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Implement Sci. 2019 Jan 18;14(1):7. doi: 10.1186/s13012-018-0851-5.

Barriers and facilitators of pediatric shared decision-making: a systematic review.

Author information

Faculty of Health Sciences, University of Ottawa, 540 King Edward Avenue, Ottawa, ON, K1N 6N5, Canada.
Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 307D-600 Peter Morand Cresent, Ottawa, ON, K1G 5Z3, Canada.
CHU de Québec Research Centre-Université Laval site Hôpital St-Francois d'Assise, 10 Rue Espinay, Quebec City, Quebec, G1L 3L5, Canada.
School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, 31 George Street Kingston, Ottawa, ON, K7L 3N6, Canada.
Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
Learning Services, The Ottawa Hospital, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada.
Faculty of Health Sciences, University of Ottawa, 540 King Edward Avenue, Ottawa, ON, K1N 6N5, Canada.
Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.



Shared decision-making (SDM) is rarely implemented in pediatric practice. Pediatric health decision-making differs from that of adult practice. Yet, little is known about the factors that influence the implementation of pediatric shared decision-making (SDM). We synthesized pediatric SDM barriers and facilitators from the perspectives of healthcare providers (HCP), parents, children, and observers (i.e., persons who evaluated the SDM process, but were not directly involved).


We conducted a systematic review guided by the Ottawa Model of Research Use (OMRU). We searched MEDLINE, EMBASE, Cochrane Library, CINAHL, PubMed, and PsycINFO (inception to March 2017) and included studies that reported clinical pediatric SDM barriers and/or facilitators from the perspective of HCPs, parents, children, and/or observers. We considered all or no comparison groups and included all study designs reporting original data. Content analysis was used to synthesize barriers and facilitators and categorized them according to the OMRU levels (i.e., decision, innovation, adopters, relational, and environment) and participant types (i.e., HCP, parents, children, and observers). We used the Mixed Methods Appraisal Tool to appraise study quality.


Of 20,008 identified citations, 79 were included. At each OMRU level, the most frequent barriers were features of the options (decision), poor quality information (innovation), parent/child emotional state (adopter), power relations (relational), and insufficient time (environment). The most frequent facilitators were low stake decisions (decision), good quality information (innovation), agreement with SDM (adopter), trust and respect (relational), and SDM tools/resources (environment). Across participant types, the most frequent barriers were insufficient time (HCPs), features of the options (parents), power imbalances (children), and HCP skill for SDM (observers). The most frequent facilitators were good quality information (HCP) and agreement with SDM (parents and children). There was no consistent facilitator category for observers. Overall, study quality was moderate with quantitative studies having the highest ratings and mixed-method studies having the lowest ratings.


Numerous diverse and interrelated factors influence SDM use in pediatric clinical practice. Our findings can be used to identify potential pediatric SDM barriers and facilitators, guide context-specific barrier and facilitator assessments, and inform interventions for implementing SDM in pediatric practice.


PROSPERO CRD42015020527.


Barriers; Facilitators; Implementation; Ottawa Model of Research Use; Pediatrics; Shared decision-making; Systematic review; Taxonomy

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