Twelve myths about shared decision making

Experiences of facilitators and barriers for fulfilment of human needs when living with restless legs syndrome: a qualitative study

PURPOSE

Restless Legs Syndrome (RLS) is a widespread condition that affects sleep leading to daytime sleepiness, depression, and reduced quality of life. This study aims to determine and describe how patients with RLS experience their everyday life, with a focus on facilitators and barriers related to Maslow's hierarchical theory of human needs.

METHOD

Semi-structured interviews were analysed with qualitative content analysis resulting in facilitators and barriers affecting the fulfilment of the five human needs.

RESULTS

Addressing RLS symptoms through medications and a quiet sleep environment fulfils psychological needs. Control over RLS symptoms, engagement in activities, trust in treatments, and social support meet safety and security needs. Social inclusion, close relationships, and meaningful interactions fulfil a sense of belongingness and love needs despite RLS. Competence in managing RLS, effective self-care strategies, confident communication, and trust-building support esteem needs. Finally, comprehensive understanding through person-centred interventions and coping fulfils the self-actualization needs in managing RLS.

CONCLUSION

Holistic and person-centred interventions, including facilitators for the fulfilment of physiological, psychological, and social needs could help healthcare professionals to provide holistic care.

"Ask for my ideas first": Experiences of antenatal care and shared decision-making for women with high body mass index

BACKGROUND

Shared decision-making supports women's choices in pregnancy. Women with high body mass index (≥35 kg/m2) experience a high rate of interventions in pregnancy, labour, and birth, providing an opportunity for clinicians to implement shared decision-making in practice. However, weight stigma may limit women's opportunities for shared decision-making.

AIM

To understand how pregnant women with high body mass index perceive their involvement in antenatal decision-making, including whether weight stigma influences their experience.

METHODS

Women with high body mass index were recruited via purposive sampling from two sites in Melbourne, Australia. Semi-structured interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis.

FINDINGS

Ten pregnant women consented to participate. Three themes and six sub-themes were identified. These were: 1) Trusting the system, 2) Who takes the lead?, and 3) Defying disease.

DISCUSSION

Shared decision-making is limited for women with high body mass index in antenatal care, and weight stigma is experienced by women. Clinical practice recommendations relating to excess weight have the potential to further limit women's involvement in decision-making if adequate support is not provided to ensure women's understanding and involvement in care.

CONCLUSION

Women's involvement in care is a central component of shared decision-making and it is currently limited for women with high body mass index. Transparency regarding the rationale for recommendations is required, and further work must be done to address the influence and impact of weight stigma on the care of women with high body mass index.

Ethical Care of Pregnant Patients During Labor, Delivery, and Nonobstetric Surgery

The 4 basic principles of ethics (beneficence, nonmaleficence, autonomy, and justice) can guide clinical decision-making for the pregnant patient during labor and delivery, as well as when undergoing nonobstetric surgery. An evidence-based decision-making conversation with the patient facilitates obtaining informed consent. When maternal-fetal conflict arises, both during labor and delivery and nonobstetric surgery, beneficence-based obligations to both parties should be considered, with discussions and decisions well documented. Labor is not an impediment to women providing consent for care. A careful balance between evidence-based clinical judgment and patient autonomy is necessary when addressing cesarean delivery.

"We will be the ones bearing the consequences": A qualitative study of barriers and facilitators to shared decision-making in hospital-based maternity care

BACKGROUND

Pregnant women involved in decisions about their care report better health outcomes for themselves and their children. Shared decision-making (SDM) is a priority for health services; however, there is limited research on factors that help and hinder SDM in hospital-based maternity settings. The purpose of this study was to explore barriers and facilitators to SDM in a large tertiary maternity care service from the perspectives of multiple stakeholders.

METHODS

Qualitative semi-structured interviews were undertaken with 39 participants including women, clinicians, health service administrators and decision-makers, and government policymakers. The interview guide and thematic analysis were based on the Theoretical Domains Framework to identify barriers and facilitators to SDM.

RESULTS

Women expect to be included in decisions about their care. Health service administrators and decision-makers, government policymakers, and most clinicians want to include them in decisions. Key barriers to SDM included lack of care continuity, knowledge, and clinician skills, as well as professional role and decision-making factors. Key facilitators pertained to policy and guideline changes, increased knowledge, professional role factors, and social influences.

CONCLUSION

This study revealed common barriers and facilitators to SDM and highlighted the need to consider perspectives outside the patient-clinician dyad. It adds to the limited literature on barriers and facilitators to SDM in hospital care settings. Organizational- and system-wide changes to service delivery are necessary to facilitate SDM. These changes may be enabled by education and training, changes to policies and guidelines to include and support SDM, and adequately timed information provision to enable SDM conversations.

A shared decision-making intervention between health care professionals and individuals undergoing Pulmonary Rehabilitation: An iterative development process with qualitative methods

BACKGROUND

Pulmonary Rehabilitation (PR) services typically offer programmes to support individuals living with COPD make rehabilitation choices that best meet their needs, however, uptake remains low. Shared Decision-Making (SDM; e.g., Patient Decision Aids (PtDA)) interventions increase informed and values-based decision-making between individuals and healthcare professionals (HCPs). We aimed to develop an intervention to facilitate PR SDM which was acceptable to individuals living with COPD and PR HCPs.

METHODS

An iterative development process involving qualitative methods was adopted. Broad overarching frameworks included: complex intervention development framework, the multiple stakeholder decision making support model, and the Ottawa Decision Support Framework. Development included: assembling a steering group, outlining the scope for the PtDA, collating data to inform the PtDA design, prototype development, alpha testing with individuals with COPD (n = 4) and PR HCPs (n = 8), PtDA finalisation, and design and development of supporting components. This took nine months.

RESULTS

The PtDA was revised six times before providing an acceptable, comprehensible, and usable format for all stakeholders. Supporting components (decision coaching training and a consultation prompt) were necessary to upskill PR HCPs in SDM and implement the intervention into the PR pathway.

CONCLUSIONS

We have developed a three-component SDM intervention (a PtDA, decision coaching training for PR healthcare professionals, and a consultation prompt) to support individuals living with COPD make informed and values-based decision about PR together with their PR healthcare professional. Clear implementation strategies are outlined which should support its integration into the PR pathway.

Shared Decision Making in Hand Surgery

Shared decision-making (SDM) is a collaborative effort between a physician and a patient to make an informed clinical decision, as defined by each patient's preferences and values. Shared decision-making is particularly used in areas of clinical equipoise or preference-sensitive conditions, which are common in hand surgery. Although there is increased interest in SDM across health care, hand surgeons receive little formal training on SDM. In this review, we explore existing barriers to SDM in hand surgery and provide a framework for participating in SDM discussions.

Effectiveness of decision aids on critically ill patients' outcomes and family members' knowledge, anxiety, depression and decisional conflict: A systematic review and meta-analysis

BACKGROUND

Decision aids (DAs) have been proposed to support patients and families with disease information processing and decision-making, but their effectiveness for critically ill patients and their families is incompletely understood.

AIM

To systematically synthesize evidence on the effectiveness of the DAs on the prognosis of critically ill patients and knowledge, anxiety, depression and decisional conflict of their family members.

STUDY DESIGN

Systematic review and meta-analysis. We conducted a systematic search of literature using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature database, Scopus, PsycNet, CNKI and Wanfang Database from the inception of the databases until May 2023 to identify randomized clinical trials (RCTs) describing DAs interventions targeted at adult intensive care unit (ICU) patients or their families. We also searched grey literature in four databases: Chinese Clinical Trials Registry, Chinese Cochrane Center, Open Grey and GreyNet International.

RESULTS

Seven RCTs were included in the review. Meta-analysis identified longer hospital length of stay (LOS) among all patients compared with usual care (mean difference [MD] = 5.64 days, 95% confidence interval, CI [0.29, 10.98], p = .04), but not in surviving patients (MD = 2.09 days, 95% CI [-3.70, 7.89], p = .48). However, there was no evidence of an effect of DAs on hospital mortality (RR = 1.25, 95% CI [0.92, 1.70], p = .15), ICU LOS (MD = 3.77 days, 95% CI [-0.17, 7.70], p = .06) and length of mechanical ventilation (MD = 0.88 days, 95% CI [-2.22, 3.97], p = .58). DAs led to a statistically significant improvement in family members' knowledge (standard mean difference = 0.84, 95% CI [0.12, 1.56], p = .02). We found no significant effect of DAs on anxiety, depression, post-traumatic stress disorder, decisional conflict and quality of communication of family members.

CONCLUSIONS

This review provides effective evidence that DAs can potentially improve the knowledge level of family members while prolonging the hospital LOS among critically ill patients.

RELEVANCE TO CLINICAL PRACTICE

Well-designed large-scale studies with DAs tailored to the individuals' preferences and existing cultural values are warranted.

To become part of the team-patient experiences of participating in decision-making for a new treatment (proton beam therapy)

PURPOSE

The aim of this study was to explore patients' experience of participation in the treatment decision of proton beam therapy versus conventional radiotherapy.

BACKGROUND

Proton beam therapy (PBT) has become a treatment option for some cancer patients receiving radiotherapy. The decision to give PBT instead of conventional radiotherapy (CRT) needs to be carefully planned together with the patient to ensure that the degree of participation is based on individuals' preferences. There is a knowledge gap of successful approaches to support patients' participation in the decision-making process, which is particularly important when it comes to the situation of having to choose between two treatment options such as PBT and CRT, with similar expected outcomes.

METHOD

We conducted a secondary analysis of qualitative data collected from interviews with patients who received PBT for their brain tumor. Transcribed verbatims from interviews with 22 patients were analyzed regarding experiences of participation in the decision-making process leading to PBT.

FINDINGS

Participants experienced their participation in the decision-making process to a varying degree, and with individual preferences. Four themes emerged from data: to be a voice that matters, to get control over what will happen, being in the hand of doctors' choice, and feeling selected for treatment.

CONCLUSION

A decision for treatment with PBT can be experienced as a privilege but can also cause stress as it might entail practical issues affecting everyday life in a considerable way. For the patient to have confidence in the decision-making process, patients' preferences, expectations, and experiences must be included by the healthcare team. Including the patient in the healthcare team as an equal partner by confirming the person enables and facilitates for patients' voice to be heard and reckoned with. Person-centered care building on a partnership between patients and healthcare professionals should provide the right basis for the decision-making process.

Using co-design methods to develop new personalised support for people living with Long Covid: The 'LISTEN' intervention

INTRODUCTION

Many Covid-19 survivors are living with unresolved, relapsing and remitting symptoms and no 'one size' of treatment is likely to be effective for everyone. Supported self-management for the varied symptoms of Long Covid (LC) is recommended by the National Institute for Health and Care Excellence in the United Kingdom. We aimed to develop a new personalised support intervention for people living with LC using a structured co-design framework to guide replication and evaluation.

METHODS

We used the improvement methodology, Experience-Based Co-Design, in an accelerated form to harness the collective experiences of people with LC. Incorporating evidence from 'Bridges Self-Management' (Bridges) an approach in which healthcare professionals (HCPs)are trained to support knowledge, confidence and skills of individuals living with long term conditions. Co-designed resources are also central to Bridges. Adults who self-identified as living with or recovered from LC, from England or Wales, aged 18 years and over were recruited, and HCPs, with experience of supporting people with LC. Participants took part in a series of small co-design group meetings and larger mixed meetings to agree priorities, core principles and generate resources and intervention content.

RESULTS

People with LC (n = 28), and HCPs (n = 9) supported co-design of a book (hard-copy and digital form) to be used in 1:1 support sessions with a trained HCP. Co-design stages prioritised stories about physical symptoms first, and psychological and social challenges which followed, nonlinear journeys and reconceptualising stability as progress, rich descriptions of strategies and links to reputable advice and support for navigating healthcare services. Co-design enabled formulation of eight core intervention principles which underpinned the training and language used by HCPs and fidelity assessments.

CONCLUSION

We have developed a new personalised support intervention, with core principles to be used in one-to-one sessions delivered by trained HCPs, with a new co-designed book as a prompt to build personalised strategies and plans using narratives, ideas, and solutions from other people with LC. Effectiveness and cost effectiveness of the 'LISTEN' intervention will be evaluated in a randomised controlled trial set within the context of the updated Framework for Developing and Evaluating Complex Interventions.

PATIENT AND PUBLIC CONTRIBUTION

The LISTEN Public and Patient Involvement (PPI) group comprised seven people living with LC. They all contributed to the design of this study and five members were part of a larger co-design community described in this paper. They have contributed to this paper by interpreting stages of intervention design and analysis of results. Three members of our PPI group are co-authors of this paper.

Shared decision-making for supporting women's decisions about breast cancer screening

BACKGROUND

In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain.

OBJECTIVES

To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health.

MAIN RESULTS

We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured.

AUTHORS' CONCLUSIONS

Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.

Empirical Study on Hospitalist System: A Value Creation Perspective

This study investigates the impact of hospitalist system awareness, motivation, and behavior on value creation within the healthcare context of Taiwan. As population aging and the prevalence of chronic diseases continue to rise, accompanied by increased medical resource consumption, the Taiwan Ministry of Health and Welfare introduced the hospitalist system. Despite its implementation, the number of participating hospitals remains low. Using a questionnaire survey conducted from October 2021 to March 2022, data were collected from medical teams involved in the hospitalist system. A total of 324 valid questionnaires were analyzed. The results reveal that hospitalist awareness positively influences participation motivation (β = 0.846, p < 0.001), which subsequently impacts participation behavior positively (β = 0.888, p < 0.001). Moreover, participation behavior significantly contributes to value creation (β = 0.869, p < 0.001), along with the direct effect of awareness (β = 0.782, p < 0.001) on value creation. In conclusion, the successful promotion and implementation of the hospitalist system rely heavily on the support and active participation of medical staff. Effective interactions and comprehensive information dissemination are essential for maximizing healthcare value creation.

Incorporating parental values in complex paediatric and perinatal decisions

Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.

Flourishing, Mental Health Professionals and the Role of Normative Dialogue

This paper explores the dilemma faced by mental healthcare professionals in balancing treatment of mental disorders with promoting patient well-being and flourishing. With growing calls for a more explicit focus on patient flourishing in mental healthcare, we address two inter-related challenges: the lack of consensus on defining positive mental health and flourishing, and how professionals should respond to patients with controversial views on what is good for them. We discuss the relationship dynamics between healthcare providers and patients, proposing that 'liberal' approaches can provide a pragmatic framework to address disagreements about well-being in the context of flourishing-oriented mental healthcare. We acknowledge the criticisms of these approaches, including the potential for unintended paternalism and distrust. To mitigate these risks, we conclude by suggesting a mechanism to minimize the likelihood of unintended paternalism and foster patient trust.

Shared decision-making in pediatric palliative care

Shared decision-making (SDM) with parents and adolescents is normative in pediatric practice in North America. In this article we discuss how it is applicable to the practice of pediatric palliative care (PPC). As PPC itself is exemplary of patient-and-family-centered care, it often uses a SDM approach in clarifying patient and family preferences, goals, and values. This often occurs in an iterative process and across care environments, wherein the patient and family narrative is elaborated. Decisions are then made incorporating both evidence-based medical practice and the unique attributes and considerations of the patient and family.

Rehabilitation professionals' views on individual peer support interventions for assisting stroke survivors with reintegration into the community: a qualitative study

PURPOSE

We aimed to explore stroke rehabilitation professionals' understanding and representations of peer support; the benefits they anticipated for patients; and the levers and barriers they perceived to implement the intervention in their practice.

MATERIALS AND METHODS

This qualitative study comprised four focus groups with 21 rehabilitation professionals and four semi-structured interviews. It was held in a French hospital. Interpretation was guided by the Consolidated Framework for Implementation Research.

RESULTS

Although professionals had poor knowledge on peer support, they identified many unmet needs of stroke survivors that peer support could meet such as social, emotional and informational support. Main barriers were the lack of human and financial resources, and of linkage between hospital and community professionals, and the fear that peer support would give false hope to survivors if not delivered properly. They showed ambivalence towards patient engagement, acknowledging its importance, but demonstrating top-down attitudes. They also identified potential avenues for the implementation of peer support for stroke survivors.

CONCLUSIONS

Our study supports the necessity to involve professionals in the construction of peer-support interventions and to sensitise them to provide patient-centred care. It delivers insights on effective implementation strategies to develop peer support interventions for stroke survivors reintegrating the community.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study

Background

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making.

Objective

To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection.

Design

Qualitative descriptive study.

Setting

Five outpatient hemodialysis centers in Calgary, Alberta.

Participants

Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists).

Methods

We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective.

Results

While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers.

Limitations

Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study.

Conclusions

Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Shared decision making: audiology student perspectives

Introduction

Shared decision making is a concept in healthcare that actively involves patients in the management of their condition. The process of shared decision making is taught in clinical training programmes, including Audiology, where there are several options for the management of hearing loss. This study sought to explore the perception of Healthcare Science (Audiology) student views on shared decision making.

Methods

Twelve students across all years of the BSc Healthcare Science degree took part in three semi-structured focus groups. Four students were work-based learners, and eight students were enrolled on the standard pathway. Data were analysed using Thematic Analysis.

Results

Students' definition and understanding of shared decision making was influenced by three key factors that were based on using a range of resources, implementation of a decision aid, and recognising Ida Institute as a pinnacle of shared decision making. Students also identified their roles as the future of healthcare workforce and the importance of disseminating best practice.

Conclusion

Shared decision making is valued by students in their roles as healthcare trainees. This study data will enhance teaching practices for healthcare science students in audiology training. Future research involving patient views in clinical training is vital.

"Your son needs help … and we're gonna help him": A qualitative study of the experiences of gun-owning caregivers of adolescents receiving lethal means counseling in the emergency department

Suicide attempts in adolescents are often transient and unpredictable, making preventative approaches crucial in reducing suicide deaths. One important approach is lethal means counseling (LMC), in which clinicians counsel caregivers to reduce access to methods used in suicide, specifically firearms and medications. Research on LMC has increasingly encouraged the use of the shared decision-making (SDM) model, which emphasizes information exchange, collaborative deliberation, and joint planning between caregivers and clinicians. We examine caregivers' experiences with LMC, using the SDM model as our analytic framework. We conducted qualitative interviews with 21 firearm-owning caregivers of adolescents who came to emergency departments (EDs) in Colorado for a behavioral health complaint. The implementation of LMC at these institutions had three central components: training for clinicians, materials (e.g., lockboxes and pamphlets) to support LMC, and the protocolization of LMC at the institution. Our semi-structured, hour-long interviews examined participants' reflections on and reactions to LMC provided in the ED and how that related to changes in their understanding of their medication and gun storage practices. We analyzed interviews using a phenomenological approach, focusing on experiences with LMC and informed by the tenets of the SDM model. Our analysis revealed that caregivers were receptive to the idea of LMC in the pediatric emergency care setting. Caregivers' engagement in LMC was reinforced by experiences with clinicians who sought to understand the circumstances of their household, shared the motivation behind LMC, and facilitated conversation around a shared concern for the child's safety. In contrast, counseling delivered mechanically and without considering the household context was tied to caregivers' confusion and alienation, both for LMC and their consideration of changes to home storage practices. These findings provide insight into adolescent caregivers' experiences with LMC implemented in EDs and how LMC may best be approached.

Real-world use and perceptions of shared decision-making for allergy and asthma care in a US population

Background

Shared decision-making (SDM), the process of engaging patients in their healthcare decisions, is an integral component of personalized medicine. The use of SDM in real-world allergy and asthma care in the United States (US) is unknown. Cross-sectional surveys of allergists and patients in a US population were conducted to assess the use and perceptions of SDM and SDM tools in real-world allergy and asthma care.

Methods

Allergists (N = 101) who were members of the American College of Allergy Asthma & Immunology (ACAAI) and who were also Dynata (a marketing research firm) research partners or in the Allergy & Asthma Network customer database completed an online survey from February-March 2022. Adult patients (N = 110) with asthma, allergy, and/or eczema in the United States who were participants of online research panels hosted by Dynata completed on online survey from February 1-7, 2022.

Results

Based on their own definition, 98% of the allergists reported familiarity with SDM, and 79% reported using it frequently. Allergists reported using SDM with an average of 44% of their patients. The most commonly used tool was the Immunotherapy SDM toolkit (40%); 43% had not used any SDM tool. Among allergists not using SDM or using it infrequently (n = 19), 42% considered it too time-consuming and 37% believed their patients have low health literacy. Of the surveyed patients, 25% reported their provider used SDM "frequently" or "occasionally" when being treated for allergies, asthma, or eczema, and 22% reported using SDM tools with their provider at some point. The most commonly used tool was the Asthma and Allergy Symptom Test (60%). Among patients whose allergists used SDM infrequently or never (n = 56), 70% reported they would be likely to ask their allergist to use SDM more often.

Conclusion

Survey responses revealed a disconnect between allergists and patients regarding SDM use. Barriers to SDM are consistent with those across the healthcare industry. Patients clearly expressed their desire for SDM.

Colorectal cancer treatment guidelines and shared decision making quality and reporting assessment: Systematic review

INTRODUCTION

Physicians must share decisions and choose personalised treatments regarding patients´ beliefs and values.

OBJECTIVE

To analyse the quality of the recommendations about shared decision making (SDM) in colorectal (CRC) and anal cancer treatment clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Guidelines were systematically reviewed following prospective registration (Prospero: CRD42021286146) without language restrictions searching 15 databases and 59 professional society websites from January 2010 to November 2021. A validated 31-item SDM quality assessment tool was employed to extract data in duplicate.

RESULTS

We identified 134 guidelines. Only 46/134 (34.3 %) mentioned SDM. Fifteen (11.1 %) made clear, precise and actionable recommendations, while 9/134 (6.7 %) indicated the strength of the SDM-related recommendations. CPGs underpinned by systematic reviews reported SDM more often than those based on consensus or reviews (35.9 % vs 32.0 %; p = 0.031). Guidelines that reported following quality tools (i.e., AGREE II) more commonly commented about SDM than when it was not reported (75.0 % vs 32.0 %; p = 0.003).

CONCLUSION AND PRACTICE IMPLICATIONS

Most of the CRC and anal treatment guidelines did not mention SDM and it was superficial. Guidelines based on systematic reviews and those using quality tools demonstrated better reporting of SDM. Recommendations about SDM in these guidelines merit urgent improvement.

Interventions for Indigenous Peoples making health decisions: a systematic review

BACKGROUND

Shared decision-making facilitates collaboration between patients and health care providers for informed health decisions. Our review identified interventions to support Indigenous Peoples making health decisions. The objectives were to synthesize evidence and identify factors that impact the use of shared decision making interventions.

METHODS

An Inuit and non-Inuit team of service providers and academic researchers used an integrated knowledge translation approach with framework synthesis to coproduce a systematic review. We developed a conceptual framework to organize and describe the shared decision making processes and guide identification of studies that describe interventions to support Indigenous Peoples making health decisions. We conducted a comprehensive search of electronic databases from September 2012 to March 2022, with a grey literature search. Two independent team members screened and quality appraised included studies for strengths and relevance of studies' contributions to shared decision making and Indigenous self-determination. Findings were analyzed descriptively in relation to the conceptual framework and reported using guidelines to ensure transparency and completeness in reporting and for equity-oriented systematic reviews.

RESULTS

Of 5068 citations screened, nine studies reported in ten publications were eligible for inclusion. We categorized the studies into clusters identified as: those inclusive of Indigenous knowledges and governance ("Indigenous-oriented")(n = 6); and those based on Western academic knowledge and governance ("Western-oriented")(n = 3). The studies were found to be of variable quality for contributions to shared decision making and self-determination, with Indigenous-oriented studies of higher quality overall than Western-oriented studies. Four themes are reflected in an updated conceptual framework: 1) where shared decision making takes place impacts decision making opportunities, 2) little is known about the characteristics of health care providers who engage in shared decision making processes, 3) community is a partner in shared decision making, 4) the shared decision making process involves trust-building.

CONCLUSIONS

There are few studies that report on and evaluate shared decision making interventions with Indigenous Peoples. Overall, Indigenous-oriented studies sought to make health care systems more amenable to shared decision making for Indigenous Peoples, while Western-oriented studies distanced shared decision making from the health care settings. Further studies that are solutions-focused and support Indigenous self-determination are needed.

[Facilitators and barriers to shared decision-making in France in 2021: National survey in cancer]

INTRODUCTION

Shared-decision making (SDM) combines clinical expertise of the healthcare professional with patient's knowledge, values and preferences. This survey explores from a patient perspective, the implementation, facilitators and barriers of SDM in oncology in France in 2021.

PATIENTS AND METHODS

From August to October 2021, the digital platform Cancer contribution conducted an online survey relayed by 11 patient associations.

RESULTS

Out of 916 responses, 727 were analyzed: 394 from patients with hematological malignancies [HM], 185 with breast cancer [BC], 93 with other solid tumors [ST] and 55 with multiple cancers [MC]. Among the participants, 47.2 % reported that they participated in a decision about their health management, with a significant variation according to the pathology (BC 43.8 %, HM 41.1 %, ST 57 %, MC 60 %, P=0.01), and regardless of age and gender. Two-thirds felt comfortable with the shared decision-making process, in relation with the time allocated and the information provided, regardless of the pathology. In addition, emotions, uncertainty and lack of information are the main reasons quoted by patients to explain their lack of ease in making a decision related to their health.

CONCLUSIONS

In this survey, less than half of the patients declared that they have been enrolled in a SDM approach, this rate varying according to the type of solid tumor or hematological malignancy. This study shows that to improve the implementation of SDM in routine clinical practice in cancer, sufficient time and use of decision aids are needed.

Integrating an approach to personalised self-management support in stroke and neurorehabilitation service contexts: People1st - a quality improvement initiative

PURPOSE

People living with stroke and neurological conditions access rehabilitation at different times but self-management is often viewed as what happens post-discharge. Personalised models that integrate self-management support within everyday care are now advocated but this may require practitioners to change their behaviour to adopt and sustain new ways of working. The People1st project evaluated integration of an existing Supported Self-Management programme ("Bridges") across varied stroke and neurorehabilitation service contexts.

MATERIALS AND METHODS

Mixed-method evaluation of training for groups of healthcare practitioners across 24 UK National Health Service (NHS) Trusts, exploring how learning from Bridges was assimilated and enacted in practice, on an individual and collective basis.

RESULTS

Staff growth in confidence and skill around supported self-management was demonstrated. Transformations to practice included changes to: the structure of, and language used in, patient interactions; induction/training processes to increase potential for sustainability; and sharing of successes. Bridges helped practitioners make changes that brought them closer to their professional ideals. Engaged leadership was considered important for successful integration.

CONCLUSIONS

Bridges was successfully integrated within a wide range of stroke and neurorehabilitation service contexts, enabled by an approach in line with practitioners' values-based motivations. Further work is required to explore sustainability and impact on service users. Implications for rehabilitationPersonalised models of care and support for self-management are advocated for people living with stroke and neurological conditions; this requires practitioners to be supported to change behaviour and practices to adopt and sustain new ways of working.Staff from a wide variety of backgrounds in neurorehabilitation and stroke can learn collaboratively about self-management practices via the Bridges programme and can integrate those practices into their service contexts.Bridges can take practitioners closer to their professional ideals of caring and making a difference and empowers them to initiate change.Organisational commitment and engaged leadership are required to facilitate a culture of support for self-management in practice.

On power and its corrupting effects: the effects of power on human behavior and the limits of accountability systems

Power is an all-pervasive, and fundamental force in human relationships and plays a valuable role in social, political, and economic interactions. Power differences are important in social groups in enhancing group functioning. Most people want to have power and there are many benefits to having power. However, power is a corrupting force and this has been a topic of interest for centuries to scholars from Plato to Lord Acton. Even with increased knowledge of power's corrupting effect and safeguards put in place to counteract such tendencies, power abuse remains rampant in society suggesting that the full extent of this effect is not well understood. In this paper, an effort is made to improve understanding of power's corrupting effects on human behavior through an integrated and comprehensive synthesis of the neurological, sociological, physiological, and psychological literature on power. The structural limits of justice systems' capability to hold powerful people accountable are also discussed.

Challenging and Facilitating Factors When Coping with the News of a Newborn's Down Syndrome Diagnosis: Perceptions of Activist Israeli Mothers

Studies have shown that healthcare professionals (HP) play a significant role in parents' experience when informed of the birth of a child with Down Syndrome (DS). Past studies have focused on faith dilemmas of religious mothers that were informed that their child was born with DS and on understanding how faith was a source of emotional support for them. Studies that focus on religious activist mothers are scarce. We utilized a qualitative methodology to explore the experiences of Jewish mothers who are religious and activists. Semistructured interviews and focus groups were conducted with 17 religious Jewish mothers of children with DS, who participated in an activist, self-support group. The data were analyzed using interpretative phenomenological analysis (IPA). Most mothers felt unsupported by the HP although a few mentioned being congratulated on the birth and empowered by a physician who focused on their child's potential to develop. The mothers appreciated when HPs considered their opinions and values. They shared the common goal of changing the existing pathological, statistics-based discourse concerning children with DS. The study reinforces the important role of HP and policymakers' in collaborating with parents and their support groups early in the diagnostic stage.

Using Shared Decision-Making Resources in Long-Term Care: a Qualitative Study

Background

Shared decision-making (SDM) incorporates people's individual preferences and context into individualized, person-centred decisions. Persons living in long-term care (LTC) should only take medications that are a good fit for them as individuals.

Methods

We conducted a pilot study to understand experiences of two LTC homes in Ontario as they tested implementing SDM resources to support medication decisions. LTC homes conducted two Plan-Do-Study-Act (PDSA) cycles supported by an Advisory Group composed of LTC home representatives and stakeholders involved in resource design. Rapid qualitative analysis of transcripts and field notes from Advisory Group meetings elucidated how SDM resources were used.

Results

Each site was positively engaged but implemented resources differently. The pharmacist and physicians at Site 1 introduced proton-pump inhibitor (PPI) deprescribing as their primary intervention, identifying suitable residents, informing residents and families of the deprescribing process, and providing selected SDM resources to residents, caregivers and staff. Representatives reported limited engagement with SDM resources and difficulty measuring the impact of PPI deprescribing. Representatives from Site 2 disseminated the SDM resources to residents and caregivers for use at care conferences and focused on front-line staff education and involvement. This site reported that some residents/caregivers were interested in participating in SDM and using the resources, while others were not. The impact of the resources on SDM at this site was unclear.

Conclusions

Within the context of LTC, further research is needed to clarify the meaning and importance of SDM in medication decision-making. Implementation of SDM will likely require a multi-faceted approach.

Assessing the impact of patient-involvement healthcare strategies on patients, providers, and the healthcare system: A systematic review

BACKGROUND

Patient involvement has become an important and lively field of research, yet existing findings are fragmented and often contested. Without a synthesis of the research field, these findings are of limited use to scholars, healthcare providers, or policy-makers.

OBJECTIVE

Examine the body of knowledge on patient involvement to determine what is known, contested, and unknown about benefits, risks, and effective implementation strategies.

PATIENT INVOLVEMENT

Patients were not involved.

METHODS

Systematic literature review of 99 journal articles using a conceptual model integrating three levels: health systems, health providers, and patients. We extracted individual research findings and organized them into the structure of our model to provide a holistic picture of patient involvement.

RESULTS

The review highlights overlaps and conflicts between various patient involvement approaches. Our results show benefits for individual patients and the health system as a whole. At the provider level, however, we identified clear barriers to patient involvement.

DISCUSSION

Patient involvement requires collaboration among health systems, healthcare providers, and patients. We showed that increasing patient responsibility and health literacy requires policy-maker interventions. This includes incentives for patient education by providers, adapting medical education curricula, and building a database of reliable health information and decision support for patients. Furthermore, policies supporting a common infrastructure for digital health data and managed patient data exchange will foster provider collaboration.

PRACTICAL VALUE

Our review shows how an approach integrating health systems, healthcare providers, and patients can make patient involvement more effective than isolated interventions. Such systematic patient involvement is likely to improve population health literacy and healthcare quality.

Outpatient clinic specific for end-stage renal disease improves patient survival rate after initiating dialysis

The importance of a shared decision-making (SDM) approach is widely recognized worldwide. In Japan, hospital accreditation involves the promotion of SDM for patients with end-stage renal disease (ESRD) when considering renal replacement therapy (RRT). This study aimed to clarify the effectiveness and long-term medical benefits of SDM in RRT. Patients with ESRD who underwent dialysis therapy were retrospectively divided into those who visited outpatient clinics specific for ESRD (ESRD clinic) supporting RRT selection with an SDM approach (visited group) and those who did not visit the ESRD clinic (non-visited group). Data of 250 patients (129 in the non-visited group and 121 in the visited group) were analyzed. Mortality was significantly higher in the non-visited group than in the visited group. Not seeing an ESRD specialist was associated with emergent initiation of dialysis and subsequent 1 year mortality. The number of patients who chose peritoneal dialysis as a modality of RRT was significantly larger in the visited group. These findings demonstrate the association between the ESRD clinic, 1 year survival in patients with ESRD after initiating dialysis, and the different RRT modalities. This specific approach in the ESRD clinic may improve the management of patients with ESRD.

A survey of patient education practices and perceptions of physiotherapists: a mixed methods study

INTRODUCTION

Patient education is an integral part of physiotherapy practice. The use of patient education and the adoption of a patient-centered approach to education has not been examined in a European setting.

OBJECTIVE

To explore the frequency and perceived importance of patient education practices of physiotherapists in Iceland.

METHODS

A convergent mixed methods study design was utilized. A cross-sectional, web-based survey was completed by 216 physiotherapists (35.1% response rate). Transformed qualitative data played a secondary role to quantitative results measuring frequencies of use and perceived importance of a spectrum of patient education practices.

RESULTS

Providing exercise and diagnostic information had the highest rated frequency and importance. Advising on social support and having the patient explain why their home exercises were important were rated lowest. A large difference was reported between frequency and importance when collaborating with patients on goal-setting. Therapists reported delivering education through discussions and physical demonstrations, while relying on visual cues and return demonstrations to evaluate education effectiveness. Patient-specific education, including preferred learning style, was not always considered. The highest-rated barriers to patient education were patient characteristics that were psychosocial in nature. Results regarding readiness for education indicated needs to assess patient motivation while managing external barriers.

CONCLUSION

The results indicate that physiotherapists engage in a wide variety of patient education activities that they consider important. Barriers to patient education identified by therapists may be managed by further skill development in a collaborative patient-centered approach to patient education.

Effectiveness of Interactive Digital Decision Aids in Prenatal Screening Decision-making: Systematic Review and Meta-analysis

BACKGROUND

Increasing prenatal screening options and limited consultation time have made it difficult for pregnant women to participate in shared decision-making. Interactive digital decision aids (IDDAs) could integrate interactive technology into health care to a facilitate higher-quality decision-making process.

OBJECTIVE

The objective of this study was to assess the effectiveness of IDDAs on pregnant women's decision-making regarding prenatal screening.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and reference lists of included studies until August 2021. We included the randomized controlled trials (RCTs) that compared the use of IDDAs (fulfilling basic criteria of International Patient Decision Aid Standards Collaboration and these were interactive and digital) as an adjunct to standard care with standard care alone and involved pregnant women themselves in prenatal screening decision-making. Data on primary outcomes, that is, knowledge and decisional conflict, and secondary outcomes were extracted, and meta-analyses were conducted based on standardized mean differences (SMDs). Subgroup analysis based on knowledge was performed. The Cochrane risk-of-bias tool was used for risk-of-bias assessment.

RESULTS

Eight RCTs were identified from 10,283 references, of which 7 were included in quantitative synthesis. Analyses showed that IDDAs increased knowledge (SMD 0.58, 95% CI 0.26-0.90) and decreased decisional conflict (SMD -0.15, 95% CI -0.25 to -0.05). Substantial heterogeneity in knowledge was identified, which could not be completely resolved through subgroup analysis.

CONCLUSIONS

IDDAs can improve certain aspects of decision-making in prenatal screening among pregnant women, but the results require cautious interpretation.

"It's That They Treated Me Like an Object": A Qualitative Study on the Participation of People Diagnosed with Psychotic Disorders in Their Health Care

The mental health recovery model is based on shared decision making, in which patients' preferences and perceptions of the care received are taken into account. However, persons with psychosis usually have very few opportunities to participate in this process. The present study explores the experiences and perceptions of a group of patients with psychosis-in some cases longstanding, in others more recently diagnosed-concerning their participation in the decisions taken about the approach to their condition and about the attention received from healthcare professionals and services. For this purpose, we performed a qualitative analysis of the outcomes derived from five focus groups and six in-depth interviews (36 participants). Two major themes, with five sub-themes, were identified: shared decision-making (drug-centred approach, negotiation process, and lack of information) and the care environment and styles of clinical practice as determinants (aggressive versus person-centred environments, and styles of professional practice). The main conclusions drawn are that users want to participate more in decision making, they want to be offered a range of psychosocial options from the outset and that their treatment should be based on accessibility, humanity and respect. These findings are in line with the guidelines for clinical practice and should be taken into account in the design of care programmes and the organisation of services for persons with psychosis.

Problem-based shared decision-making in diabetes care: a secondary analysis of video-recorded encounters

OBJECTIVES

To describe the range of collaborative approaches to shared decision-making (SDM) observed in clinical encounters of patients with diabetes and their clinicians.

DESIGN

A secondary analysis of videorecordings obtained in a randomised trial comparing usual diabetes primary care with or without using a within-encounter conversation SDM tool.

SETTING

Using the purposeful SDM framework, we classified the forms of SDM observed in a random sample of 100 video-recorded clinical encounters of patients with type 2 diabetes in primary care.

MAIN OUTCOME MEASURES

We assessed the correlation between the extent to which each form of SDM was used and patient involvement (OPTION12-scale).

RESULTS

We observed at least one instance of SDM in 86 of 100 encounters. In 31 (36%) of these 86 encounters, we found only one form of SDM, in 25 (29%) two forms, and in 30 (35%), we found ≥3 forms of SDM. In these encounters, 196 instances of SDM were identified, with weighing alternatives (n=64 of 196, 33%), negotiating conflicting desires (n=59, 30%) and problemsolving (n=70, 36%) being similarly prevalent and developing existential insight accounting for only 1% (n=3) of instances. Only the form of SDM focused on weighing alternatives was correlated with a higher OPTION12-score. More forms of SDM were used when medications were changed (2.4 SDM forms (SD 1.48) vs 1.8 (SD 1.46); p=0.050).

CONCLUSIONS

After considering forms of SDM beyond weighing alternatives, SDM was present in most encounters. Clinicians and patients often used different forms of SDM within the same encounter. Recognising a range of SDM forms that clinicians and patients use to respond to problematic situations, as demonstrated in this study, opens new lines of research, education and practice that may advance patient-centred, evidence-based care.

Patient-reported outcomes for congenital diaphragmatic hernia: A qualitative study

OBJECTIVE

To identify Patient-reported outcomes (PROs) for parents with a lived experience of a prenatal diagnosis of isolated congenital diaphragmatic hernia (CDH).

METHOD

Thematic analysis of in-depth interview transcripts.

RESULTS

Interviews (n = 26) identified 11 PROs for given time points throughout the CDH trajectory. At the time of diagnosis, acceptable quality of life was selected as relevant PRO to decide whether to continue or terminate the pregnancy. During pregnancy, (neonatal) survival chances and the eligibility for foetal therapy were prominent outcomes with foetal and maternal complications adding distress. After birth, postnatal management options became the next milestone. When survival was deemed likely, post-hospital discharge complications and future care for infant and child became important. In retrospect, impact on family, bonding, parental mental health, and parental satisfaction with care were reported as relevant outcomes.

CONCLUSION

PROs are relevant in addition to hard medical outcomes, as they help parents to make decisions suiting their unique needs and personal situation. Given the knowledge inherently related to the parent's perspective, our findings provide relevant directions for clinicians to support parents and their family in facing challenging decisions in healthcare. The outcomes impacting parents are essential to prepare parents for the steep journey ahead.

Effect of communication skills training on documentation of shared decision-making for patients with life-limiting illness: An observational study in an intensive care unit

Objectives

This article aims to examine the association between a shared decision-making (SDM) clinical communication training program and documentation of SDM for patients with life-limiting illness (LLI) admitted to intensive care.

Methods

This article used a prospective, longitudinal observational study in a tertiary intensive care unit (ICU). Outcomes included the proportion of patients with SDM documented on an institutional Goals of Care Form during hospital admission, as well as characteristics, outcomes, and factors associated with an SDM admission.

Intervention

Clinical communication skills training (iValidate) and clinical support program are the intervention for this study.

Results

A total of 325 patients with LLI were admitted to the ICU and included in the study. Overall, 184 (57%) had an SDM admission, with 79% of Goals of Care Form completed by an iValidate-trained doctor. Exposure to an iValidate-trained doctor was the strongest predictor of an ICU patient with LLI having an SDM admission (odds ratio: 22.72, 95% confidence interval: 11.91-43.54, p < 0.0001). A higher proportion of patients with an SDM admission selected high-dependency unit-level care (29% vs. 12%, p < 0.001) and ward-based care (36% vs. 5%, p < 0.0001), with no difference in the proportion of patients choosing intensive care or palliative care. The proportion of patients with no deterioration plan was higher in the non-SDM admission cohort (59% vs. 0%, p < 0.0001).

Conclusions

Clinical communication training that explicitly teaches identification of patient values is associated with improved documentation of SDM for critically ill patients with LLI. Understanding the relationship between improved SDM and patient, family, and clinical outcomes requires appropriately designed high-quality trials randomised at the patient or cluster level.

Practical Guidance for Healthcare Providers on Collaborating with People with Type 2 Diabetes: Advancing Treatment and Initiating Injectable Therapy

Type 2 diabetes (T2D) progresses over time, and to achieve and maintain adequate glucose control, many people eventually require injectable therapies such as insulin. However, there can be significant barriers to the initiation of these medications, both from people living with T2D and from healthcare practitioners (HCPs). Misconceptions and misinformation relating to the potential risks and benefits of injectable therapies are common and can contribute to negative perceptions regarding their use. Additionally, HCPs are often unaware of the emotional burden associated with T2D. In particular, diabetes distress is a key contributory factor that needs to be addressed to alleviate fears before diabetes education can be successful. The onus is often on the HCP to initiate effective, individualized communication with each patient and make that person feel an active and equal participant in the management of their T2D. Shared decision-making has been demonstrated to improve understanding of the pathophysiology and treatment options, to increase risk awareness, adherence, and persistence, and to improve self-management behaviors (e.g., exercise, self-care) and patient satisfaction. While therapeutic inertia can result from both patient and HCP, HCPs need to bear the responsibility for escalating therapy when necessary. A proactive approach by the HCP, combined with shared decision-making and a patient-centric approach, are important for optimal T2D management; therefore, an open and effective relationship between the HCP and the person living with T2D is essential. This article is written by a person with T2D, a nurse practitioner/Certified Diabetes Care and Education Specialist, and a clinical endocrinologist, with the goal of providing a holistic view of the management experience, exploring patient needs and expectations, recognizing and avoiding HCP and patient barriers, and providing practical advice to HCPs to empower patients who would benefit from injectable therapy.Infographic and video abstract available for this article.

Survey of patients and physicians on shared decision-making in treatment selection in relapsed/refractory multiple myeloma

Shared decision-making (SDM) is a key component of patient-centered healthcare. SDM is particularly pertinent in the relapsed and/or refractory multiple myeloma (RRMM) setting, in which numerous treatment options can present challenges for identifying optimal care. However, few studies have assessed the extent and relevance of SDM and patient-centered communication (PCC) in RRMM. To describe treatment decision-making patterns between physicians and patients in the RRMM setting, we conducted online surveys of patients and physicians in the USA to compare their perspectives on the process of treatment decision-making. We analyzed the surveys descriptively. Two hundred hematologists/oncologists and 200 patients with RRMM receiving second-line (n = 89), third-line (n = 65), and fourth-line (n = 46) therapy participated. Top treatment goals for physicians and patients included extending overall survival (among 76% and 83% of physicians and patients, respectively) and progression-free survival (among 54% and 77% of physicians and patients, respectively), regardless of the number of prior relapses. Thirty percent of physicians believed patients preferred a shared approach to treatment decision-making, while 40% of patients reported most often preferring a shared role in treatment decision-making. One-fourth of patients most often preferred physicians to make the final treatment decision after seriously considering their opinion. Thirty-two percent of physicians and 16% of patients recalled ≥3 treatment options presented at first relapse. Efficacy was a primary treatment goal for patients and physicians. Discrepancies in their perceptions during RRMM treatment decision-making exist, indicating that communication tools are needed to facilitate SDM and PCC.

Decision Aids for Decision Making about Locally Advance Breast Cancer: A Systematic Review

Locally advanced breast cancer (LABC) is a subset of breast cancer with locoregional progression without distant metastasis. The multimodality treatment (surgery, chemotherapy, radiotherapy, hormonal and targeted therapy if required) could significantly improve results in this specific group of patients. The complex and multiple options of treatment with similar mortality rates but different outcomes depending on the patient's desires, preferences and social environment require aid to facilitate the individual patient's decisions (e.g. Decision Aids (DAs) targeting patients considering primary or adjuvant treatment in LABC). In this context, DAs have been proven fundamental to help patients and clinicians share and agree on the best value option. The current systematic review aimed to evaluate the existing DAs related to these patients with LABC and identify current status and possible improvement areas (possible scarcity and heterogeneity of instruments, the status of their development, explanation of their purpose,…). No previous systematic reviews have been published on this topic. Following Prospero registration no: CRD42021286173, studies about LABC DAs were identified, without data or language restrictions, through a systematic search of bibliographic databases in December 2021. Quality was assessed using Qualsyst criteria (range 0.0-1.0). The quality of the 17 selected studies ranged from 0.46 to 0.95. Of them, 14/17 (82%) were DAs about treatment, only one (6%) about diagnosis, and 2/17 (12%) about the employment of DAs. No screening or follow-up DAs were retrieved. Twelve (70.6%) DAs were online tools. They varied broadly regarding their characteristics and purposes. Most of the studies focused on developing and testing different DAs (5/17; 29.4%) and their impact (7/17; 41.2%). Only 4/17 (23.5%) analysed their implementation and cost. These instruments have proven to improve patient's knowledge and decision-making, decrease patient anxiety, and patients tend to undergo treatment. However, nowadays, there is still a need for further research and consensus on methodology to develop practical DAs.

Implementation of a patient-centered mobile shared decision making platform and healthcare workers' evaluation: a case in a medical center

Shared decision making is a patient-centered clinical decision-making process that allows healthcare workers to share the existing empirical medical outcomes with patients before making critical decisions. This study aims to explore a project in a medical center of developing a mobile SDM in Taiwan. Chi Mei Medical Center developed the mobile SDM platform and conducted a survey of evaluation from healthcare workers. A three-tier platform that based on cloud infrastructure with seven functionalities was developed. The survey revealed that healthcare workers with sufficient SDM knowledge have an antecedent effect on the three perceptive factors of acceptance of mobile SDM. Resistance to change and perceived ease of use show significant effect on behavioral intention. We provided a comprehensive architecture of mobile SDM and observed the implementation in a medical center. The majority of healthcare workers expressed their acceptancem; however, resistance to change still present. It is, therefore, necessary to be eliminated by continuously promoting activities that highlight the advantages of the Mobile SDM platform. In clinical practice, we validated that the mobile SDM provides patients and their families with an easy way to express their concerns to healthcare workers improving significantly their relationship with each other.

Sharing decision-making between the older person and the nurse: A scoping review

BACKGROUND

Sharing decision-making is globally recognised as an important concept in healthcare research, policy, education and practice which enhances person-centred care. However, it is becoming increasingly evident shared decision-making has not been successfully translated into everyday healthcare practice. Sharing decision-making has strong links with person-centred practice. Core to person-centredness and shared decision making, is the need to recognise that as we age, greater reliance is placed on emotion and life experience to inform decision making processes. With the world's ageing population, older persons facing more complex decisions and transitions of care, it is more important than ever it is understood how shared decision-making occurs.

OBJECTIVES

This scoping literature review aims to find out how sharing decision making between nurses and older persons in healthcare settings is understood and presented in published literature.

METHODS

This scoping review utilised the Arksey and O'Malley methodological framework, advanced by Levac et al. Electronic databases and grey literature were searched, returning 362 records which were examined against defined inclusion criteria. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Twenty-two records met inclusion criteria for the review. Results indicate while shared decision-making is included in research, education and policy literature, it has not been effectively translated to inform practice and the relationship between a nurse and an older person. The records lack definitions of shared decision-making and theoretical or philosophical underpinnings. There is also no consideration of emotion and life experience in decision-making and how nurses 'do' shared decision-making with older persons.

CONCLUSIONS

The findings demonstrate sharing decision-making between nurses and older persons is not well understood in the literature, and therefore is not translated into nursing practice. Further research is needed.

A systematic review of shared decision making interventions in child and youth mental health: synthesising the use of theory, intervention functions, and behaviour change techniques

Reviews around interventions to improve shared decision making (SDM) for child and youth mental health have produced inconclusive findings on what approaches increase participation. Importantly, the previous reviews did not explore the use of theory, as well as mechanisms of change (intervention functions) and active units of change (behaviour change techniques). The aim of this review was to explore these factors and ascertain how, if at all, these contribute to SDM. Five databases were searched up until April 2020. Studies met inclusion criteria if they were: (a) an intervention to facilitate SDM; (b) aimed at children, adolescence, or young people aged up to 25, with a mental health difficulty, or their parents/guardians; and (c) included a control group. Data were extracted on patient characteristics, study design, intervention, theoretical background, intervention functions, behaviour change techniques, and SDM. Quality assessment of the studies was undertaken using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Eight different interventions met inclusion criteria. The role of theory to increase SDM remains unclear. Specific intervention functions, such as 'education' on SDM and treatment options and 'environmental restructuring' using decision aids, are being used in SDM interventions, as well as 'training' for clinicians. Similarly, behaviour change techniques linked to these, such as 'adding objects to the environment', 'discussing pros/cons', and clinicians engaging in 'behavioural practice/rehearsal'. However, as most studies scored low on the quality assessment criteria, as well as a small number of studies included and a low number of behaviour change techniques utilised, links between behaviour change techniques, intervention functions and increased participation remain tentative. Intervention developers and clinicians may wish to consider specific intervention functions and behaviour change techniques to facilitate SDM.

Comprehensive Implementation of Shared Decision Making in a Neuromedical Center Using the SHARE TO CARE Program

PURPOSE

SHARE TO CARE (S2C) is a comprehensive, multi-module implementation program for shared decision making (SDM). It is currently applied at the University Hospital Schleswig-Holstein in Kiel, Germany, and among general practitioners at the Federal State of Bremen. This study examines the results of the full implementation of S2C in terms of effectiveness within the Kiel Neuromedical Center comprising the departments of neurology and neurosurgery.

METHOD AND DESIGN

The S2C program consists of four combined intervention modules: 1) multimodal training of physicians; 2) a patient activation campaign including the ASK-3 method; 3) digital evidence-based patient decision aids; and 4) SDM support by nurses, e.g., as decision coaches. The SDM level before and immediately after implementation was retrospectively assessed in consecutively selected patients on the subscale "Patient Decision Making" of the Perceived Involvement in Care Scale (PICS_PDM). Mean scores were compared with t-tests.

RESULTS

Eighty-nine percent of all physicians (N = 56) completed the SDM training. We developed a total of 12 evidence-based digital decision aids in the center, educated two decision coaches to support patients' decision processes by using decision aids. Physicians adjusted patients' pathways to incorporate the use of decision aids. Patients (n = 261) reported a significant increase in participation (p<0.001; Hedges' g = 0.49) in medical decision making.

CONCLUSION

The S2C program has been successfully implemented within the entire Neuromedical Center. Patients reported a medium to small increase of perceived involvement in decision making demonstrating the effectiveness of the implementation. For future research, it might be interesting to investigate the sustainability of the effects of S2C. In addition, it seems useful to complement the patient-based evaluation with observer-based data.

'What you suggest is not what I expected': How pre-consultation expectations affect shared decision-making in patients with low back pain

OBJECTIVE

Existing studies on shared decision-making (SDM) have hardly taken into consideration that patients could have independently developed expectations prior to their consultation with a healthcare provider, nor have studies explored how such expectations affect SDM. Therefore, we explore how pre-consultation expectations affect SDM in patients with low back pain.

METHODS

We performed a qualitative study through telephone interviews with 10 patients and seven care professionals (physicians, nurse, physician assistants) and 63 in-person observations of patient-physician consultations in an outpatient clinic in the Netherlands. Transcripts were analyzed through an open coding process.

RESULTS

A discrepancy existed between what patients expected and what care professionals could offer. Professionals perceived they had to undertake additional efforts to address patients' 'unrealistic' expectations while attempting SDM. Patients, in turn, were often dissatisfied with the outcomes of the SDM encounter, as they believed their own expectations were not reflected in the final decision.

CONCLUSION

Unaddressed pre-consultation expectations form a barrier to constructive SDM encounters.

PRACTICAL IMPLICATIONS

Patients' pre-consultation expectations need to be explored during the SDM encounter. To achieve decisions that are truly shared by care professionals and patients, patients' pre-consultation expectations should be better incorporated into SDM models and education.

Exploring clinician perspectives on patients with atrial fibrillation who are not prescribed anticoagulation therapy

Objective

To explore themes underlying why anticoagulants are under-prescribed for stroke prevention in atrial fibrillation (AF) patients from the clinician's perspective and characteristics of those patients.

Methods

Clinicians at the University of Utah Health system were recruited for semi-structured 15-minute interviews. An interview guide focused on anticoagulant prescribing practices for patients with AF. Interviews were transcribed verbatim. Two reviewers independently coded passages corresponding with key themes.

Results

Eleven practitioners were interviewed from cardiology, internal medicine, and family practice. Five themes were found: the role of compliance in anticoagulation decision making, the role of pharmacists in supporting clinicians, the use of shared decision making and risk communication, risk of bleeding as the main barrier to taking anticoagulants, and the variety of reasons patients have for not starting or discontinuing anticoagulants.

Conclusion

Fear of bleeding was the foremost reason underlying anticoagulant underutilization in patients with AF followed by compliance, and patient worries. Communication between patients and clinicians as well as interdisciplinary teamwork are key to understanding and improving anticoagulant prescribing in AF.

Innovation

Our study was the first to assess the role pharmacists play in prescribing clinician's decisions surrounding anticoagulant use in AF. Pharmacists could play an important collaborative role in SDM.

Cross-sectional analysis of generational differences in pain attitudes and beliefs of patients receiving physical therapy care in outpatient clinics

BACKGROUND

Musculoskeletal pain is a common reason to seek outpatient physical therapy care. Generational differences regarding attitudes and beliefs have been found in many areas, but it has not been explored regarding pain.

OBJECTIVES

This study aimed to examine generational differences in attitudes and beliefs regarding pain and the potential differences between beneficial and non-beneficial treatment options in patients receiving care in outpatient physical therapy clinics.

DESIGN

Cross-sectional descriptive survey.

METHOD

A survey was developed to explore attitudes, beliefs, and treatment preferences. The survey was emailed out to past and current physical therapy patients as part of the customer satisfaction survey over a four-month period.

RESULTS/FINDINGS

2260 surveys were completed during the collection period. Generational differences were found between the different generational groups. Younger generations were more in line with current pain neuroscience, understanding that pain is normal and part of the survival mechanism and less likely to believe that pain meant something wrong with one's tissues. Younger generations also reported more agreeance to the ability to cope without medication. However, significant variations existed in treatment choices that were most beneficial and least beneficial between respondents.

CONCLUSION

Generational differences do exist in some areas of pain attitudes and beliefs. Less variation was noted in treatment options between generations, but there were significant variations within all patient respondents.

Patients' experiences with an audio-visual intervention, the use of a tailored explanimation video in patients with bladder cancer

Objective

This qualitative study explored the experiences of patients with bladder cancer with a tailored 'explanimation' video (EV) as a supportive information tool used before and during treatment.

Methods

Using a qualitative approach, data were collected through semi-structured interviews with 12 patients with bladder cancer and thematically analysed.

Results

Participants advised future use of the EV, noting it is user friendly and has a fitting difficulty level and clarifying animations. However, some mentioned practical information on 'life after treatment' was lacking, and some emphasized the importance of choosing the right moment of delivery. Patients' experiences were described in four major themes: taking own responsibility, providing opportunity for postponed information supply, easing decision-making processes and gaining a sense of calm.

Conclusion

Findings indicate the EV supported patients with bladder cancer in the process of being informed and in decision-making. Future use of the EV in the treatment of patients with bladder cancer is recommended.

Innovation

The use of audiovisual information in patient education is innovative. Tailored audiovisual information in shape of the EV is a step forward in streamlining information processes, meeting individual preferences and highlighting the most important general information for patients with bladder cancer.

Healthcare providers' and policymakers' experiences and perspectives on barriers and facilitators to chronic disease self-management for people living with hypertension and diabetes in Cameroon

BACKGROUND

Hypertension and diabetes are chronic noncommunicable diseases ranked among the leading causes of morbidity and mortality in resource-limited settings. Interventions based on patient empowerment (PE) have been shown to be effective in the management of these diseases by improving a variety of important health outcomes. This study aims to examine from the healthcare providers' and policymakers' experiences and perspectives, the facilitators and barriers in the management of hypertension and diabetes for patient empowerment to achieve better health outcomes in the context of the healthcare system in Cameroon.

METHODS

We carried out a qualitative study involving three levels of embedded analysis in a public primary healthcare delivery system in Cameroon, through 22 semi-structural interviews with healthcare providers and policymakers and 36 observations of physicians' consultations. We combined thematic and lexicometric analyses to identify robust patterns of differences and similarities in the experiences and perspectives of healthcare providers and policymakers about direct and indirect factors associated with patients' self-management of disease.

RESULTS

We identified 89 barriers and 42 facilitators at the central, organizational, and individual levels; they were preponderant at the organizational level. Factors identified by healthcare providers mainly related to self-management of the disease at the organizational and individual levels, whereas policymakers reported factors chiefly at the central and organizational levels. Healthcare providers involved in the decision-making process for the delivery of healthcare tended to have a sense of ownership and responsibility over what they were doing to help patients develop self-management abilities to control their disease.

CONCLUSION

While interventions focused on improving patient-level factors are essential to PE, there is a need for interventions paying more attention to organizational and political barriers to PE than so far. Interventions targeting simultaneously these multilevel factors may be more effective than single-level interventions.

Patient views on asthma diagnosis and how a clinical decision support system could help: A qualitative study

INTRODUCTION

Making a diagnosis of asthma can be challenging for clinicians and patients. A clinical decision support system (CDSS) for use in primary care including a patient-facing mode, could change how information is shared between patients and healthcare professionals and improve the diagnostic process.

METHODS

Participants diagnosed with asthma within the last 5 years were recruited from general practices across four UK regions. In-depth interviews were used to explore patient experiences relating to their asthma diagnosis and to understand how a CDSS could be used to improve the diagnostic process for patients. Interviews were audio recorded, transcribed verbatim and analysed using a thematic approach.

RESULTS

Seventeen participants (12 female) undertook interviews, including 14 individuals and 3 parents of children with asthma. Being diagnosed with asthma was generally considered an uncertain process. Participants felt a lack of consultation time and poor communication affected their understanding of asthma and what to expect. Had the nature of asthma and the steps required to make a diagnosis been explained more clearly, patients felt their understanding and engagement in asthma self-management could have been improved. Participants considered that a CDSS could provide resources to support the diagnostic process, prompt dialogue, aid understanding and support shared decision-making.

CONCLUSION

Undergoing an asthma diagnosis was uncertain for patients if their ideas and concerns were not addressed by clinicians and were influenced by a lack of consultation time and limitations in communication. An asthma diagnosis CDSS could provide structure and an interface to prompt dialogue, provide visuals about asthma to aid understanding and encourage patient involvement.

PATIENT AND PUBLIC CONTRIBUTION

Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team and piloted with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Findings were regularly discussed within the research group and with PPI colleagues to aid the interpretation of data.