Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making.

Objective: To systematically review patient-reported barriers and facilitators to shared decision making (SDM) and develop a taxonomy of patient-reported barriers.

Methods: Systematic review and thematic synthesis. Study findings/results for each included paper were extracted verbatim and entered into qualitative software for inductive analysis.

Results: Electronic and follow-up searches yielded 2956 unique references; 289 full-text articles were retrieved, of which 45 articles from 44 unique studies met inclusion criteria. Key descriptive themes were grouped under two broad analytical themes: how the healthcare system is organized (4 descriptive themes) and what happens during the decision-making interaction (4 descriptive themes, 10 sub-themes). Predominant emergent themes related to patients' knowledge and the power imbalance in the doctor-patient relationship. Patients need knowledge and power to participate in SDM - knowledge alone is insufficient and power is more difficult to attain.

Conclusions: Many barriers are potentially modifiable, and can be addressed by attitudinal changes at the levels of patient, clinician/healthcare team, and the organization. The results support the view that many patients currently can't participate in SDM, rather than they won't participate because they do not want to. Conclusions: Future implementation efforts should address patient-reported factors together with known clinician-reported barriers and the wider organizational context.