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Larsen MK, Schultz H, Mortensen MB, Birkelund R. Decision making in the oesophageal cancer trajectory a source of tension and edginess to patients and relatives: a qualitative study. Int J Qual Stud Health Well-being 2023; 18:2170018. [PMID: 36727528 PMCID: PMC9897738 DOI: 10.1080/17482631.2023.2170018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The curative oesophageal cancer continuum-diagnosis, treatment and survivorship represents different phases with its own challenges for the involved parties. The process of treatment decisions and interactions between patients with oesophageal cancer (EC), relatives and health professionals is vital yet not well described. The purpose of the study was to explore patients' and relatives' experiences with the process of decision-making through the EC illness and treatment trajectory. METHODS Longitudinal explorative design was employed based on ethnographic fieldwork in the form of participant observations inspired by the American anthropologist James Spradley. RESULTS Sixteen patients and 18 relatives were recruited for participant observations. In total, 184 hours of participant observations were conducted. The study showed that decision-making was filled with tension and edginess. Four themes were identified: 1) The encounter with the medical authority, 2) The need to see the big picture in the treatment trajectory, 3) A predetermined treatment decision, and 4) Meeting numerous different health professionals. CONCLUSION The EC trajectory and decision-making were filled with anxiety. Patients and relatives lacked an overview of the treatment pathway, leading to their role in decision-making often being governed by the medical authority. Timing information and continuity are vital factors in decision-making.
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Affiliation(s)
- Malene Kaas Larsen
- Department of Surgery, Odense University Hospital, Odense, Denmark,Institute of Clinical Research, University of Southern Denmark, Odense M, Denmark,CONTACT Malene Kaas Larsen Department of Surgery, Odense University Hospital, J.B. Winsløws Vej 4, Odense C5000, Denmark
| | - Helen Schultz
- Department of Surgery, Odense University Hospital, Odense, Denmark,Institute of Clinical Research, University of Southern Denmark, Odense M, Denmark
| | - Michael Bau Mortensen
- Department of Surgery, Odense University Hospital, Odense, Denmark,Institute of Clinical Research, University of Southern Denmark, Odense M, Denmark
| | - Regner Birkelund
- Health Services Research Unit, Lillebaelt Hospital, Vejle, Denmark,Institute of Regional Health Research, University of Southern Denmark, Odense M, Denmark
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Nurhidayah I, Nurhaeni N, Allenidekania A, Gayatri D, Rustina Y. Uncertainty of parents due to having children with cancer: A concept analysis. BELITUNG NURSING JOURNAL 2023; 9:218-226. [PMID: 37492752 PMCID: PMC10363973 DOI: 10.33546/bnj.2612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/06/2023] [Accepted: 05/19/2023] [Indexed: 07/27/2023] Open
Abstract
Background Parents of newly diagnosed cancer children often experience significant concerns about the implications of the diagnosis. They find themselves in challenging decision-making situations, navigating through uncertain conditions following the disclosure. Uncertainty is a prevailing issue in healthcare, yet its interpretation and application within the context of health and nursing practice exhibit multiple meanings and variations. Objective This study aimed to clarify the concept of parental uncertainty arising from having children with cancer. Methods The concept analysis followed the steps outlined by Walker and Avant. A thorough literature search was conducted using the Embase, CINAHL, and MEDLINE databases to identify articles published between 1980 and 2022. Results The literature search yielded 147 articles from various disciplines, including health, nursing, medicine, psycho-oncology, and management. After analysis, 20 articles were selected for inclusion. This study identified four key attributes of parental uncertainty associated with having a child with cancer: (1) emotional disturbance, (2) unpredictability, (3) insufficient information, and (4) problems with decision-making. The antecedents of parental uncertainty encompassed the complexity of the disease, the diagnostic and treatment processes, the hospital environment, communication, and support from credible authorities. The consequences of parental uncertainty included the pursuit of new information, parental adaptability to their role, and parental distress. Conclusion Understanding the four attributes of parental uncertainty, along with their antecedents and consequences, can facilitate the future development and operational translation of the concept of uncertainty in nursing practice. This concept is valuable in the evidence-based provision of nursing care to parents of children with cancer, enabling comprehensive recognition and assessment of parental uncertainty and the implementation of appropriate interventions that are sensitive to parental experiences. Ultimately, this approach promotes the adaptation of both the child and the parent.
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Affiliation(s)
- Ikeu Nurhidayah
- Postgraduate Program, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
- Pediatric Nursing Department, Faculty of Nursing, Universitas Padjadjaran, Jatinangor, Indonesia
| | - Nani Nurhaeni
- Pediatric Nursing Department, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | | | - Dewi Gayatri
- Basic Science and Fundamental Nursing Department, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Yeni Rustina
- Pediatric Nursing Department, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
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Costa N, Mescouto K, Dillon M, Olson R, Butler P, Forbes R, Setchell J. The ubiquity of uncertainty in low back pain care. Soc Sci Med 2022; 313:115422. [PMID: 36215924 DOI: 10.1016/j.socscimed.2022.115422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 01/26/2023]
Abstract
Despite clinicians being important actors in the context of uncertainty, their experiences navigating uncertainty remain largely unexplored. Drawing on a theory-driven post-qualitative approach, we used Mol's logic of choice/care as a lens through which we made sense of interviews with 22 clinicians who work with patients who experience low back pain (LBP). Our analysis suggests that uncertainty is ubiquitous in LBP care and not limited to particular domains. Clinicians navigated uncertainty when considering patients' personal and social contexts; making therapeutic decisions; navigating emotions and mental health; communicating with, and educating, patients, among others. These uncertainties are intertwined with clinical aspects such as treatment choices and evidence-based education about LBP. At times, clinicians resolved these uncertainties by producing certainty at the cost of attending to human aspects of care. We argue that epistemic shifts, theorisation and practical engagement with theory in training, research and clinical practice may prompt clinicians to embrace uncertainty and enact the logic of care.
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Affiliation(s)
- Nathalia Costa
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia; The University of Sydney, Sydney School of Public Health, Menzies Centre for Health Policy and Economics, Sydney, New South Wales, Australia.
| | - Karime Mescouto
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Miriam Dillon
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Australia
| | - Rebecca Olson
- The University of Queensland, School of Social Science, Brisbane, Queensland, Australia
| | - Prudence Butler
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia; Physiotherapy Department, Royal Brisbane and Women's Hospital, Australia
| | - Roma Forbes
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
| | - Jenny Setchell
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia
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Eachempati P, Büchter RB, Ks KK, Hanks S, Martin J, Nasser M. Developing an integrated multilevel model of uncertainty in health care: a qualitative systematic review and thematic synthesis. BMJ Glob Health 2022; 7:bmjgh-2021-008113. [PMID: 35501069 PMCID: PMC9062775 DOI: 10.1136/bmjgh-2021-008113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/07/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Uncertainty is an inevitable part of healthcare and a source of confusion and challenge to decision-making. Several taxonomies of uncertainty have been developed, but mainly focus on decisions in clinical settings. Our goal was to develop a holistic model of uncertainty that can be applied to both clinical as well as public and global health scenarios. Methods We searched Medline, Embase, CINAHL, Scopus and Google scholar in March 2021 for literature reviews, qualitative studies and case studies related to classifications or models of uncertainty in healthcare. Empirical articles were assessed for study limitations using the Critical Appraisal Skills Programme (CASP) checklist. We synthesised the literature using a thematic analysis and developed a dynamic multilevel model of uncertainty. We sought patient input to assess relatability of the model and applied it to two case examples. Results We screened 4125 studies and included 15 empirical studies, 13 literature reviews and 5 case studies. We identified 77 codes and organised these into 26 descriptive and 11 analytical themes of uncertainty. The themes identified are global, public health, healthcare system, clinical, ethical, relational, personal, knowledge exchange, epistemic, aleatoric and parameter uncertainty. The themes were included in a model, which captures the macro, meso and microlevels and the inter-relatedness of uncertainty. We successfully piloted the model on one public health example and an environmental topic. The main limitations are that the research input into our model predominantly came from North America and Europe, and that we have not yet tested the model in a real-life setting. Conclusion We developed a model that can comprehensively capture uncertainty in public and global health scenarios. It builds on models that focus solely on clinical settings by including social and political contexts and emphasising the dynamic interplay between different areas of uncertainty.
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Affiliation(s)
- Prashanti Eachempati
- Department of Prosthodontics, Faculty of Dentistry, Manipal University College Malaysia, Bukit Baru, Malaysia
| | - Roland Brian Büchter
- Institute for Research in Operative Medicine (IFOM), Faculty of Health-School of Medicine, Witten/Herdecke University, Cologne, Nordrhein-Westfalen, Germany
| | - Kiran Kumar Ks
- Department of Prosthodontics, Faculty of Dentistry, Manipal University College Malaysia, Bukit Baru, Malaysia
| | - Sally Hanks
- Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth, UK
| | - John Martin
- Sustainable Earth Institute, University of Plymouth, Plymouth, UK
| | - Mona Nasser
- Peninsula Dental School, Faculty of Health, University of Plymouth, Plymouth, UK
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Epstein RM. Facing epistemic and complex uncertainty in serious illness: The role of mindfulness and shared mind. PATIENT EDUCATION AND COUNSELING 2021; 104:2635-2642. [PMID: 34334265 DOI: 10.1016/j.pec.2021.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown"). DISCUSSION Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement. CONCLUSION For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.
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Affiliation(s)
- Ronald M Epstein
- Center for Communication and Disparities Research, Department of Family Medicine, and Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Lee C, Hall K, Anakin M, Pinnock R. Towards a new understanding of uncertainty in medical education. J Eval Clin Pract 2021; 27:1194-1204. [PMID: 33089607 DOI: 10.1111/jep.13503] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 12/21/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Uncertainty is a complex and constant phenomenon in clinical practice. How medical students recognize and respond to uncertainty impacts on their well-being, career choices, and attitudes towards patients. It has been suggested that curricula should do more to prepare medical students for an uncertain world. In order to teach medical students about uncertainty, we need to understand how uncertainty has been conceptualized in the literature to date. The aim of this article is to explore existing models of uncertainty and to develop a framework of clinical uncertainty to aid medical education. METHOD A scoping literature review was performed to identify conceptual models of uncertainty in healthcare. Content and inductive analyses were performed to explore three dimensions of clinical uncertainty: sources of uncertainty, subjective influencers and responses to uncertainty. RESULTS Nine hundred one references were identified using our search strategy, of which, 24 met our inclusion criteria. It was possible to classify these conceptual models using one or more of three dimensions of uncertainty; sources, subjective influencers, and responses. Exploration and further classification of these dimensions led to the development of a framework of uncertainty for medical education. CONCLUSION The developed framework of clinical uncertainty highlights sources, subjective influencers, responses to uncertainty, and the dynamic relationship among these elements. Our framework illustrates the different aspects of knowledge as a source of uncertainty and how to distinguish between those aspects. Our framework highlights the complexity of sources of uncertainty, especially when including uncertainty arising from relationships and systems. These sources can occur in combination. Our framework is also novel in how it describes the impact of influencers such as personal characteristics, experience, and affect on perceptions of and responses to uncertainty. This framework can be used by educators and curricula developers to help understand and teach about clinical uncertainty.
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Affiliation(s)
- Ciara Lee
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Katherine Hall
- Department of General Practice and Rural Health, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Megan Anakin
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ralph Pinnock
- Education Unit, Otago Medical School, University of Otago, Dunedin, New Zealand
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Han PKJ, Babrow A, Hillen MA, Gulbrandsen P, Smets EM, Ofstad EH. Uncertainty in health care: Towards a more systematic program of research. PATIENT EDUCATION AND COUNSELING 2019; 102:1756-1766. [PMID: 31227333 DOI: 10.1016/j.pec.2019.06.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research. METHODS We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research. RESULTS A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated. CONCLUSION Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community. PRACTICE IMPLICATIONS A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, USA; Tufts University School of Medicine, Boston, USA.
| | - Austin Babrow
- School of Communication Studies, Ohio University, Athens, USA
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; HØKH Research Center, Akershus University Hospital, Lørenskog, Norway
| | - Ellen M Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Eirik H Ofstad
- Department of Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Medendorp NM, Hillen MA, Murugesu L, Aalfs CM, Stiggelbout AM, Smets EMA. Uncertainty in consultations about genetic testing for cancer: an explorative observational study. PATIENT EDUCATION AND COUNSELING 2018; 101:2083-2089. [PMID: 30082116 DOI: 10.1016/j.pec.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/18/2018] [Accepted: 08/01/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Persons seeking cancer genetic counseling mainly aim to obtain information and certainty about their medical situation. However, the information that counselees receive often involves many uncertainties. To develop strategies to enable optimal communication about uncertainties, the spectrum of uncertainty expressed within cancer genetic counseling needs to be established. This study aimed to gain insight into the uncertainties verbally expressed by counselors and counselees. METHODS Twenty-five consultations were audiotaped, transcribed and qualitatively analyzed. A coding scheme identifying all uncertainties was developed parallel to the coding of the transcripts. RESULTS Several uncertainties were identified varying in their source (i.e. the cause of uncertainty) and the issues involved (i.e. the topic to which uncertainty pertained). The main sources of uncertainty were the unpredictability of the future and a lack of knowledge. Counselees also expressed uncertainty related to the amount and complexity of the information. Counselors expressed uncertainties mainly related to scientific issues, whereas counselees' uncertainty mainly related to personal and practical issues. CONCLUSION A wide range of uncertainties was expressed by both groups. Counselors differ from counselees in the degree and types of uncertainty they express. PRACTICE IMPLICATIONS Counselors should address scientific uncertainties during genetic counseling to increase awareness and understanding in counselees.
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Affiliation(s)
- Niki M Medendorp
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Cancer Centre Amsterdam, Amsterdam, The Netherlands.
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Laxsini Murugesu
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cora M Aalfs
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Clinical Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anne M Stiggelbout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands; Cancer Centre Amsterdam, Amsterdam, The Netherlands
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Ghodraty Jabloo V, Alibhai SMH, Fitch M, Tourangeau AE, Ayala AP, Puts MTE. Antecedents and Outcomes of Uncertainty in Older Adults With Cancer: A Scoping Review of the Literature. Oncol Nurs Forum 2018. [PMID: 28632247 DOI: 10.1188/17.onf.e152-e167] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PROBLEM IDENTIFICATION Uncertainty is a major source of distress for cancer survivors. Because cancer is primarily a disease of older adults, a comprehensive understanding of the antecedents and outcomes of uncertainty in older adults with cancer is essential.
. LITERATURE SEARCH MEDLINE®, PsycINFO®, Scopus, and CINAHL® were searched from inception to December 2015. Medical Subject Headings (MeSH) terms and free text words were used for the search concepts, including neoplasms, uncertainty, and aging.
. DATA EVALUATION Extracted data included research aims; research design or analysis approach; sample size; mean age; type, stage, and duration of cancer; type and duration of treatment; uncertainty scale; and major results.
. SYNTHESIS Of 2,584 articles initially identified, 44 studies (30 qualitative, 12 quantitative, and 2 mixed-methods) were included. Evidence tables were developed to organize quantitative and qualitative data. Descriptive numeric and thematic analyses were used to analyze quantitative results and qualitative findings, respectively. Outcomes were reported under four main categories. CONCLUSIONS Uncertainty is an enduring and common experience in cancer survivorship. Uncertainty is affected by a number of demographic and clinical factors and affects quality of life (QOL) and psychological well-being.
. IMPLICATIONS FOR PRACTICE Uncertainty should be considered a contributing factor to psychological well-being and QOL in older adults with cancer. Nurses are in a unique position to assess negative effects of uncertainty and manage these consequences by providing patients with information and emotional support.
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Hurt CS, Cleanthous S, Newman SP. Further explorations of illness uncertainty: carers’ experiences of Parkinson’s disease. Psychol Health 2017; 32:549-566. [DOI: 10.1080/08870446.2017.1283041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Catherine S. Hurt
- Centre for Health Services Research, School of Health, City, University London, London, UK
| | | | - Stanton P. Newman
- Centre for Health Services Research, School of Health, City, University London, London, UK
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Dean M. "It's not if I get cancer, it's when I get cancer": BRCA-positive patients' (un)certain health experiences regarding hereditary breast and ovarian cancer risk. Soc Sci Med 2016; 163:21-7. [PMID: 27376595 DOI: 10.1016/j.socscimed.2016.06.039] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 06/14/2016] [Accepted: 06/22/2016] [Indexed: 12/01/2022]
Abstract
RATIONALE Women with a harmful mutation in the BReast CAncer (BRCA) gene are at significantly increased risk of developing hereditary breast and ovarian cancer (HBOC) during their lifetime, compared to those without. Such patients-with a genetic predisposition to develop cancer but who have not yet been diagnosed with cancer-live in a constant state of uncertainty and wonder not if they might get cancer but when. OBJECTIVE Framed by uncertainty management theory, the purpose of this study was to explore BRCA-positive patients' health experiences after testing positive for the BRCA genetic mutation, specifically identifying their sources of uncertainty. METHODS Thirty-four, qualitative interviews were conducted with female patients. Participants responded to online research postings on the non-profit organization Facing Our Risk of Cancer Empowered's (FORCE) message board and social media pages as well as HBOC-specific Facebook groups. The interview data were coded using the constant comparison method. RESULTS Two major themes representing BRCA-positive patients' sources of uncertainty regarding their genetic predisposition and health experiences emerged from the data. Medical uncertainty included the following three subthemes: the unknown future, medical appointments, and personal cancer scares. Familial uncertainty encompassed the subthemes traumatic family cancer memories and motherhood. CONCLUSIONS Overall, the study supports and extends existing research on uncertainty-revealing uncertainty is inherent in BRCA-positive patients' health experiences-and offers new insight regarding uncertainty management and HBOC risk.
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Affiliation(s)
- Marleah Dean
- Department of Communication, University of South Florida, 4202 E. Fowler CIS 3057, Tampa, FL 33620, USA.
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Cleanthous S, Isenberg DA, Newman SP, Cano SJ. Patient Uncertainty Questionnaire-Rheumatology (PUQ-R): development and validation of a new patient-reported outcome instrument for systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) in a mixed methods study. Health Qual Life Outcomes 2016; 14:33. [PMID: 26927364 PMCID: PMC4772528 DOI: 10.1186/s12955-016-0432-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 02/22/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND An in-depth qualitative exploration of uncertainty in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) led to the development of a five-domain conceptual framework of patient uncertainty in these two conditions. The purpose of this study was to develop and evaluate a new patient-reported outcome (PRO) instrument for patient uncertainty in SLE and RA on the basis of this empirically developed conceptual framework. METHODS Cognitive debriefing interviews were conducted to pre-test the initial items generated on the basis of the preliminary qualitative exploration of patient uncertainty in SLE and RA. Two separate field tests were conducted in five hospital sites to evaluate the measurement properties of the new instrument; the first to identify and form scales, and the second to assess measurement properties of the final version in an independent sample. Psychometric evaluation was conducted in line with the Rasch Measurement Theory (RMT), examining the extent to which sample to scale targeting was satisfactory, measurement scales were constructed effectively and the sample was measured successfully. Traditional psychometric techniques were also used to provide complementary analyses best understood by clinicians. RESULTS Pre-testing supported the relevance, acceptability and comprehensibility of the initial items. Findings indicated that the Patient Uncertainty Questionnaire for Rheumatology PUQ-R instrument fulfilled the expectations of RMT to a large extent (including person separation index 0.73 - 0.91). The PUQ-R comprises 49 items across five scales; symptoms and flares (14 items), medication (11 items), trust in doctor (8 items), self-management (6 items) and impact (10 items) which further displayed excellent measurement properties as assessed against the traditional psychometric criteria (including Cronbach's alpha 0.82 - 0.93). CONCLUSION The PUQ-R has been developed and evaluated specifically for patients with SLE and RA. By quantifying uncertainty, the PUQ-R has the potential to support evidence-based management programmes and research.
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Affiliation(s)
- Sophie Cleanthous
- Modus Outcomes, Suite 210b, Spirella Building, Bridge Road, Letchworth Garden City, SG6 4ET, UK.
| | - David Alan Isenberg
- Centre for Rheumatology Research, University College London, 5 University Street, London, WC1E 6JH, UK.
| | - Stanton Peter Newman
- School of Health Sciences, City University, Northampton Square, London, EC1V OHB, UK.
| | - Stefan John Cano
- Modus Outcomes, Suite 210b, Spirella Building, Bridge Road, Letchworth Garden City, SG6 4ET, UK.
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Berger-Höger B, Liethmann K, Mühlhauser I, Haastert B, Steckelberg A. Informed shared decision-making supported by decision coaches for women with ductal carcinoma in situ: study protocol for a cluster randomized controlled trial. Trials 2015; 16:452. [PMID: 26458964 PMCID: PMC4603943 DOI: 10.1186/s13063-015-0991-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with breast cancer want to participate in treatment decision-making. Guidelines have confirmed the right of informed shared decision-making. However, previous research has shown that the implementation of informed shared decision-making is suboptimal for reasons of limited resources of physicians, power imbalances between patients and physicians and missing evidence-based patient information. We developed an informed shared decision-making program for women with primary ductal carcinoma in situ (DCIS). The program provides decision coaching for women by specialized nurses and aims at supporting involvement in decision-making and informed choices. In this trial, the informed shared decision-making program will be evaluated in breast care centers. METHODS/DESIGN A cluster randomized controlled trial will be conducted to compare the informed shared decision-making program with standard care. The program comprises an evidence-based patient decision aid and training of physicians (2 hours) and specialized breast care and oncology nurses (4 days) in informed shared decision-making. Sixteen certified breast care centers will be included, with 192 women with primary DCIS being recruited. Primary outcome is the extent of patients' involvement in shared decision-making as assessed by the MAPPIN-Odyad (Multifocal approach to the 'sharing' in shared decision-making: observer instrument dyad). Secondary endpoints include the sub-measures of the MAPPIN-inventory (MAPPIN-Onurse, MAPPIN-Ophysician, MAPPIN-Opatient, MAPPIN-Qnurse, MAPPIN-Qpatient and MAPPIN-Qphysician), informed choice, decisional conflict and the duration of encounters. It is expected that decision coaching and the provision of evidence-based patient decision aids will increase patients' involvement in decision-making with informed choices and reduce decisional conflicts and duration of physician encounters. Furthermore, an accompanying process evaluation will be conducted. DISCUSSION To our knowledge, this is the first study investigating the implementation of decision coaches in German breast care centers. TRIAL REGISTRATION Current Controlled Trials ISRCTN46305518 , date of registration: 5 June 2015.
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Affiliation(s)
- Birte Berger-Höger
- University of Hamburg, MIN-Faculty, Unit of Health Sciences and Education, Martin-Luther-King-Platz 6, D-20146, Hamburg, Germany.
| | - Katrin Liethmann
- University of Hamburg, MIN-Faculty, Unit of Health Sciences and Education, Martin-Luther-King-Platz 6, D-20146, Hamburg, Germany.
| | - Ingrid Mühlhauser
- University of Hamburg, MIN-Faculty, Unit of Health Sciences and Education, Martin-Luther-King-Platz 6, D-20146, Hamburg, Germany.
| | - Burkhard Haastert
- mediStatistica Neuenrade, Lambertusweg 1b, D-58809, Neuenrade, Germany.
| | - Anke Steckelberg
- University of Hamburg, MIN-Faculty, Unit of Health Sciences and Education, Martin-Luther-King-Platz 6, D-20146, Hamburg, Germany.
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14
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Hope-Stone L, Brown SL, Heimann H, Damato B, Salmon P. How do patients with uveal melanoma experience and manage uncertainty? A qualitative study. Psychooncology 2015; 24:1485-91. [PMID: 25873360 DOI: 10.1002/pon.3813] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 03/05/2015] [Accepted: 03/07/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Cancer survivors experience uncertainty about the future, which can be distressing. A prognostication tool is available for uveal melanoma survivors, which can provide accurate estimates of life expectancy - a key source of uncertainty. Accurate prognostic information has not previously been available for healthy cancer survivors. The aims of this study were to identify how patients experience prognostic information and how it affects their experience of uncertainty. METHODS Semi-structured interviews were conducted with 25 healthy survivors of uveal melanoma 6-60 months after treatment (approximately 8-62 months after receiving prognostic information). Data were analysed qualitatively. RESULTS Patients did not feel that the prognostic information relieved uncertainty, which still overshadowed their lives. Different prognoses engendered different experiences of uncertainty. Those receiving poor life expectancy estimates reported uncertainties regarding the timing and form of metastases that they were likely to experience, but they also used uncertainty to justify feeling hopeful. Those receiving good prognoses were often unable wholly to accept these. Patients whose test results failed or were intermediate retained their original uncertainties. Patients managed their uncertainties by suppressing thoughts about them and by trusting in the care of clinicians and the health-care system. CONCLUSIONS Uncertainty in the context of uveal melanoma is a complex and multifaceted experience that is not easily resolved by prognostication. Additional approaches are needed to help patients with the uncertainty that persists despite prognostication.
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Affiliation(s)
- Laura Hope-Stone
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK.,The Liverpool Ocular Oncology Centre, The Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Stephen L Brown
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Heinrich Heimann
- The Liverpool Ocular Oncology Centre, The Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, UK
| | - Bertil Damato
- The Liverpool Ocular Oncology Centre, The Royal Liverpool and Broadgreen University Hospital NHS Trust, Liverpool, UK.,Ocular Oncology Service, University of California, San Francisco, CA, USA
| | - Peter Salmon
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
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15
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Esmaeili M, Cheraghi MA, Salsali M. Cardiac patients' perception of patient-centred care: a qualitative study. Nurs Crit Care 2014; 21:97-104. [PMID: 25522757 DOI: 10.1111/nicc.12148] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/02/2014] [Accepted: 11/10/2014] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to explore cardiac patients' perception of patient-centred care. BACKGROUND Despite patient's importance in the process of care, less attention has been paid to experiences and expectations of patients in definitions of patient-centred care. As patients are an important element in process of patient-centred care, organizing care programs according to their perceptions and expectations will lead to enhanced quality of care and greater patient satisfaction. DESIGN This study is a descriptive qualitative study. METHODS Content analysis approach was performed for data analysis. Participants were 18 cardiac patients (10 women and 8 men) hospitalized in coronary care units of teaching hospitals affiliated to Tehran University of Medical Sciences. We collected the study data through conducting personal face-to-face semi-structured interviews. FINDINGS The participants' perceptions of patient-centred care fell into three main themes including managing patients uncertainty, providing care with more flexibility and establishing a therapeutic communication. The second theme consisted of two sub-themes: empathizing with patients and having the right to make independent decisions. CONCLUSIONS Receiving patient-centred care is essential for cardiac patients. Attention to priorities and preferences of cardiac patients and making decisions accordingly is among effective strategies for achieving patient-centred care. IMPLICATIONS FOR PRACTICE Cardiac care unit nurses ought to be aware that in spite of technological developments and advances, it is still important to pay attention to patients' needs and expectations in order to achieve patient satisfaction. In planning care programs, they should consider accountability towards patients' needs, flexibility in process of care and establishing medical interactions as an effective strategy for improving quality of care.
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Affiliation(s)
- Maryam Esmaeili
- School of Nursing and Midwifery, Nursing Critical Care Department, Tehran University of Medical Sciences Tehran, Iran
| | - Mohammad A Cheraghi
- School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahvash Salsali
- School of Nursing and Midwifery, Medical-Surgical Department, Tehran University of Medical Sciences, Tehran, Iran
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16
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Cristancho SM, Apramian T, Vanstone M, Lingard L, Ott M, Novick RJ. Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1516-21. [PMID: 23969352 PMCID: PMC5578757 DOI: 10.1097/acm.0b013e3182a3116f] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PURPOSE In clinical settings, uncertainty is part of everyday practice. However, a lack of insight into how experts approach uncertainty limits the ability to explicitly teach and assess it in training. This study explored how experienced surgeons perceived and handled uncertainty during challenging intraoperative situations, to develop a theoretical language supporting both education and research. METHOD This constructivist qualitative study included observations and interviews during 26 surgical cases. The cases, drawn from seven staff surgeons from various specialties at a medical school, were purposively sampled after being preidentified by the surgeon as "likely challenging." The authors combined template and inductive analyses. In template analysis, an existing theory was used to identify instances of uncertainty in the dataset. Inductive analysis was used to elaborate and refine the concepts. RESULTS Template analysis confirmed that existing theoretical concepts are relevant to surgery. However, inductive analysis revealed additional concepts and positioned existing concepts within new relationships. Two new theoretical themes were recognizing uncertainty and responding to uncertainty, each with corresponding subthemes. Factors such as the novelty of the situation, difficulty in predicting the outcome, and difficulty deciding the course of action mainly characterize an uncertain situation in surgery according to the participants. CONCLUSIONS The results offer a refined language for conceptualizing uncertainty in surgery. Although further research could elaborate and test the explanatory power of this language, the authors anticipate that it has implications both for current discussions of surgical safety and for future development of explicit training for effective management of surgical uncertainty.
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Affiliation(s)
- Sayra M Cristancho
- Dr. Cristancho is assistant professor, Department of Surgery, Department of Medical Biophysics, and scientist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Mr. Apramian is research associate, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Vanstone is assistant professor, Centre for Health Economics and Policy Analysis, Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada. Dr. Lingard is professor, Department of Medicine, and director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Ott is assistant professor, Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. Dr. Novick is professor, Division of Cardiac Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
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17
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Heesen C, Köpke S, Solari A, Geiger F, Kasper J. Patient autonomy in multiple sclerosis--possible goals and assessment strategies. J Neurol Sci 2013; 331:2-9. [PMID: 23711752 DOI: 10.1016/j.jns.2013.02.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
Abstract
Patient autonomy has been increasingly acknowledged as prerequisite for successful medical decision making in Western countries. In medical decisions with a need to involve a health professional, patient autonomy becomes apparent in the extent of patients' participation in the communication as described in the concept of shared decision making. Patient autonomy can be derived from different perspectives or goals and the focus of evaluation approaches may vary accordingly. Multiple sclerosis (MS) is a paradigmatic disease to study patient autonomy mainly because MS patients are highly disease competent and due to ambiguous evidence on many aspects of disease-related medical decision making. This review gives an overview on measurement issues in studying decision making in MS, categorized according to prerequisites, process measures and outcomes of patient autonomy. As relevant prerequisites role preferences, risk attribution, risk tolerance, and risk knowledge are discussed. Regarding processes, we distinguish intra-psychic and interpersonal aspects. Intra-psychic processes are elucidated using the theory of planned behavior, which guided development of a 30-item scale to capture decisions about immunotherapy. Moreover, a theory of uncertainty management has been created resulting in the development of a corresponding measurement concept. Interpersonal processes evolving between physician and patient can be thoroughly analyzed from different perspectives by use of the newly developed comprehensive MAPPIN'SDM inventory. Concerning outcomes, besides health related outcomes, we discuss match of preferred roles during the decision encounters (preference match), decisional conflict as well as an application of the multidimensional measure of informed choice to decisions of MS patients. These approaches provide an overview on patient-inherent and interpersonal factors and processes modulating medical decision making and health behavior in MS and beyond.
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Affiliation(s)
- C Heesen
- Institute of Neuroimmunology and Clinical MS Research, University Medical Center Hamburg, Hamburg, Germany.
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18
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Cleanthous S, Newman S, Shipley M, Isenberg D, Cano S. What constitutes uncertainty in systemic lupus erythematosus and rheumatoid arthritis? Psychol Health 2013; 28:171-88. [DOI: 10.1080/08870446.2012.701628] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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19
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Vos J, Menko FH, Oosterwijk JC, van Asperen CJ, Stiggelbout AM, Tibben A. Genetic counseling does not fulfill the counselees' need for certainty in hereditary breast/ovarian cancer families: an explorative assessment. Psychooncology 2012; 22:1167-76. [PMID: 22777929 DOI: 10.1002/pon.3125] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/30/2012] [Accepted: 05/30/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Many cancer-patients undergo DNA testing in the BRCA1/2 genes to receive information about the likelihood that cancer is heritable. Previous nonsystematic studies suggested that DNA testing often does not fulfill the counselees' needs for certainty. We explored the balance between the counselees' need for certainty and perceived certainty (NfC-PC, i.e., level of fulfillment of NfC) regarding the specific domains of DNA test result, heredity and cancer. We also examined relationships of NfC-PC with coping styles and distress. METHOD Before disclosure of BRCA1/2 test results for hereditary breast/ovarian cancer (T1), questionnaires were filled in by 467 cancer-patients. Another questionnaire (T2) was filled in after disclosure of pathogenic mutation results (n = 30), uninformative results (n = 202) or unclassified-variants (n = 16). RESULTS Before and after DNA test result disclosure, overall 58-94% of all counselees experienced unfulfilled NfC regarding the DNA test result, heredity and cancer. Compared with T1, the communication of pathogenic mutations (T2) caused more fulfillment of the NfC about the DNA test result, but less about cancer and heredity (p < .01). Compared with T1, unclassified variants (T2) did not significantly change the extent of fulfillment of all counselees' needs for certainty (NfC > PC). Compared with T1, uninformative results (T2) caused more fulfillments of all needs than before disclosure (p < 0.01). Counselees differentiated NfC and PC between the domains of DNA-test result, heredity and cancer (p < 0.01). The unfulfilled needs for certainty (NfC-PC) were uncorrelated with cognitive understanding of the DNA test result. CONCLUSION The counselees' NfC needs more attention in research and practice, for example, when the potential uncertainties of testing are discussed. The counselees' NfC may be assessed and used in tailored, mutual communication of DNA test results.
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Affiliation(s)
- Joël Vos
- Department of Clinical Genetics, Center for Human and Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
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20
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A counselee-oriented perspective on risk communication in genetic counseling: explaining the inaccuracy of the counselees' risk perception shortly after BRCA1/2 test result disclosure. Genet Med 2012; 13:800-11. [PMID: 21885922 DOI: 10.1097/gim.0b013e31821a36f9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Genetic counseling may help counselees understand their genetic risk of developing breast/ovarian cancer. However, many studies have shown that their perception of their risks is inaccurate. Information-oriented variables often predicted the level of accuracy, focusing on specific processes of receiving and processing risks. We examined counselee-oriented predictors about how counselees embed cancer risks in their lives. These predictors reflect the personal meaning of genetic risks and are expected to explain/mediate the impact of genetic counseling on risk-perception-accuracy. METHOD We analyzed 248 questionnaires of a prospective study, filled in by probands with breast/ovarian cancer and pathogenic mutations, unclassified variants, or uninformative results (n = 30, 16, and 202, respectively). Mediation regression analyses were performed to examine whether counselee predictors mediated/explained the influence of information predictors on the accuracy. Information-oriented predictors regarded presentation format, communicated information, question format, education, pedigree information, cancer experience, and cognitive processes/heuristics. Counselee-oriented predictors regarded their self/personality, life/existence, and need for certainty about DNA test result, heredity, and cancer. RESULTS Both information-oriented and counselee-oriented variables significantly predicted the accuracy of the counselees' risk perception, with moderate to large effect sizes. Counselee-oriented variables completely mediated/explained the effects of information-oriented variables on the accuracy. DISCUSSION Counselees seemed to transform objective cancer risks into personally relevant information. Only through this personal meaning of genetic information, information-oriented processes seemed to cause inaccurate perceptions. Genetic counselors are suggested to focus communication on these personal processes.
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21
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The decisional conflict scale: moving from the individual to the dyad level. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2012; 106:247-52. [DOI: 10.1016/j.zefq.2012.02.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/21/2012] [Accepted: 02/24/2012] [Indexed: 11/22/2022]
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22
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Martinez JM. Managing scientific uncertainty in medical decision making: the case of the advisory committee on immunization practices. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2011; 37:6-27. [PMID: 22198966 DOI: 10.1093/jmp/jhr056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This article explores the question of how scientific uncertainty can be managed in medical decision making using the Advisory Committee on Immunization Practices as a case study. It concludes that where a high degree of technical consensus exists about the evidence and data, decision makers act according to a clear decision rule. If a high degree of technical consensus does not exist and uncertainty abounds, the decision will be based on a variety of criteria, including readily available resources, decision-process constraints, and the available knowledge base, among other things. Decision makers employ a variety of heuristic devices and techniques, thereby employing a pragmatic approach to uncertainty in medical decision making. The article concludes with recommendations for managing scientific uncertainty in medical decision making.
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Affiliation(s)
- J Michael Martinez
- Kennesaw State University, Department of Political Science and International Affairs, 1000 Chastain Road, Kennesaw, Georgia 30144, USA.
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23
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Abstract
Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
| | - William M P Klein
- Division of Cancer Control and Population Sciences, National CancerInstitute, Bethesda, Maryland (WMPK, NKA)
| | - Neeraj K Arora
- Division of Cancer Control and Population Sciences, National CancerInstitute, Bethesda, Maryland (WMPK, NKA)
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24
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Geiger F, Liethmann K, Hoffmann F, Paschedag J, Kasper J. Investigating a training supporting Shared Decision Making (IT'S SDM 2011): study protocol for a randomized controlled trial. Trials 2011; 12:232. [PMID: 22029737 PMCID: PMC3267675 DOI: 10.1186/1745-6215-12-232] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 10/26/2011] [Indexed: 11/19/2022] Open
Affiliation(s)
- Friedemann Geiger
- Tumor Center, University Medical Center Schleswig-Holstein, Niemannsweg 4, 24105 Kiel, Germany.
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25
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McCormack LA, Treiman K, Rupert D, Williams-Piehota P, Nadler E, Arora NK, Lawrence W, Street RL. Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach. Soc Sci Med 2011; 72:1085-95. [PMID: 21376443 DOI: 10.1016/j.socscimed.2011.01.020] [Citation(s) in RCA: 215] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Revised: 11/07/2010] [Accepted: 01/15/2011] [Indexed: 11/19/2022]
Abstract
Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institute's Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.
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Affiliation(s)
- Lauren A McCormack
- Health Communication Program, RTI International, 3040 Cornwallis Road, RTP, NC 27709, USA.
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26
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Kasper J, Légaré F, Scheibler F, Geiger F. Turning signals into meaning--'shared decision making' meets communication theory. Health Expect 2011; 15:3-11. [PMID: 21323823 DOI: 10.1111/j.1369-7625.2011.00657.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Shared decision making (SDM) is being increasingly challenged for promoting an innovative role model while adhering to an archaic approach to patient-clinician communication, both in clinical practice and the research field. Too often, SDM has been studied at the individual level, which ignores the interpersonal system between patients and physicians. We aimed to encourage debate by reflecting on the essentials of SDM in terms of epistemology. We operationalized the SDM core concept of information exchange in terms of social systems theory. An epistemological analysis of the term information refers to its inherent process character. Exchange of information thereby becomes synonymous with social sense construction, indicating that, rather than just being a vehicle, the act of communication itself is the information. We plead for the adoption of existing dyadic analytical methods such as those offered by the interpersonal paradigm. Implications of an updated concept of information for the use of SDM-evaluation methods, for SDM-goal setting, and for clinical practice of SDM are described.
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Affiliation(s)
- Jürgen Kasper
- Institute of Neuroimmunology and Clinical MS-Research, University Medical Center, Hamburg, Germany.
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27
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Abstract
Uncertainty is a pervasive and important problem that has attracted increasing attention in health care, given the growing emphasis on evidence-based medicine, shared decision making, and patient-centered care. However, our understanding of this problem is limited, in part because of the absence of a unified, coherent concept of uncertainty. There are multiple meanings and varieties of uncertainty in health care that are not often distinguished or acknowledged although each may have unique effects or warrant different courses of action. The literature on uncertainty in health care is thus fragmented, and existing insights have been incompletely translated to clinical practice. This article addresses this problem by synthesizing diverse theoretical and empirical literature from the fields of communication, decision science, engineering, health services research, and psychology and developing a new integrative conceptual taxonomy of uncertainty. A 3-dimensional taxonomy is proposed that characterizes uncertainty in health care according to its fundamental sources, issues, and locus. It is shown how this new taxonomy facilitates an organized approach to the problem of uncertainty in health care by clarifying its nature and prognosis and suggesting appropriate strategies for its analysis and management.
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Affiliation(s)
- Paul K. J. Han
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (WMPK, NKA)
| | - William M. P. Klein
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (WMPK, NKA)
| | - Neeraj K. Arora
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine (PKJH)
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (WMPK, NKA)
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28
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Kasper J, Légaré F, Scheibler F, Geiger F. [Shared decision-making and communication theory: grounding the tango]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2010; 104:636-41. [PMID: 21129700 DOI: 10.1016/j.zefq.2010.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Shared decision-making (SDM) has the potential to overcome outdated social role models in the health care system. The concept, however, adheres to archaic epistemological assumptions as can be inferred from the rudimentary stage of the measurement methods used and from the information monopoly that the physician still holds in this concept. Advantages of an up-to-date model of knowledge for understanding and operationalising SDM are outlined. To this purpose, essential definitions of the concept are reflected in terms of epistemology. Accordingly, information emerges through a process of social construction. Likewise, interpersonal relations do not represent a static condition; rather, they develop anew with each interaction. Therefore, constructs suitable to focus on dyadic interaction processes can be used as indicators of sharing in SDM. Theories and methods of the interpersonal paradigm are advocated.
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Affiliation(s)
- Jürgen Kasper
- Gesundheitswissenschaften, MIN Fakultät, Universität Hamburg, Hamburg.
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