Training Interventions to Equip Health Care Professionals With Shared Decision-Making Skills: A Systematic Scoping Review

Co-creation of a health literate-sensitive training and conversation aid to support shared decision-making in maternity care

Background

Maternity care increasingly aims to achieve Shared Decision-making (SDM), yet seemingly not to the benefit of clients with low health literacy (HL). We developed an SDM training for healthcare professionals (HCPs) and a conversation aid to support HL-sensitive SDM in maternity care.

Methods

The training and conversation aid were based on previous needs assessments and expert consultation, and were developed in co-creation with clients (n = 15) and HCPs (n = 7). Usability, acceptability and comprehension of the conversation aid were tested among new clients (n = 14) and HCPs (n = 6). Acceptability of the training was tested among midwifery students (n = 5).

Results

In the co-creation sessions, clients reported to expect that their midwife becomes acquainted with their general values, priorities and daily context. Clients also emphasized wanting to be supported in their preferred decisional role. User test interviews showed that clients and HCPs were positive towards using the conversation aid, but also apprehensive about the time it required. The user test of the training showed that more attention was needed for recognizing and adapting information provision to clients' HL level.

Conclusion and innovation

The newly developed conversation aid and training have potential to support HCPs and clients in HL-sensitive SDM.

Assessing the educational quality of shared decision-making interventions for residents: A systematic review

OBJECTIVES

Many studies on educational interventions to enhance residents' shared decision-making (SDM) skills show limited improvement in SDM skills and clinical outcomes. One plausible explanation for these suboptimal results is the insufficient emphasis on the educational quality of training interventions.

METHODS

This review evaluates interventions' educational quality using an evaluation framework based on a previous study on effective skills transfer and a well-known SDM model. A systematic review was conducted, searching three databases until December 13, 2022. We assessed study quality by calculating MERSQI scores, examined the levels of study effects based on Kirkpatrick's model, and applied our evaluation framework to assess the interventions' educational quality. Given the heterogeneity among the studies, a meta-analysis was not feasible.

RESULTS

Twenty-six studies were included. Role-play and feedback were common training characteristics (65% and 54% of interventions). Only four studies (15%) met our framework's high educational quality threshold. No correlation was found between MERSQI scores and educational quality.

CONCLUSIONS

This review is a valuable attempt to assess the educational quality of SDM interventions beyond measuring study outcomes.

PRACTICE IMPLICATIONS

Future evaluation frameworks should consider study results, training characteristics, and training content. Our framework offers a sound basis for such an evaluation framework.

Changes in intention to use an interprofessional approach to decision-making following training: a cluster before-and-after study

BACKGROUND

Health professionals in home care work in interprofessional teams. Yet most training in decision support assumes a one-on-one relationship with patients. We assessed the impact of an in-person training session in interprofessional shared decision-making (IP-SDM) on home care professionals' intention to adopt this approach.

METHODS

We conducted a secondary analysis of a cluster stepped-wedge trial using a before-and-after study design. We collected data among home care professionals from November 2016 to February 2018 in 9 health and social services centers in Quebec, Canada. The intervention was an in-person IP-SDM training session. Intention to engage in IP-SDM pre- and post-session (dependent variable) was compared using a continuing professional development evaluation scale (CPD-Reaction) informed by the Godin's Integrated Behavioral Model for health professionals. We also assessed socio-demographic and psychosocial variables (beliefs about capabilities, beliefs about consequences, social influence and moral norm). We performed bivariate and multivariate analysis to identify factors influencing post-intervention intention. We used the STROBE reporting guidelines for observational studies to report our results.

RESULTS

Of 134 respondents who provided complete pairs of questionnaires (pre- and post-), most were female (90.9%), mean age was 42 (± 9.3) years and 66.9% were social workers. Mean intention scores decreased from 5.84 (± 1.19) to 5.54 (± 1.35) (Mean difference = -0.30 ± 1.16; p = 0.02). Factors associated with higher intention post-intervention were social influence (ß = 0.34, p = 0.01) and belief about capabilities (ß = 0.49, p < 0.01).

CONCLUSION

After in-person IP-SDM training, healthcare professionals' intention to engage in IP-SDM decreased. However, the scope of this decrease is probably not clinically significant. Due to their association with intention, beliefs about capabilities, which translate into having a sense of self-competency in the new clinical behavior, and social influences, which translate into what important others think one should be doing, could be targets for future research aiming to implement IP-SDM in home care settings.

The Impact of Involvement in Whole Health System for Veterans or Participating in It for Oneself on Job Attitudes in VA Employees

OBJECTIVE

The aim of the study is to examine how involvement in the Whole Health System of care, clinically and personally (through employee-focused activities), would affect employee satisfaction, engagement, burnout, and turnover intent in the Veterans Health Administration.

METHODS

Multivariate logistic regression analysis of cross-sectional survey from Veterans Health Administration employees was used to determine the influence of Whole Health System involvement and Employee Whole Health participation on job attitudes.

RESULTS

Whole Health System involvement was associated higher job satisfaction, higher levels of engagement, lower burnout, and lower turnover intent. A similar pattern of results was identified when looking specifically at Employee Whole Health participation and associated job attitudes.

CONCLUSIONS

Employees who are either directly involved in delivering Whole Health services to veterans or who have participated in Whole Health programming for their own benefit may experience a meaningful positive impact on their well-being and how they experience the workplace.

Talking, not training, increased the accuracy of physicians' diagnosis of their patients' preferences for colon cancer screening

OBJECTIVE

Identify if primary care physicians (PCPs) accurately understand patient preferences for colorectal cancer (CRC) testing, whether shared decision making (SDM) training improves understanding of patient preferences, and whether time spent discussing CRC testing improves understanding of patient preferences.

METHODS

Secondary analysis of a trial comparing SDM training plus a reminder arm to a reminder alone arm. PCPs and their patients completed surveys after visits assessing whether they discussed CRC testing, patient testing preference, and time spent discussing CRC testing. We compared patient and PCP responses, calculating concordance between patient-physician dyads. Multilevel models tested for differences in preference concordance by arm or time discussing CRC.

RESULTS

382 PCP and patient survey dyads were identified. Most dyads agreed on whether CRC testing was discussed (82%). Only 52% of dyads agreed on the patient's preference. SDM training did not impact accuracy of PCPs preference diagnoses (55%v.48%,p = 0.22). PCPs were more likely to accurately diagnose patient's preferences when discussions occurred, regardless of length.

CONCLUSION

Only half of PCPs accurately identified patient testing preferences. Training did not impact accuracy. Visits where CRC testing was discussed resulted in PCPs better understanding patient preferences.

PRACTICE IMPLICATIONS

PCPs should take time to discuss testing and elicit patient preferences.

Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study

PROBLEM

Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions.

BACKGROUND

Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth.

AIM

We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians.

METHODS

The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews.

FINDINGS

The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process.

DISCUSSION

The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice.

CONCLUSION

Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.

Finding Your Way - A shared decision making resource developed by and for Aboriginal people in Australia: Perceived acceptability, usability, and feasibility

BACKGROUND

Finding Your Way is a culturally adapted shared decision making (SDM) resource for Aboriginal (First Nations) people of Australia. It integrates the Eight Ways of Aboriginal Learning (8 Ways) and was created by Aboriginal health workers and community members in New South Wales (NSW), Australia.

OBJECTIVE

To explore the perceived acceptability, usability, and feasibility of Finding Your Way as a SDM resource for Aboriginal people making health and wellbeing decisions.

METHODS

The web-based resources were disseminated using social media, professional networks, publications, and the 'Koori grapevine'. Thirteen 'champions' also promoted the resources. An online questionnaire was available on the website for three months. Framework analysis determined early indications of its acceptability, usability, and feasibility. Web and social media analytics were also analysed. Partnership with and leadership by Aboriginal people was integrated at all phases of the project.

RESULTS

The main landing page was accessed 5219 times by 4259 users. 132 users completed the questionnaire. The non-linear and visual aspects of the resources 'speak to mob' and identified with Aboriginal culture. The inclusion of social and emotional well-being, and the holistic approach were well received by the small number of users who opted to provide feedback. They suggested that non-digital formats and guidance on the resources are required to support use in clinical practice.

CONCLUSION

The 8 Ways enabled the development of a culturally safe SDM resource for Aboriginal people, which was well received by users who took the time to provide feedback after a brief dissemination process. Additional accessible formats, practice guides and training are required to support uptake in clinical practice.

PRACTICE IMPLICATIONS

Finding Your Way could be used to help improve experiences, health literacy, decision making quality and outcomes of healthcare for Aboriginal Australians.

What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care

OBJECTIVE

Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training.

DISCUSSION

Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients.

CONCLUSIONS

We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.

Teaching strategies for shared decision-making within the context of evidence-based healthcare practice: A scoping review

OBJECTIVE

To describe the nature of teaching Shared Decision Making (SDM) within the context of Evidence Based Practice (EBP) to support development of contemporaneous EBP education programmes for healthcare learners.

METHODS

A scoping review following the Joanna Briggs Institute (JBI) guidance was conducted with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) used to guide reporting.

RESULTS

The narrative overview of 23 studies provides insight into the 'what' and 'how' of teaching SDM within the context of EBP education. A minority of studies explicitly and concurrently incorporated EBP and SDM in terms of how programme content was organised. Teaching strategies most often used regardless of learner cohort or setting included didactic, face-to-face lectures, together with role-play/modelling, small group workshops and video recordings. Programme evaluation outcomes predominantly focused on participant reactions to training and participant learning.

CONCLUSION

While a disconnect between EBP and SDM remains evident in healthcare programmes, increased recognition by educators to actively facilitate this interdependent relationship is emerging.

PRACTICE IMPLICATIONS

Intentionally structuring learning activities in a manner which demonstrates the relevance and interdependence of SDM and EBP may mitigate 'learning silos' and enhance learners' abilities to make connections required in practice.

Blended online learning for oncologists to improve skills in shared decision making about palliative chemotherapy: a pre-posttest evaluation

PURPOSE

To improve shared decision making (SDM) with advanced cancer patients, communication skills training for oncologists is needed. The purpose was to examine the effects of a blended online learning (i.e. e-learning and online training session) for oncologists about SDM in palliative oncological care and to compare this blended format with a more extensive, fully in-person face-to-face training format.

METHODS

A one-group pre-posttest design was adopted. Before (T0) and after (T2) training, participants conducted simulated consultations (SPAs) and surveys; after the e-learning (T1), an additional survey was filled out. The primary outcome was observed SDM (OPTION12 and 4SDM). Secondary outcomes included observed SDM per stage, SPA duration and decision made as well as oncologists' self-reported knowledge, clinical behavioural intentions, satisfaction with the communication and evaluation of the training. Additionally, outcomes of the blended learning were compared with those of the face-to-face training cohort. Analyses were conducted in SPSS by linear mixed models.

RESULTS

Oncologists (n = 17) showed significantly higher SDM scores after the blended online learning. The individual stages of SDM and the number of times the decision was postponed as well as oncologists' beliefs about capabilities, knowledge and satisfaction increased after the blended learning. Consultation duration was unchanged. The training was evaluated as satisfactory. When compared with the face-to-face training, the blended learning effects were smaller.

CONCLUSION

Blended online SDM training for oncologists was effective. However, the effects were smaller compared to face-to-face training. The availability of different training formats provides opportunities for tailoring training to the wishes and needs of learners.

Shared decision-making in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic and progressive neurological disorder impacting physical, cognitive, and psychosocial health. The disease course, severity, and presence of symptoms differ within and between persons over time and are unpredictable. Given the preference-sensitive nature of many key decisions to be made, and the increasing numbers of disease-modifying therapies, shared decision-making (SDM) with patients seems to be key in offering optimum care and outcomes for people suffering from MS. In this paper, we describe our perspective on how to achieve SDM in patients with MS, following key SDM-elements from established SDM-frameworks. As for deliberation in the clinical encounter, SDM communication training of professionals and feedback on their current performance are key aspects, as well as encouraging patients to participate. Concerning information for patients, it is important to provide balanced, evidence-based information about the benefits and the harms of different treatment options, including the option of surveillance only. At the same time, attention is needed for the optimal dosage of that information, given the symptoms of cognitive dysfunction and fatigue among MS-patients, and the uncertainties they have to cope with. Finally, for broader communication, a system is required that assures patient preferences are actually implemented by multidisciplinary MS-teams. As SDM is also being implemented in many countries within the context of value-based health care, we consider the systematic use of outcome information, such as patient-reported outcome measures (PROMs) and Patient Decision Aids, as an opportunity to achieve SDM.

A Description of Breast Models Used to Teach Clinical Skills

Background: Health care trainees lack opportunities to practice breast assessment and clinical skills with patients, making breast models significant for hands-on training. Insufficient training leads to low competence across practitioners in breast health areas of practice, including clinical lactation. The aim of this review was to describe types of breast models used to teach clinical skills of the breast across breast health areas. The secondary aims were to describe education interventions that included each model and identify whether multiple skin tones were available in models. Methods: Authors conducted a scoping review to identify which types of breast models are used to teach clinical skills across breast health areas of practice and determine gaps in literature regarding how clinical lactation skills are taught. The literature search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, MedLine, and ProQuest. Inclusion criteria were students/professionals engaging in breast model simulation. Eighteen studies were reviewed. Authors extracted data on participants, breast health area, breast model, intervention, evaluation, general outcomes, skin tone, and research design. Results: The most common skill area was clinical breast exam (n = 7), while least was breastfeeding education (n = 1). Most models were commercial (n = 12). Zero studies described skin tone. Generally, breast model simulations were correlated with increased clinical skills and confidence regardless of model used. Conclusions: Despite demonstrated gain of skills, this review reveals inconsistent use of breast models and evaluation, exclusion of diverse skin tones, and lack of breast models reported to teach clinical lactation skills.

Ready for SDM- evaluation of an interprofessional training module in shared decision making - A cluster randomized trial

OBJECTIVE

Ready for SDM was developed in Norway as a comprehensive modularized curriculum for health care providers (HCP). The current study evaluated the efficacy of one of the modules, a 2-hour interprofessional SDM training designed to enhance SDM competencies.

METHODS

A cluster randomized controlled trial was conducted with eight District Psychiatric Centres randomized to wait-list control (CG) or intervention group (IG). Participants and trainers were not blinded to their allocation. The IG received a 2-hour didactic and interactive training, using video examples. The primary outcome was the agreement between the participants' and an expert assessment of patient involvement in a video recorded consultation. The SDM-knowledge score was a secondary outcome.

RESULTS

Compared to the CG (n = 65), the IG (n = 69) judged involvement behavior in a communication example more accurately (mean difference of weighted T, adjusted for age and gender:=-0.098, p = 0.028) and demonstrated better knowledge (mean difference=-0.58; p = 0.014). A sensitivity analysis entering a random effect for cluster turned out not significant.

CONCLUSION

The interprofessional group training can improve HCPs' SDM-competencies.

PRACTICE IMPLICATIONS

Addressing interprofessional teams using SDM communication training could supplement existing SDM training approaches. More research is needed to evaluate the training module's effects as a component of large-scale implementation of SDM.

Nurse-led decision coaching by specialized nurses for healthy BRCA1/2 gene mutation carriers - adaptation and pilot testing of a curriculum for nurses: a qualitative study

Background

Women with BRCA1/2 mutations are at high risk to develop breast and ovarian cancer. To support these women to participate in shared decision-making, structured nurse-led decision coaching combined with an evidence-based decision aid may be employed.

In preparation of the interprofessional randomized controlled trial to evaluate a decision coaching program to support preventive decisions of healthy female BRCA 1/2 gene mutation carriers (EDCP-BRCA), we adapted and piloted an existing training program for specialized nurses and included elements from an existing physician communication training.

Methods

The training was adapted according to the six-step-approach for medical curriculum development. The educational design is based on experience- and problem-based learning.

Subsequently, we conducted a qualitative pilot study. Nurses were recruited from six German centers for familial breast and ovarian cancer. The acceptability and feasibility were assessed by structured class observations, field notes and participants’ feedback. Data were analyzed using qualitative content analysis. The training was revised according to the results.

Due to the COVID-19 pandemic, the patient intervention was adapted as a virtual coaching and a brief additional training for nurses was added.

Results

The training consists of two modules (2 + 1 day) that teach competences in evidence-based medicine and patient information, (risk) communication and decision coaching. One pilot test was conducted with six nurses of which three were specialized and experienced in patient counselling. A final set of eight main categories was derived from the data: framework conditions; interaction; schedule, transparency of goals, content, methods, materials and practical relevance and feasibility. Overall, the training was feasible and comprehensible. Decision coaching materials were awkward to handle and decision coaching role plays were set too short. Therefore, materials will be sent out in advance and the training was extended.

Conclusions

Specialized nurses are rarely available and nurse-led counselling is not routinely implemented in the centers of familial breast and ovarian cancer. However, training of less qualified nurses seems feasible. Decision coaching in a virtual format seems to be a promising approach. Further research is needed to evaluate its feasibility, acceptability and effectiveness.

Trial registration

The main trial is registered under DRKS-ID: DRKS00015527.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00810-8.

Potential impact of encounter patient decision aids on the patient-clinician dialogue: a qualitative study on Dutch and American medical specialists' experiences

OBJECTIVES

To examine the experiences among Dutch and American clinicians on the impact of using encounter patient decision aids (ePDAs) on their clinical practice, and subsequently to formulate recommendations for sustained ePDA use in clinical practice.

DESIGN

Qualitative study using semi-structured interviews with clinicians who used 11 different ePDAs (applicable to their specialty) for 3 months after a short training. The verbatim transcribed interviews were coded with thematic analysis by six researchers via ATLAS.ti.

SETTING

Nine hospitals in the Netherlands and two hospitals in the USA.

PARTICIPANTS

Twenty-five clinicians were interviewed: 16 Dutch medical specialists from four different disciplines (gynaecologists, ear-nose-throat specialists, neurologists and orthopaedic surgeon), 5 American gynaecologists and 4 American gynaecology medical trainees.

RESULTS

The interviews showed that the ePDA potentially impacted the patient-clinician dialogue in several ways. We identified six themes that illustrate this: that is, (1) communication style, for example, structuring the conversation; (2) the patient's role, for example, encouraging patients to ask more questions; (3) the clinician's role, for example, prompting clinicians to discuss more information; (4) workflow, for example, familiarity with the ePDA's content helped to integrate it into practice; (5) shared decision-making (SDM), for example, mixed experiences whether the ePDA contributed to SDM; and (6) content of the ePDA. Recommendations to possibly improve ePDA use based on the clinician's experiences: (1) add pictorial health information to the ePDA instead of text only and (2) instruct clinicians how to use the ePDA in a flexible (depending on their discipline and setting) and personalised way adapting the ePDA to the patients' needs (e.g., mark off irrelevant options).

CONCLUSIONS

ePDAs contributed to the patient-clinician dialogue in several ways according to medical specialists. A flexible and personalised approach appeared appropriate to integrate the use of ePDAs into the clinician's workflow, and customise their use to individual patients' needs.

Shared Decision Making - A Key Competence of All Health Care Professionals. Evaluation and Adaptation of a Digitally Enhanced Learning and Teaching Unit

The Covid-19 pandemic induced a radical shift towards digitally enhanced learning and teaching (DELT). Success of this adaptation depended on how much DELT had been provided before. The Bavarian Virtual University (BVU) is a university network to fund, promote and support DELT. The Ludwig-Maximilians-University Munich as a part of this network implemented the DELT course “Shared decision making (SDM) - a part of evidence-based medicine” in 2015. Based on regular evaluations and due to the latest developments, a media-didactic and content-related adaptation will be conducted now. Clinical cases will be embedded in a framework structure of SDM. Videos, podcasts and literature of doctor–patient interaction will be provided. To enable different health care professions to have a positive learning experience, the course will be linguistically adapted. The interaction between students and teacher will be enhanced by a transparent distribution of tasks and an issue-specific chat forum. SDM is an interdisciplinary general concept. With regard to the academization of different health care professions, the demand for DELT will increase. However, medical competencies can`t be taught fully online, since face-to-face patient interaction is mandatory. Communication skills can be practiced theoretically but have to be applied in reality.

Teaching clinicians shared decision making and risk communication online: an evaluation study

OBJECTIVES

To describe the development and initial evaluation of a brief e-learning course as a means of teaching shared decision making and risk communication skills to clinicians of all specialties.

DESIGN

Comparison pre-course and post-course of scores in subjective confidence and objective knowledge about shared decision making and risk communication.

SETTING

Online and open to all specialties and levels of clinical experience, including students.

PARTICIPANTS

The course is freely available online and all who started the course from September 2018 to May 2020 were invited to participate in the evaluation study.

INTERVENTION

The self-guided e-learning course is made up of four modules and takes approximately 2 hours to complete. It is hosted on the website of the Winton Centre for Risk Communication and the UK's National Health Service e-learning platform.

MAIN OUTCOME MEASURES

Pre-course and post-course confidence in performing shared decision making (as measured by a 10-item scale adapted from the OPTION tool; total score range 10-50), and objective knowledge about basic principles of shared decision making and risk communication, as measured by performance on four knowledge questions and three calculations. At course commencement, a single item from the Berlin Numeracy Test, and the eight-item Subjective Numeracy Test were also asked.

RESULTS

Of 366 unique participants who consented and commenced the course, 210 completed all modules and the final post-course test. Participants' mean age was 38.1 years, 69% were in current clinical practice and had a mean of 10.5 years of clinical practice. Numeracy was relatively low, with 50.7% correctly answering the Berlin Numeracy Test item pre-course. Participants who completed the course showed a significant improvement in their confidence by a mean summed score of 3.7 units (95% CI 2.9 to 4.6, p<0.0001) from a mean pre-course of 37.4 (SD 6.1) to post-course of 41.1 (SD 6.9). There was an increase in the proportion of correct answers for most knowledge questions (p<0.0001, p=0.013 for two directly compared), although no improvement in most skill questions that involved numbers (eg, calculating relative risks). Participants with higher numeracy appeared to show higher skill and confidence on most questions.

CONCLUSIONS

This online, free e-learning course was successful in increasing participants' confidence in, and some aspects of knowledge about, shared decision making and risk communication. It also highlighted the need for improvements in clinicians' numerical skills as a vital part of training. We suggest that the course is used in combination with practical face-to-face experience and more intensive numerical skills training.

Barriers to shared decision-making with women of reproductive age affected by a chronic inflammatory disease: a mixed-methods needs assessment of dermatologists and rheumatologists

OBJECTIVES

The main study objective was to identify challenges and barriers experienced by dermatologists and rheumatologists when engaging women of reproductive age in shared decision-making (SDM) related to treatment and management of chronic inflammatory disease (CID) before, during and after pregnancy.

DESIGN

A mixed-methods study was conducted, employing (1) semistructured interviews, (2) an online survey and (3) triangulation of findings.

PARTICIPANTS

524 dermatologists and rheumatologists entered the study; 495 completed it; 388 met inclusion criteria for analysis. Participants were included if actively practising in Germany (GER), the UK or the USA; had a minimum 5% caseload of female patients of reproductive age with either axial spondyloarthritis, psoriasis, psoriatic arthritis or rheumatoid arthritis; and had experience prescribing biologics.

RESULTS

48 interviews and 340 surveys were analysed. Interviews underscored dermatologists and rheumatologists' suboptimal integration of SDM in clinical practice. In the survey, 90% (n=305) did not know about SDM models. A perceived lack of competency counselling patients on pregnancy and family planning was also identified during interviews. Among the survey sample, 44% (n=150) of specialists agreed they preferred leaving pregnancy-related discussions to obstetricians and/or gynaecologists and 57% (n=189) reported having suboptimal skills discussing contraceptive methods with patients. Another finding that emerged from interviews was the perception that all biologics are strictly contraindicated during pregnancy. Suboptimal knowledge was noted among 57% (n=95) of dermatologists and 48% (n=83) of rheumatologists surveyed in that regard, with a statistically significant difference by country among dermatologists (GER: 42% vs UK: 71% vs USA: 57%, p=0.015).

CONCLUSIONS

This study identified low levels of knowledge, skill and confidence, as well as attitudinal issues, that explain why SDM is not fully integrated in dermatology and rheumatology clinical practice. Blended-learning interventions are recommended to assist CID specialists in developing effective communication and patient engagement competencies.

Beyond rationality: Expanding the practice of shared decision making in modern medicine

The contemporary healthcare field operates according to an autonomy model of medical decision-making. This model stipulates that patients have the right to make informed choices about their care. Shared decision making (SDM) has arisen as the dominant approach for clinicians and patients to collaborate in care planning and implementation. This approach relies heavily on normative (rational) decision-making processes, and often leaves out descriptive influences that stem from personal, social, and environmental factors and explain how decisions are typically made in the real world. The lack of attention to descriptive decision-making limits SDM in many ways. A multi-level approach to expanding the practice of SDM is proposed, including tailoring the decision encounter based on patients' social, cultural, and environmental context; using relational elements strategically as part of the SDM process; and modifying incentive models to promote greater attention to descriptive impacts on decision-making. These modifications are expected to make SDM, and thus patient care, more inclusive, effective, and acceptable to diverse patients.

Exploring variation in the performance of planned birth: A mixed method study

OBJECTIVE

Variation in practice in relation to indications and timing for both induction of labour (IOL) and planned caesarean section (CS) clearly exists. However, the extent of this variation, and how this variation is explained by clinicians remains unclear. The aim of this study was to map the variation in IOL and planned CS at eight Australian hospitals, and understand why variation occurs from the perspective of clinicians at these hospitals. Our ultimate aim was to identify opportunities for improvement as evidenced by hospital data, clinician experiences, and feedback.

DESIGN

A two-phased mixed method study using sequential explanatory study design. The first phase consisted of an analysis of routinely collected patient data to map variation between hospitals. The second phase consisted of focus groups with clinicians to gain their perspectives on the reasons for variation.

SETTING AND PARTICIPANTS

Patient data consisted of routine data from 19,073 women giving birth at eight Sydney hospitals between November 2017 and October 2018. Focus groups were attended by a total of 61 medical staff and 121 midwives.

RESULTS

Hospital data analysis found substantial variation, before and after adjustment for case-mix, in rates of both IOL (adjusted rates 27.6%-42%) and planned CS (adjusted rate 15.4%-22.6%). Planned CS by gestation also showed variation, although after restricting analysis to term (≥37 weeks gestation) births, variation was reduced. At focus groups, five main themes explaining variation emerged: local guidelines, policies and procedures (inconsistency and ambiguity); uncertainty of the evidence/what is best practice (contradictory research and different interpretations of evidence); clinician preferences, beliefs and values; the culture of the unit; and organisational influences (access to specialised clinics, theatre time).

KEY CONCLUSIONS

Considerable variation in IOL and planned CS, even after case-mix adjustment, was found in this sample of Australian hospitals. Engagement with hospital clinicians identified likely sources of this variation and enabled clinicians at each hospital to consider appropriate local responses to address variation, such as more detailed review of their planned birth cases.

IMPLICATIONS FOR PRACTICE

At a macro level, measures to reduce unwarranted variation should initially focus on consistent national guidelines, while supporting equitable access to operating theatres for optimal CS timing, and shared decision-making training to reduce influence of clinician preference.

The experiences of shared decision-making of women who had an induction of labour

OBJECTIVES

The importance of shared decision-making (SDM) in relation to induction of labour (IOL) is recognised, little is known about women's experiences of and satisfaction with decision-making and how this can be improved. The aim of this study was to 1) gain insight into women's experiences of SDM in relation to IOL, 2) understand the factors associated with satisfaction versus dissatisfaction during SDM, and 3) identify recommendations for service improvement.

METHODS

Qualitative semi-structured telephone interviews were conducted with 32 women who had a recent IOL at one of eight public hospitals in Sydney, Australia. An inductive approach to coding and categorisation of themes was used.

RESULTS

While women reported varied experiences with SDM, many reported not feeling that they had a choice about IOL, not being presented with the risks and benefits of different birth options, and receiving insufficient information about the IOL process and methods. Satisfaction versus dissatisfaction with SDM appeared more closely related to a woman's willingness to have an IOL and their willingness to defer decision-making, rather than the process of SDM. Recommendations for improvement included improved SDM practices, access to guidelines and continuity of care.

CONCLUSION

There is a need to improve SDM processes around IOL.

PRACTICE IMPLICATIONS

Particular areas for improvement include more comprehensive discussions surrounding the pros and cons of different birth methods and the IOL process. Decision aids and clinician training may assist with SDM.

The Attitudes and Beliefs of Australian Midwives and Obstetricians About Birth Options and Labor Interventions

INTRODUCTION

The global rise in the rate of induction of labor and cesarean birth shows considerable unexplained variation both within and between countries. Prior research suggests that the extent to which women are engaged in the decision-making process about birth options, such as elective cesarean, induction of labor, or use of fetal monitoring, is heavily influenced by clinician beliefs and preferences. The aim of this study was to investigate the beliefs about labor interventions and birth options held by midwives and obstetric medical staff from 8 Sydney hospitals and assess how the health care providers' beliefs were associated with discipline or years of experience.

METHODS

This is a survey study of midwives and obstetric staff that was distributed between November 2018 and July 2019. Modified from the previously validated birth attitudes survey for the Australian context, survey domains include (1) maternal choice and woman's role in birth, (2) safety by mode or place of birth, (3) attitudes toward cesarean birth for preventing urinary incontinence, (4) approaches to decrease cesarean birth rates, and (5) fears of birth mode. Responses were compared between professions and within professions by years of experience using Mann-Whitney U testing.

RESULTS

A total of 217 midwives and 58 medical staff completed the survey (response rate, 30.5%). Midwifery staff responses generally favored a physiologic approach to birth, versus beliefs more in favor of intervention (particularly cesarean birth) among medical staff. There was interprofessional discrepancy on most items, particularly regarding safety of mode or place of birth and approaches to decrease cesarean birth rates. Within disciplines, there was more variation in medical staff attitudes than within the midwifery staff. No clinically important differences in beliefs by years of experience were noted.

DISCUSSION

Clinicians need to be aware of their own beliefs and preferences about birth as a potential source of bias when counselling women, particularly when there are a range of treatment options and the evidence may not strongly favor one option over another. As both groups had similar perceptions about the importance of women's autonomy, shared decision-making training could help bridge belief gaps and improve care around birth decisions.