective medical imperatives further constrained decision space: “Admitted and operated on the same day, I had no choice but to follow the doctor’s advice” (BP8). Unpredictable timing compounded passivity—some patients could not participate in intraoperative BR decisions under general anesthesia: “The doctor decided based on surgical findings, and my subsequent treatment depended on those results” (AP1).

Decision complexity arose from specialized options and social interference. Patients struggled with multiple technical choices (e.g., implant-based v. autologous tissue reconstruction), as noted by “Breast cancer diagnosis confronts patients with complex, nonprescriptive questions, making decisions extremely challenging” (BH1). The social sensitivity of BR amplified external pressures, as revealed by “BR is not just a personal choice—it affects family and social perceptions. Coping with others’ curiosity and pity post-surgery is a psychological ordeal” (BP4).

Patient level: Vicious cycle of physical–mental burden and support gaps

Disease-related physical and psychological effects significantly hindered decision participation. Sixty percent of patients avoided discussions due to psychological stress (“The emotional toll of cancer made me reluctant to communicate with anyone, including doctors” [BP4]), while 35% adopted fatalistic attitudes (“This is my destiny—no decision will reduce my suffering” [BP7]); “It feels predetermined, beyond my control even if I understood the options” [AP1]).

Weak support systems exacerbated dilemmas: emotional neglect from families prioritizing survival over choice (“My family only cares about my survival, deeming BR choices irrelevant” [CP15]), financial strain leading patients to forgo BR for family savings (“At my age, saving for my son’s marriage is more important than understanding BR options” [BP20]), and patients lacking experiential or reliable information (“No one around me has undergone BR, and I receive conflicting advice from patient groups” [BP20]). Cognitive deficits included role ambiguity (“I didn’t know my role—the doctor mentioned BR but didn’t seem to seek my input” [BP7]), low self-efficacy (“My family and I trusted the doctor blindly due to limited understanding” [BP17]), and insufficient grasp of risks/benefits (“I wondered about post-surgery appearance, implant rejection, and long-term complications—but received no clarity” [BP2]).

HCP level: Tensions between role conflicts and competency demands

Role-perception conflicts pervaded SDM practice. Physicians’ authoritative roles and time constraints dominated decision making (“Doctors are too busy to engage fully in SDM, focusing only on core explanations for patients and families” [AH2]), while nurses’ expertise was undervalued (“Nurses detect patient changes first but are often overlooked in SDM by physicians” [AH2]), with hierarchical norms discouraging nurse initiative (“Physicians’ dominance prevents nurses from taking SDM responsibility” [AH2]).

High competency demands underscored training needs: translating medical jargon into lay terms (“Simplifying explanations for low-literacy patients requires skill” [BH2]), tailoring communication to diverse backgrounds (“Patients’ varied life experiences necessitate flexible, context-aware communication” [BH1]), and eliciting values effectively (“Equal opportunity for expression is key, but mastering question design for meaningful insights is a learned skill” [AH3]). Despite challenges, HCPs expressed proactive attitudes (“I encourage patients to ask questions and am eager to expand my knowledge” [BH1]; “Collaborative decision making with physicians, especially in resolving patient difficulties, is essential” [AH2]).

Organizational level: Constraints of process fragmentation and resource shortages

Ineffective team coordination resulted in decision-making gaps. Poor integration between departments, such as outpatient and inpatient services, was evident (“Most breast cancer patients have a short interval from diagnosis to hospitalization, so outpatient departments must participate in decision making to fill information gaps” [BH5]). Ambiguous role delineation among HCPs caused conflicting messages (“Nurses’ health education often contradicts physicians’ instructions—ideally, a tripartite consensus among all stakeholders should be achieved” [AH2]), while nurses avoided proactive involvement due to unclear accountability (“We fear making mistakes or contradicting physicians’ orders” [CH3]).

Systemic support deficiencies included inadequate workflow integration (HCPs reported that SDM was not embedded in routine practice: “Staff workloads are already saturated; SDM can only be promoted if integrated into daily workflows” [AH3]), lack of technological tools (manpower shortages necessitated digital solutions: “Understaffing requires technologies like internet-based videos to alleviate burdens” [BH5]), and insufficient training/policy incentives (HCPs desired communication skills training: “Specific guidance on effective SDM communication is urgently needed” [AH4]). Financial and institutional support remained scarce (“SDM processes would improve if mandated by hospitals” [AH3]; “Media and hospital advocacy could enhance public acceptance of SDM” [AH1]).

Societal level: Implicit impacts of trust crisis and cultural values

The fragility of doctor–patient trust exacerbated risk aversion in decision making. HCPs expressed concerns about medical disputes: “What safeguards exist if patients are dissatisfied with postoperative outcomes following SDM?” (AH2). Traditional role stereotypes simultaneously devalued nurses’ participation in SDM: “Patients trust only physicians, viewing nurses as mere caregivers or even servants” (AH2), while “Patients perceive HCPs through a consumerist lens—‘I pay, so you serve’—rejecting collaborative decision making as equals” (BH6).

Cultural values exerted dual influences: a collectivist survival mindset led patients to prioritize health over appearance, with older generations more inclined to save resources for family members (“Traditional norms emphasize health over aesthetics, particularly among elders who sacrifice personal choices for familial needs” [BH1]). Conversely, HCPs attempted to integrate traditional Chinese medicine (TCM) philosophy—“TCM’s holistic view sees patients as integrated beings. By aligning cultural perspectives and TCM education with SDM, we aim to make patients feel truly heard” (BH3)—demonstrating potential for culturally adaptive SDM promotion.

Discussions

The Complexity of Decision Making and Patient Participation Challenges

The decision-making process for BR in female breast cancer patients is highly complex, shaped by medical factors and personal challenges such as body image issues, quality-of-life concerns, and social discrimination.³² This study identified that tight decision timelines and the emotional burden of diagnosis hinder SDM. Newly diagnosed patients often struggle with anxiety and fear, affecting their ability to engage in decision-making effectively.³³

In addition, the study revealed that patients often lack understanding and confidence in the decision-making process, largely influenced by Confucian culture and the traditional authoritative role of doctors in China.^34–36 This cultural dynamic leads patients to rely heavily on oncologists, often suppressing their own emotions and preferences. Burdened by heavy workloads and limited awareness of promoting patient participation, doctors struggle to provide neutral and comprehensive treatment options or to fully grasp patient values. The study highlights “insufficient decision support” and “insufficient knowledge” as key barriers, emphasizing that timely, comprehensive information is essential for informed decisions—consistent with prior research by Hui Zheng et al.³⁷ and Wu Qing et al.³⁸ Early provision of such information enables patients to compare treatment options rationally and choose plans aligned with their values.

Enhancing HCPs’ Role Recognition in SDM

Globally, rigid professional roles and work patterns limit oncologists’ deep engagement with patients, restricting interactions to consultations and routine care.^39–41 In contrast, nurses—integral to continuous patient care—are better positioned to understand patients’ needs and psychological states,⁴² fostering the growth of nurse-led SDM,^43–47 as seen in diabetes care, where such models improve outcomes such as glycemic control, satisfaction, and self-management.^48–50

However, our study revealed that traditional Chinese health care stereotypes, such as viewing nurses as “servants,”“doctors’ legs,” or “only capable of administering injections and infusions,” undermine their SDM involvement. Limited recognition of their role and authority hinders patient trust and cooperation in nurse-led SDM, while insufficient doctor–nurse respect and hierarchical constraints (e.g., nurses needing doctors’ permission to contribute to decisions) further restrict their SDM participation, impeding organizational cooperation.

Notably, China’s nursing workforce is evolving, particularly in tertiary hospitals: the proportion of undergraduate nurses is rising, alongside growing numbers of master’s and doctoral-prepared nurses^51–53; specialized nurses are also expanding in numbers and professional capacity.^54,55 These highly qualified nurses are capable of taking on more complex and specialized care tasks, with the potential to play a more significant role in SDM.

Therefore, efforts should focus on enhancing nurses’ roles in medical decision making through improved social awareness, medical education, and hospital management. For instance, media and public education can highlight their SDM role to reshape stereotypes and build trust. Policies should grant nurses more decision-making autonomy, clarify doctor–nurse collaboration standards in SDM, and establish accountability mechanisms to reduce dispute concerns. Such strategies can elevate nurses’ SDM role and promote its clinical integration.

Integrating SDM into Clinical Workflows

Given China’s large patient population and limited health care workforce, it is crucial to strike a delicate balance between meeting the demands of SDM and addressing the realities of daily patient care. This study highlights that ensuring the convenience of SDM should be a key organizational priority, particularly by integrating SDM into existing clinical workflows.

Research indicates that health care institutions should prioritize reconfiguring clinical workflows to prevent SDM implementation from excessively increasing staff workload, which could compromise efficiency and the quality of patient care.⁵⁶ In addition, using decision support tools (such as online platforms, personal digital assistants, and multimedia resources) can effectively alleviate personnel workload⁵⁷—a key consideration given China’s medical resource constraints. These tools enhance and simplify complex medical information for patients via streamlined transmission and personalized education and improve the patient experience.^57–59 Interviews indicate urgent provider demand for such tools, underscoring the need for their development and full utilization.

Integrating SDM is an innovative step for organizations yet to implement it, with success requiring financial and policy support—including monetary incentives, expanded human resources, and policy guidance. In China’s context of top-down reform, such supports are foundational to SDM’s smooth implementation.⁶⁰ Policy makers and hospital administrators should introduce incentive measures, combining “encouragement” and “pressure” to drive successful SDM adoption and enhance overall medical service quality.

Furthermore, the interview results highlight HCPs’ urgent need for SDM-related training, echoing the calls of Coughlin et al.⁶¹ Therefore, health care institutions planning to implement SDM should incorporate courses on communication skills, patient engagement techniques, and SDM ethics into HCPs’ onboarding training and continuing education.^62,63

Cultural Influences on SDM in China

Influenced by traditional Chinese cultural philosophies of Confucianism, Buddhism, and Taoism, Chinese life perspectives emphasize enduring life’s ordinariness and hardships and facing death with resilience and perseverance.⁶⁴ For many Chinese, encountering illness often entails bearing burdens and confronting death with fortitude,⁶⁵ as captured in a bestselling book: “The word ‘alive’ in Chinese is imbued with strength. Its power does not come from shouting or attacking, but from enduring the responsibilities that life imposes on us, enduring the happiness and hardships, the boredom and ordinariness.”⁶⁶

This resilience manifests in patients prioritizing family interests over personal ones, particularly financially—avoiding additional financial burdens on families while safeguarding health. Consequently, many patients choose to endure the physical and psychological impacts of surgery, autonomously forgoing considerations of BR decisions. Some older patients, viewing breast cancer as an inevitable hardship with fatalistic attitudes, consciously disregard BR options. Clinically, HCPs should identify such patients and use culturally appropriate methods to facilitate their decision-making involvement.

The interviewees in this study noted several key capabilities HCPs need for effective SDM: translating specialized language into lay terms; conducting personalized care dialogues; understanding patient preferences, values, and beliefs; demonstrating insight into medical care; and judging when to initiate SDM. In the clinical context of China, these abilities can be prioritized by transforming existing competencies among Chinese HCPs rather than separate cultivation.

In China, patient seeking and health care delivery are deeply influenced by the philosophical and cultural underpinnings of TCM.⁶⁷ TCM philosophy emphasizes the integration of subjective and objective aspects, upholding the unity of nature and humanity.⁶⁸ This holistic perspective views patients as whole individuals within their environment, not just symptom collections, encouraging HCPs to communicate thoroughly with patients and respect their perspectives.⁶⁹ Within the cultural backdrop of TCM, the concept of “;仁” (benevolence) can be interpreted within a broader SDM framework, and its core principles such as “patient-centeredness,”“harmony between nature and humanity,” and “medicine as an art of benevolence” reflect the spiritual and psychological needs of Chinese patients seeking medical care.⁷⁰

Therefore, the promotion and training of SDM among HCPs in China should integrate SDM with TCM culture. Aligning the “talk” process of SDM with TCM’s diagnostic methods of “looking, listening, questioning, and palpating” can foster a culturally sensitive exploration and adaptation of the SDM model with Chinese characteristics, strengthening contemporary HCPs’ identification with TCM culture.

Cross-Contextual Comparisons and Generalizability Implications

While contextualized within China’s health care and cultural settings, this study offers insights for cross-cultural discussions on SDM in BR. China’s family-centered decision making—where family consensus often influences treatment choices—contrasts with the individual autonomy-driven frameworks dominant in Western SDM research.⁷¹ This distinction highlights how Confucian-based collectivist cultural norms shape patient engagement in decision-making processes,⁷² suggesting that SDM interventions in similar contexts may need to integrate family involvement as a core component rather than focusing solely on individuals.

In addition, the analysis of systemic barriers to SDM (e.g., time constraints, standardized protocols) enables comparisons of centralized versus decentralized health care systems. In China’s hierarchical medical structure, SDM is constrained by provider workloads and top-down practice guidelines, whereas Western systems may face challenges related to fragmented care coordination or variable insurance coverage.⁷³ These observations contribute to a global dialogue on tailoring SDM tools to institutional realities, such as developing structured communication templates for time-limited consultations or enhancing interdisciplinary training to promote SDM across diverse practice environments.

By documenting these context-specific dynamics, this study enriches the international SDM literature with a non-Western perspective on how cultural values and health care infrastructure mediate patient–provider interactions. The insights are particularly relevant for regions with collectivist traditions or centralized health care models, as they highlight the need for SDM frameworks that balance evidence-based guidance with local sociocultural norms. This bridges gaps between universal SDM principles and context-specific applications, fostering more inclusive and effective decision-making practices globally.

Limitations

The limitations of this study primarily stem from the narrow sample source, which includes only 3 regions in mainland China. This geographic and cultural selection bias may affect the generalizability and representativeness of the research findings. To enhance the study’s breadth, future research should incorporate samples from more regions, encompassing stakeholders from diverse geographic, cultural, and social backgrounds. In addition, due to data acquisition constraints and the scope of the study, family members of patients were excluded. However, influenced by Confucianism and collectivist culture, families play a significant role in medical decision making in China. Patients and their families are often considered a decision-making unit, particularly evident in SDM processes. Future research should include family members in the sample to explore their influence in SDM, analyze the interactive mechanisms between patients and their families in decision making, and delineate their roles in the process.

Conclusions

This qualitative study provides an in-depth exploration of the facilitators and barriers to implementing SDM for BR among breast cancer patients within the Chinese context. Our findings highlight several critical factors influencing successful SDM implementation, including enhancing patients’ self-efficacy, addressing their information needs, improving HCPs’ role recognition and SDM-related competencies, strengthening medical team coordination, and ensuring the convenience of SDM. The results also underscore the unique cultural nuances that shape SDM processes in China, emphasizing the need for HCPs to understand and respect patients’ cultural perspectives rooted in Confucian, Buddhist, and Taoist philosophies.

Notably, our study suggests an innovative approach to SDM implementation in China: integrating TCM diagnostic methods with SDM practices. This integration could potentially create a culturally tailored SDM model. Future research should focus on developing and evaluating culturally adapted SDM interventions that incorporate these facilitators and address the identified barriers.

Practice Implications

To enhance the implementation of SDM in BR for breast cancer patients in China, health care institutions should integrate SDM into clinical workflows through standardized protocols, such as embedding decision checklists in electronic health records and allocating dedicated 30-min consultation slots with PtDAs (e.g., interactive 3-dimensinoal models) to enhance patient comprehension. Culturally tailored practices are critical, requiring providers to use structured family consultation guides that align with Confucian values, balancing patient autonomy with family consensus via scripts for addressing intergenerational preferences. Training programs should emphasize role-playing for empathetic communication and ethics workshops grounded in Confucian “仁” (benevolence) to harmonize decision-making dynamics. Systemically, incorporating SDM into tertiary hospital accreditation criteria ensures institutional accountability, while health insurance coverage for PtDA development and National Health Commission–established SDM training funds would financially sustain capacity building for HCPs. These integrated strategies—merging protocol standardization, cultural adaptation, and policy-backed resourcing—will anchor SDM as a sustainable, patient-centered practice in China’s health care system.

Supplemental Material

sj-docx-1-mpp-10.1177_23814683251386466 – Supplemental material for Barriers and Facilitators for Shared Decision Making in Breast Reconstruction among Stakeholders in the Chinese Context: A Qualitative Study

Supplemental material, sj-docx-1-mpp-10.1177_23814683251386466 for Barriers and Facilitators for Shared Decision Making in Breast Reconstruction among Stakeholders in the Chinese Context: A Qualitative Study by Xuejing Li, Meiqi Meng, Yiyi Yin, Dan Yang, Junqiang Zhao, Xiaohua Li, Xiaoyan Zhang, Liu Han, Sihan Chen, Ziyan Wang, Pei Xue and Yufang Hao in MDM Policy & Practice

Footnotes

Acknowledgements

We extend our sincere gratitude to all the participants, including the patients, doctors, nurses, and hospital administrators from Beijing, Hebei, and Guangzhou, who contributed to this study. Their insights and experiences were foundational to the completion of this research. Meng Meiqi acknowledges the support of the China Scholarship Council program (project ID: 202406550037).

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this study was provided entirely by a grant from Basic Research Grant Program for 2023 at Beijing University of Chinese Medicine (grant No. 2023-JYB-XJSJJ019). The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Ethical Considerations

Ethical approval for this study was obtained from the Medical Ethics Committee of Beijing University of Chinese Medicine, with approval number 2021BZYLL0307.

Consent to Participate

All participants provided written informed consent to participate in this study.

Consent for Publication

Not applicable.

ORCID iDs

Sihan Chen

Yufang Hao

Data Availability

The data supporting the findings of this study are available from the corresponding author, Yufang Hao, upon reasonable request. Access to the data will be granted in accordance with ethical guidelines and participant consent.

References

Sung

Ferlay

Siegel

, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–49. DOI: 10.3322/caac.21660

Jagsi

Jiang

Momoh

, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol. 2014;32(9):919–26. DOI: 10.1200/jco.2013.52.2284

Koçan

Gürsoy

Body image of women with breast cancer after mastectomy: a qualitative research. J Breast Health. 2016;12(4):145–50. DOI: 10.5152/tjbh.2016.2913

Pusic

Matros

Fine

, et al. Patient-reported outcomes 1 year after immediate breast reconstruction: results of the mastectomy reconstruction outcomes consortium study. J Clin Oncol. 2017;35(22):2499–506. DOI: 10.1200/jco.2016.69.9561

Unukovych

Johansson

Brandberg

Preoperative psychosocial characteristics may predict body image and sexuality two years after risk-reducing mastectomy: a prospective study. Gland Surg. 2017;6(1):64–72. DOI: 10.21037/gs.2017.01.04

Dean

Chetty

Forrest

AP.

Effects of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 1983;1(8322):459–62. DOI: 10.1016/s0140-6736(83)91452-6

Panchal

Matros

Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg. 2017;140:7s–13s. DOI: 10.1097/prs.0000000000003941

Zieliński

Lorenc-Podgórska

Antoszewski

Why women who have mastectomy decide not to have breast reconstruction?

Pol Przegl Chir. 2015;86(10):451–5. DOI: 10.2478/pjs-2014-0081

Berlin

Tandon

, et al. Hospital variations in clinical complications and patient-reported outcomes at 2 years after immediate breast reconstruction. Ann Surg. 2019;269(5):959–65. DOI: 10.1097/sla.0000000000002711

10.

Ter Stege

Woerdeman

LAE

Hahn

DEE

, et al. The impact of an online patient decision aid for women with breast cancer considering immediate breast reconstruction: study protocol of a multicenter randomized controlled trial. BMC Med Inform Decis Mak. 2019;19(1):165. DOI: 10.1186/s12911-019-0873-1

11.

Lam

Chan

, et al. Reducing treatment decision conflict difficulties in breast cancer surgery: a randomized controlled trial. J Clin Oncol. 2013;31(23):2879–85. DOI: 10.1200/jco.2012.45.1856

12.

Flitcroft

Brennan

Spillane

Decisional regret and choice of breast reconstruction following mastectomy for breast cancer: a systematic review. Psychooncology. 2018;27(4):1110–20. DOI: 10.1002/pon.4585

13.

Clarke

Paraskeva

White

, et al. PEGASUS: the design of an intervention to facilitate shared decision-making in breast reconstruction. J Cancer Educ. 2021;36(3):508–18. DOI: 10.1007/s13187-019-01656-6

14.

Elwyn

Frosch

Thomson

, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7. DOI: 10.1007/s11606-012-2077-6

15.

Myers

Advani

Myers

, et al. Engaging patients with late-stage non-small cell lung cancer in shared decision making about treatment. J Pers Med. 2021;11(10):998. DOI: 10.3390/jpm11100998

16.

Barry

Edgman-Levitan

Shared decision making—pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–1. DOI: 10.1056/NEJMp1109283

17.

Zeuner

Frosch

Kuzemchak

, et al. Physicians’ perceptions of shared decision-making behaviours: a qualitative study demonstrating the continued chasm between aspirations and clinical practice. Health Expect. 2015;18(6):2465–76. DOI: 10.1111/hex.12216

18.

Meng

Zhao

, et al. Shared decision-making in breast reconstruction for breast cancer patients: a scoping review. Patient Prefer Adherence. 2021;15:2763–81. DOI: 10.2147/ppa.S335080

19.

Joseph-Williams

Lloyd

Edwards

, et al. Implementing shared decision making in the NHS: lessons from the MAGIC programme. BMJ. 2017;357:j1744. DOI: 10.1136/bmj.j1744

20.

Oprea

Ardito

Ciani

Implementing shared decision-making interventions in breast cancer clinical practice: a scoping review. BMC Med Inform Decis Mak. 2023;23(1):164. DOI: 10.1186/s12911-023-02263-8

21.

Fagerlin

Lakhani

Lantz

, et al. An informed decision? Breast cancer patients and their knowledge about treatment. Patient Educ Couns. 2006;64(1–3):303–12. DOI: 10.1016/j.pec.2006.03.010

22.

Hippman

Balneaves

LG.

Women’s decision making about antidepressant use during pregnancy: a narrative review. Depress Anxiety. 2018;35(12):1158–67. DOI: 10.1002/da.22821

23.

Luo

Yan

Yang

, et al. Current practice, attitude and views of providing pregnancy care for women with type 1 diabetes in China: a qualitative study. BMJ Open. 2022;12(11):e061657. DOI: 10.1136/bmjopen-2022-061657

24.

Yang

Meng

, et al. Shared decision-making in healthcare in mainland China: a scoping review. Front Public Health. 2023;11:1162993. DOI: 10.3389/fpubh.2023.1162993

25.

Liu

Bell

Zhang

Conjugal intimacy, gender and modernity in contemporary China. Br J Sociol. 2019;70(1):283–305. DOI: 10.1111/1468-4446.12338

26.

Lee

Chen

, et al. What is lacking in patient-physician communication: perspectives from Asian American breast cancer patients and oncologists. J Behav Health. 2012;1(2). DOI: 10.5455/jbh.20120403024919

27.

Beccia

Causio

Hoxhaj

, et al. Integrating China in the international consortium for personalised medicine. A position paper on healthcare professionals’ education and citizens’ empowerment in personalised medicine. BMC Med Educ. 2023;23(1):438. DOI: 10.1186/s12909-023-04420-z

28.

Meng

Yang

, et al. “All about the value?” Decisional needs of breast reconstruction for breast cancer patients in the Chinese context: a mixed-methods study. Patient Educ Couns. 2024;120:108102. DOI: 10.1016/j.pec.2023.108102

29.

Tong

Sainsbury

Craig

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. DOI: 10.1093/intqhc/mzm042

30.

Moser

Korstjens

Series: practical guidance to qualitative research. Part 3: sampling, data collection and analysis. Eur J Gen Pract. 2018;24(1):9–18. DOI: 10.1080/13814788.2017.1375091

31.

Braun

Clarke

Using thematic analysis in psychology. Qualit Res Psychol. 2006;3(2):77–101.

32.

Han

Wang

, et al. Sex-based heterogeneity in the clinicopathological characteristics and prognosis of breast cancer: a population-based analysis. Front Oncol. 2021;11:642450. DOI: 10.3389/fonc.2021.642450

33.

Farmer

Pearson

Skylark

, et al. Redevelopment of the predict: breast cancer website and recommendations for developing interfaces to support decision-making. Cancer Med. 2021;10(15):5141–53. DOI: 10.1002/cam4.4072

34.

Bai

Song

Liu

, et al. The application of Confucian bioethics in the integration of medical care and elderly care [in Chinese]. Chinese Med Ethics. 2019;32(01):91–4.

35.

Hamline

Sauers-Ford

Kair

, et al. Parent and physician qualitative perspectives on reasons for pediatric hospital readmissions. Hosp Pediatr. 2021;11(10):1057–65. DOI: 10.1542/hpeds.2020-004499

36.

Dimitrova

Naghavi

Richter

, et al. Influence of migrant background on patient preference and expectations in breast and gynecological malignancies (NOGGO-expression V study): results of a prospective multicentre study in 606 patients in Germany. BMC Cancer. 2021;21(1):1018. DOI: 10.1186/s12885-021-08731-6

37.

Zheng

Toupin-April

, et al. Patient decisional needs when considering treatment intensification for type 2 diabetes: a qualitative study in China. Diabetes Res Clin Pract. 2020;170:108471. DOI: 10.1016/j.diabres.2020.108471

38.

Patients with Atrial Fibrillation Participated in the Study of Treatment Decision-Making Process, Influencing Factors and Information Processing Characteristics. Shanghai (China): Chinese People’s Liberation Army Navy Medical University; 2019.

39.

Kane

Halpern

Squiers

, et al. Implementing and evaluating shared decision making in oncology practice. CA Cancer J Clin. 2014;64(6):377–88. DOI: 10.3322/caac.21245

40.

Zhang

Zhou

, et al. Research progress on the role and function of nurses in cancer-related doctor-patient shared decision-making [in Chinese]. J Contin Educ Nurs. 2021;36(19):1808–12. DOI: 10.16821/j.cnki.hsjx.2021.19.016

41.

Lamb

Taylor

Lamb

, et al. Facilitators and barriers to teamworking and patient centeredness in multidisciplinary cancer teams: findings of a national study. Ann Surg Oncol. 2013;20(5):1408–16. DOI: 10.1245/s10434-012-2676-9

42.

Rich

Baldwin

Beckett

, et al. ERS statement on harmonised standards for lung cancer registration and lung cancer services in Europe. Eur Respir J. 2018;52(6):1800610. DOI: 10.1183/13993003.00610-2018

43.

Berger-Höger

Liethmann

Mühlhauser

, et al. Implementation of shared decision-making in oncology: development and pilot study of a nurse-led decision-coaching programme for women with ductal carcinoma in situ. BMC Med Inform Decis Mak. 2017;17(1):160. DOI: 10.1186/s12911-017-0548-8

44.

Bissonnette

Woodend

Davies

, et al. Evaluation of a collaborative chronic care approach to improve outcomes in kidney transplant recipients. Clin Transplant. 2013;27(2):232–8. DOI: 10.1111/ctr.12068

45.

Komatsu

Yagasaki

Yamaguchi

Effects of a nurse-led medication self-management programme in cancer patients: protocol for a mixed-method randomised controlled trial. BMC Nurs. 2016;15:9. DOI: 10.1186/s12912-016-0130-1

46.

Truglio-Londrigan

Slyer

JT.

Shared decision-making for nursing practice: an integrative review. Open Nurs J. 2018;12:1–14. DOI: 10.2174/1874434601812010001

47.

Hsu

Lin

Lee

, et al. Development and testing of the shared decision-making attitudes scale among nurses in Taiwan: a cross-sectional scale development study. BMJ Open. 2021;11(9):e044733. DOI: 10.1136/bmjopen-2020-044733

48.

Guo

Liu

Zeng

, et al. Feasibility and efficacy of nurse-led team management intervention for improving the self-management of type 2 diabetes patients in a Chinese community: a randomized controlled trial. Patient Prefer Adherence. 2019;13:1353–62. DOI: 10.2147/ppa.S213645

49.

Liu

Jiang

, et al. A culturally sensitive nurse-led structured education programme in patients with type 2 diabetes. Int J Nurs Pract. 2019;25(5):e12757. DOI: 10.1111/ijn.12757

50.

Wang

Shen

Chen

, et al. Impacts of nurse-led clinic and nurse-led prescription on hemoglobin A1c control in type 2 diabetes: a meta-analysis. Medicine (Baltimore). 2019;98(23):e15971. DOI: 10.1097/md.0000000000015971

51.

Chang

Discussion of the development and problems of nursing education in China: a data analysis [in Chinese]. Nurs Sci. 2020;9(2):124–31.

52.

Yang

, et al. The development status and countermeasures of postgraduate education for nursing master’s degree in China [in Chinese]. Nurs Res. 2017;31(21):2568–72.

53.

Master’s specialty directory search (in Chinese) China graduate enrollment information network. 2024. Available from: https://yz.chsi.com.cn/zsml/queryAction.do [Accessed 14 May, 2024].

54.

National Human Commission. National Nursing Development Plan (2021-2025) [in Chinese]. China: Chinese Nursing Management; 2022. p. 801–4.

55.

Cheng

Chen

Wang

, et al. The development and prospect of specialist nurses in China [in Chinese]. Chin Nurs Manag. 2021;21(5):649–52.

56.

Iaccarino

Simmons

Gould

, et al. Clinical equipoise and shared decision-making in pulmonary nodule management. A survey of American Thoracic Society Clinicians. Ann Am Thorac Soc. 2017;14(6):968–75. DOI: 10.1513/AnnalsATS.201609-727OC

57.

Salwei

Ancker

Weinger

MB.

The decision aid is the easy part: workflow challenges of shared decision making in cancer care. J Natl Cancer Inst. 2023;115(11):1271–7. DOI: 10.1093/jnci/djad133

58.

Boateng

Lee

Foraker

, et al. Implementing an electronic clinical decision support tool into routine care: a qualitative study of stakeholders’ perceptions of a post-mastectomy breast reconstruction tool. MDM Policy Pract. 2021;6(2):23814683211042010. DOI: 10.1177/23814683211042010

59.

Stacey

Légaré

Lewis

, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4(4):Cd001431. DOI: 10.1002/14651858.CD001431

60.

Zhao

Wang

, et al. Design and challenge of doctor-patient co-decision process in clinical practice in China [in Chinese]. Med Philos. 2019;40(18):1–6+22.

61.

Coughlin

Politi

MC.

Shared decision-making in dermatologic care: a call for more training and resources. JAMA Dermatol. 2021;157(3):271–2. DOI: 10.1001/jamadermatol.2020.5360

62.

Légaré

Politi

Drolet

, et al. Training health professionals in shared decision-making: an international environmental scan. Patient Educ Couns. 2012;88(2):159–69. DOI: 10.1016/j.pec.2012.01.002

63.

Boland

Lawson

Graham

, et al. Post-training shared decision making barriers and facilitators for pediatric healthcare providers: a mixed-methods study. Acad Pediatr. 2019;19(1):118–29. DOI: 10.1016/j.acap.2018.05.010

64.

Hung

Leung

Chiu

, et al. Perceptions about traditional Chinese medicine use among Chinese breast cancer survivors: a qualitative study. Cancer Med. 2023;12(2):1997–2007. DOI: 10.1002/cam4.5046

65.

Lee

Chen

, et al. Challenges and needs of Chinese and Korean American breast cancer survivors: in-depth interviews. N Am J Med Sci (Boston). 2013;6(1):1–8. DOI: 10.7156/najms.2013.0601001

66.

. Life meaning reconstruction: a narrative study of breast cancer patients [in Chinese]. Master’ Thesis, Northwest University; 2022. DOI: 10.27405/d.cnki.gxbdu.2022.000159

67.

Kwan

Chooi

Yoon

, et al. Professionalism in traditional Chinese medicine (TCM) practitioners: a qualitative study. BMC Complement Med Ther. 2020;20(1):335. DOI: 10.1186/s12906-020-03127-8

68.

Chen

YC.

Chinese values, health and nursing. J Adv Nurs. 2001;36(2):270–3. DOI: 10.1046/j.1365-2648.2001.01968.x

69.

Song

Gao

Jia

Usage and promotion on Chinese medicine in Portuguese-speaking countries. Pharmacol Res. 2021;168:105591. DOI: 10.1016/j.phrs.2021.105591

70.

Engebretson

Culture and complementary therapies. Complement Ther Nurs Midwifery. 2002;8(4):177–84. DOI: 10.1054/ctnm.2002.0638

71.

Gao

Corrigan

Qin

, et al. Comparing Chinese and European American mental health decision making. J Ment Health. 2019;28(2):141–7. DOI: 10.1080/09638237.2017.1417543

72.

Meng

Zhao

, et al. When Western concept meets Eastern culture: exploring the impact of Confucianism on shared decision-making in China. Asia Pac J Oncol Nurs. 2024;11(11):100586. DOI: 10.1016/j.apjon.2024.100586

73.

Zagt

Bos

Bakker

, et al. A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients. Patient Educ Couns. 2024;118:108030. DOI: 10.1016/j.pec.2023.108030

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