A blended learning for general practitioners and nurses on skills to support shared decision-making with patients about palliative cancer treatment: A one-group pre-posttest study

OBJECTIVE

To evaluate a newly developed blended learning programme for general practitioners (GPs) and nurses in supporting shared decision making (SDM) about palliative cancer treatment in a simulated setting.

METHODS

In a pre-posttest study, healthcare professionals (HCPs) participated in the blended learning (i.e. e-learning and (online) training session). HCPs filled out surveys (T0 (baseline), T1 (after e-learning) and T2 (after full blended learning)) and engaged in simulated consultations at T0 and T2. The primary outcome was observed SDM support (Triple-S; DSAT-10 for validation). Secondary outcomes included satisfaction, knowledge about and attitude towards SDM support. Repeated measures General Linear Models were conducted.

RESULTS

33 HCPs (17 GPs and 16 nurses) participated. SDM support significantly improved after training (Triple-S; medium effect). Observers' overall rating of SDM support (medium effect) as well as HCPs' knowledge (large effect) and beliefs about their capabilities (medium effect) improved after training. There was no difference in decision support skills (DSAT-10), HCPs' other clinical behavioural intentions and satisfaction. HCPs evaluated the training positively.

CONCLUSION

Blended learning for HCPs on supporting SDM in palliative cancer care improved their skills, knowledge and confidence in simulated consultations.

PRACTICE IMPLICATIONS

These first findings are promising for evaluating interprofessional SDM in clinical practice.

Effectiveness of Shared Decision-making Training Programs for Health Care Professionals Using Reflexivity Strategies: Secondary Analysis of a Systematic Review

BACKGROUND

Shared decision-making (SDM) leads to better health care processes through collaboration between health care professionals and patients. Training is recognized as a promising intervention to foster SDM by health care professionals. However, the most effective training type is still unclear. Reflexivity is an exercise that leads health care professionals to question their own values to better consider patient values and support patients while least influencing their decisions. Training that uses reflexivity strategies could motivate them to engage in SDM and be more open to diversity.

OBJECTIVE

In this secondary analysis of a 2018 Cochrane review of interventions for improving SDM by health care professionals, we aimed to identify SDM training programs that included reflexivity strategies and were assessed as effective. In addition, we aimed to explore whether further factors can be associated with or enhance their effectiveness.

METHODS

From the Cochrane review, we first extracted training programs targeting health care professionals. Second, we developed a grid to help identify training programs that used reflexivity strategies. Third, those identified were further categorized according to the type of strategy used. At each step, we identified the proportion of programs that were classified as effective by the Cochrane review (2018) so that we could compare their effectiveness. In addition, we wanted to see whether effectiveness was similar between programs using peer-to-peer group learning and those with an interprofessional orientation. Finally, the Cochrane review selected programs that were evaluated using patient-reported or observer-reported outcome measurements. We examined which of these measurements was most often used in effective training programs.

RESULTS

Of the 31 training programs extracted, 24 (77%) were interactive, among which 10 (42%) were considered effective. Of these 31 programs, 7 (23%) were unidirectional, among which 1 (14%) was considered effective. Of the 24 interactive programs, 7 (29%) included reflexivity strategies. Of the 7 training programs with reflexivity strategies, 5 (71%) used a peer-to-peer group learning strategy, among which 3 (60%) were effective; the other 2 (29%) used a self-appraisal individual learning strategy, neither of which was effective. Of the 31 training programs extracted, 5 (16%) programs had an interprofessional orientation, among which 3 (60%) were effective; the remaining 26 (84%) of the 31 programs were without interprofessional orientation, among which 8 (31%) were effective. Finally, 12 (39%) of 31 programs used observer-based measurements, among which more than half (7/12, 58%) were effective.

CONCLUSIONS

Our study is the first to evaluate the effectiveness of SDM training programs that include reflexivity strategies. Its conclusions open avenues for enriching future SDM training programs with reflexivity strategies. The grid developed to identify training programs that used reflexivity strategies, when further tested and validated, can guide future assessments of reflexivity components in SDM training.

Interventions for interpersonal communication about end of life care between health practitioners and affected people

BACKGROUND

Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes.

OBJECTIVES

To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing.

SELECTION CRITERIA

This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life,  we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes.

DATA COLLECTION AND ANALYSIS

Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies.

MAIN RESULTS

Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials.  Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication.  Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations.  Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions  (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life.  Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear.

AUTHORS' CONCLUSIONS

Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.

Are shared decision making studies well enough described to be replicated? Secondary analysis of a Cochrane systematic review

Background

Interventions to change health professionals’ behaviour are often difficult to replicate. Incomplete reporting is a key reason and a source of waste in health research. We aimed to assess the reporting of shared decision making (SDM) interventions.

Methods

We extracted data from a 2017 Cochrane systematic review whose aim was to determine the effectiveness of interventions to increase the use of SDM by healthcare professionals. In a secondary analysis, we used the 12 items of the Template for Intervention Description and Replication (TIDieR) checklist to analyze quantitative data. We used a conceptual framework for implementation fidelity to analyze qualitative data, which added details to various TIDieR items (e.g. under “what materials?” we also reported on ease of access to materials). We used SAS 9.4 for all analyses.

Results

Of the 87 studies included in the 2017 Cochrane review, 83 were randomized trials, three were non-randomized trials, and one was a controlled before-and-after study. Items most completely reported were: “brief name” (87/87, 100%), “why” (rationale) (86/87, 99%), and “what” (procedures) (81/87, 93%). The least completely reported items (under 50%) were “materials” (29/87, 33%), “who” (23/87, 26%), and “when and how much” (18/87, 21%), as well as the conditional items: “tailoring” (8/87, 9%), “modifications” (3/87, 4%), and “how well (actual)” (i.e. delivered as planned?) (3/87, 3%). Interventions targeting patients were better reported than those targeting health professionals or both patients and health professionals, e.g. 84% of patient-targeted intervention studies reported “How”, (delivery modes), vs. 67% for those targeting health professionals and 32% for those targeting both. We also reported qualitative analyses for most items. Overall reporting of items for all interventions was 41.5%.

Conclusions

Reporting on all groups or components of SDM interventions was incomplete in most SDM studies published up to 2017. Our results provide guidance for authors on what elements need better reporting to improve the replicability of their SDM interventions.

Ottawa Decision Support Framework to Improve Iranian Nurses' Decision Coaching Skills

Introduction

Nurses play an important role in providing decision coaching (DC) and developing informed decision-making in families of patients hospitalized in intensive care units (ICUs). Therefore, taking necessary measures to develop nurses' DC skills is essential. The present study was conducted to analyze the application of the Ottawa Decision Support Framework (ODSF) in developing Iranian nurses' DC skills.

Methodology

In this experimental pretest-posttest study, two hospitals (Imam Reza and Shahid Kamyab hospitals) in the city of Mashhad were randomly placed in either the experimental or the control group. Based on a simple random sampling method, 60 ICU nurses were selected. For nurses in the experimental group, a 2-day workshop was conducted based on the ODSF, whereas nurses in the control group received no intervention. Using the SPSS-16 software and statistical tests of paired-samples t-test, independent-samples t-test, and Chi-square test (p <0.05), the data were analyzed.

Results

Before the intervention, no difference was observed in the mean DC scores obtained by the nurses in the experimental and control groups (p = 0.891). However, after the intervention, a significant difference was observed in the mean DC scores obtained by the nurses in the experimental and control groups (p <0.001).

Conclusion

The results indicated that applying the ODSF is effective in improving Iranian nurses' DC skills. It was also indicated that the concepts presented in this framework are consistent with Iranian nurses' cultural backgrounds. Accordingly, the application of the ODSF is offered in Iranian nurses' continuing education programs to improve their DC skills.

How to cite this article

Moghadam ES, Manzari ZS, Ghalenow HR, Sanchooli HN. Ottawa Decision Support Framework to Improve Iranian Nurses' Decision Coaching Skills. Indian J Crit Care Med 2022;26(2):199-203.

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.

20th Anniversary Ottawa Decision Support Framework: Part 3 Overview of Systematic Reviews and Updated Framework

Introduction. The Ottawa Decision Support Framework (ODSF) has guided practitioners and patients facing difficult decisions for 20 years. It asserts that decision support interventions that address patients' decisional needs improve decision quality. Purpose. To update the ODSF based on a synthesis of evidence. Methods. We conducted an overview of systematic reviews, searching 9 electronic databases. Eligible reviews included decisional needs assessments, decision support interventions, and decisional outcome measures guided by the ODSF. We extracted data and synthesized results narratively. Eight ODSF developers/expert users from 4 disciplines revised the ODSF. Results. Of 4656 citations, we identified 4 eligible reviews (>250 studies, >100 different decisions, >50,000 patients, 18 countries, 5 continents). They reported current ODSF decisional needs and their most frequent manifestations in the areas of inadequate knowledge/information, unclear values, decisional conflict/uncertainty, and inadequate support. They uncovered 11 new manifestations of 6 decisional needs. Using the Decisional Conflict Scale (DCS) to assess decisional needs, average scores were elevated at baseline and declined shortly after decision making, even without information interventions. Patient decision aids were superior to usual care in reducing total DCS scores and improving decision quality. We revised the ODSF by refining definitions of 6 decisional needs and adding new interventions to address 4 needs. We added a decision process outcome and eliminated secondary outcomes unlikely to improve across a range of decisions, retaining the implementation/continuance of the chosen option and appropriate use/costs of health services. Conclusions. We updated the ODSF to reflect the current evidence and identified implications for practice and further research.

Sex and gender considerations in implementation interventions to promote shared decision making: A secondary analysis of a Cochrane systematic review

Background

Shared decision making (SDM) in healthcare is an approach in which health professionals support patients in making decisions based on best evidence and their values and preferences. Considering sex and gender in SDM research is necessary to produce precisely-targeted interventions, improve evidence quality and redress health inequities. A first step is correct use of terms. We therefore assessed sex and gender terminology in SDM intervention studies.

Materials and methods

We performed a secondary analysis of a Cochrane review of SDM interventions. We extracted study characteristics and their use of sex, gender or related terms (mention; number of categories). We assessed correct use of sex and gender terms using three criteria: “non-binary use”, “use of appropriate categories” and “non-interchangeable use of sex and gender”. We computed the proportion of studies that met all, any or no criteria, and explored associations between criteria met and study characteristics.

Results

Of 87 included studies, 58 (66.7%) mentioned sex and/or gender. The most mentioned related terms were “female” (60.9%) and “male” (59.8%). Of the 58 studies, authors used sex and gender as binary variables respectively in 36 (62%) and in 34 (58.6%) studies. No study met the criterion “non-binary use”. Authors used appropriate categories to describe sex and gender respectively in 28 (48.3%) and in 8 (13.8%) studies. Of the 83 (95.4%) studies in which sex and/or gender, and/or related terms were mentioned, authors used sex and gender non-interchangeably in 16 (19.3%). No study met all three criteria. Criteria met did not vary according to study characteristics (p>.05).

Conclusions

In SDM implementation studies, sex and gender terms and concepts are in a state of confusion. Our results suggest the urgency of adopting a standardized use of sex and gender terms and concepts before these considerations can be properly integrated into implementation research.

The effectiveness of training interventions on nurses' communication skills: A systematic review

OBJECTIVES

The objective of this systematic review was to identify, critically appraise and synthesise evidence for the effectiveness of communication skills training interventions in nursing practice.

DESIGN

A systematic review of literature.

DATA SOURCES

Randomised controlled trials published in English from 1998 to 2018, identified in five computerised databases (Medline, Cinahl, Embase, Psychinfo and Cochrane Database). Studies were included if they reported an educational intervention to enhance nurses' communication with patients and contained an objective measure of communication skills and/or patient outcome measures.

REVIEW METHODS

The Preferred reporting Items for Systematic reviews and Meta-Analyses guided the review. Data were extracted regarding study design and effectiveness on nurses' communication skills. Trial quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The heterogeneity of the included studies prohibited meta-analysis.

RESULTS

Of the 7811 papers identified, seven trials met the eligibility criteria. The quality was modest. Training programs varied significantly in duration, structure, location and use of outcome measurement tools. Five trials focused on communication with cancer patients using simulated patients. All trials found at least one statistically significant improvement for nurses' communication skills.

CONCLUSIONS

Educational interventions to enhance nurses' capacity to communicate with patients show promise. The paper reports the first systematic review of randomised controlled trials concerning the effect of communication skills training on nurses' abilities to communicate with patients, inclusive of non-cancer settings. The direct impact of educational interventions on nurses' communication skills is difficult to measure arising from non-standardised outcome measurement tools. Further research is particularly needed in acute, chronic illness, aged care and community settings.

Optimizing the role of social workers in advance care planning within an academic hospital: an educational intervention program

Advance Care Planning (ACP) promotes communication to help patients express future health-care preferences and goals for their medical care. Social workers (SWs) are trained to facilitate complex conversations and assist in various ACP tasks across clinical settings. This three-part mixed-method interventional study implemented a comprehensive education and training program for SWs of a large academic hospital, which used pre- and post-training evaluations, chart review, and qualitative data from debrief sessions to examine ACP skills and confidence, and assess the number of ACP conversations initiated with patients. Self-reported level of preparation to facilitate ACP conversations improved significantly (n = 26; pre 36% versus post 82%; p < .05). A 4-month post-intervention chart audit showed an 8.69 fold increase in the number of initiated ACP conversations. Qualitative analysis identified key themes regarding barriers and enablers of initiating ACP conversations during standard care from the perspective of SWs.

Teaching Palliative Care to Health Professional Students: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background:

End-of-life care is challenging on health professionals’ mental and emotional state. Palliative care education can support health professional students’ transition, helping them to cope with the challenges of working in this complex setting. Students feel that they need more preparation in this area.

Purpose:

To collate the relevant information regarding how to teach health professional students about palliative care.

Method:

The full holdings of Medline, PsycINFO, EBM Reviews, Cinahl Plus, ERIC, and EMBASE via Elsevier were searched until April 7, 2019. Inclusion criteria were randomized controlled trials of group interventions that aimed to increase health professional students’ knowledge, skills, or attitudes in palliative care. Studies were appraised using the PEDro scale. Data were synthesized using meta-analysis.

Results:

The results favored the intervention and were statistically significant for knowledge and attitudes but not for skills. A 2-hour seminar accompanied by readings seems sufficient to improve both knowledge and attitudes. Quality assessment scores ranged from 1/10 to 7/10 (mean 5, standard deviation 1.73). When studies at high risk of bias were excluded, then only knowledge improved significantly. Key areas where rigor was lacking were in concealing the randomization, omitting intention-to-treat analysis and not blinding of participants, therapists, or assessors.

Conclusions:

Palliative care education is effective in improving health professional students’ knowledge and attitudes toward palliative care. More research is required into skill development. This review highlights the need for more high-quality trials in both the short and long-term to determine the most effective mode of palliative care education.

Strategies to evaluate healthcare provider trainings in shared decision-making (SDM): a systematic review of evaluation studies

DESIGN AND OBJECTIVES

We performed a systematic review of studies evaluating healthcare provider (HCP) trainings in shared decision-making (SDM) to analyse their evaluation strategies.

SETTING AND PARTICIPANTS

HCP trainings in SDM from all healthcare settings.

METHODS

We searched scientific databases (Medline, PsycInfo, CINAHL), performed reference and citation tracking, contacted experts in the field and scanned the Canadian inventory of SDM training programmes for healthcare professionals. We included articles reporting data of summative evaluations of HCP trainings in SDM. Two reviewers screened records, assessed full-text articles, performed data extraction and assessed study quality with the integrated quality criteria for review of multiple study designs (ICROMS) tool. Analysis of evaluation strategies included data source use, use of unpublished or published measures and coverage of Kirkpatrick's evaluation levels. An evaluation framework based on Kirkpatrick's evaluation levels and the Quadruple Aim framework was used to categorise identified evaluation outcomes.

RESULTS

Out of 7234 records, we included 41 articles reporting on 30 studies: cluster-randomised (n=8) and randomised (n=9) controlled trials, controlled (n=1) and non-controlled (n=7) before-after studies, mixed-methods (n=1), qualitative (n=1) and post-test (n=3) studies. Most studies were conducted in the USA (n=9), Germany (n=8) or Canada (n=7) and evaluated physician trainings (n=25). Eleven articles met ICROMS quality criteria. Almost all studies (n=27) employed HCP-reported outcomes for training evaluation and most (n=19) additionally used patient-reported (n=12), observer-rated (n=10), standardised patient-reported (n=2) outcomes or training process and healthcare data (n=10). Most studies employed a mix of unpublished and published measures (n=17) and covered two (n=12) or three (n=10) Kirkpatrick's levels. Identified evaluation outcomes covered all categories of the proposed framework.

CONCLUSIONS

Strategies to evaluate HCP trainings in SDM varied largely. The proposed evaluation framework maybe useful to structure future evaluation studies, but international agreement on a core set of outcomes is needed to improve evidence.

PROSPERO REGISTRATION NUMBER

CRD42016041623.

A systematic review of the effects of advance care planning facilitators training programs

BACKGROUND

Advance care planning (ACP) is the process of ongoing communication among patients, family and health care professionals regarding what plans for future care are preferred in the event that patients become unable to make their own decisions. Clinicians play an important role in ACP as both initiators and decision coaches. However, lack of training for clinicians has frequently been reported as the reason for low involvement in ACP discussions - hence the present review evaluates the effectiveness of ACP training programs for healthcare professionals to guide the development of novel training programs for them in the future.

METHODS

A literature search for intervention studies was conducted independently by two reviewers in July 2018. Participants included all healthcare professionals working with adult patients suffering from terminal illness. The primary outcomes were the professionals' knowledge of and attitudes towards ACP, and self-perceived competence in ACP conversations. The Effective Public Health Practice Project appraisal tool was used to examine the quality of the studies included.

RESULTS

A total of 4025 articles were identified, and ten eligible articles, covering 1081 participants, were included in the review. However, there is a lack of high quality randomized controlled trials of providing ACP training for nurses working in non-palliative care hospital settings. The overall quality of the intervention studies was moderate. All the studies included used instructional sessions in their interventions, while some contained group discussion, role-play and the use of advanced technology. The training programs increased the knowledge, attitudes towards shared decision-making, perceived communication skills, confidence, comfort and experiences concerned with discussing end-of-life (EOL) issues. Patient advocacy, job satisfaction and perceived level of adequate training for EOL care were improved. The use of 'decision aids' was rated as acceptable and clinically useful.

CONCLUSIONS

Training for healthcare professionals in ACP has positive effects on their knowledge, attitude and skills. The use of decision aids and advanced technology, instructional sessions with role play, training content focused on ACP communication skills and the needs and experience of patient in the ACP process, and a values-based ACP process are all those factors that made the ACP training programs effective.

Evaluation of a shared decision making educational program: The Ottawa Decision Support Tutorial

OBJECTIVE

To evaluate the Ottawa Decision Support Tutorial (ODST), an open-access shared decision making educational program.

METHODS

We conducted a post-test study. Eligible participants completed a knowledge test and/or acceptability survey after completing ODST version 1 (2007-2013), version 2 (2013-2015), or version 3 (2015-2017). We conducted descriptive analysis and compared outcomes across versions using log transformed linear regression (knowledge) and log binomial regression (acceptability). Content analysis explored verbatim suggestions to improve the ODST.

RESULTS

Overall, 6604 users completed the knowledge test and 4276 completed the acceptability survey. The median knowledge test score was 8/10 (IQR = 7-9) with 68% of users achieving a passing grade of 7.5/10. Users who completed version 2 had the highest median knowledge scores (version 1 = 7.9, version 2 = 8.5, version 3 = 8.0, p < 0.001) and pass rate (version 1 = 63%, version 2 = 73%, version 3 = 69%). Acceptability was high, with 90% reporting a good or excellent overall impression. Few users suggested improvements (readability, presentation, audiovisual).

CONCLUSIONS

Most users passed the ODST knowledge test and rated the tutorial as acceptable. We will use feedback to improve the ODST.

PRACTICE IMPLICATIONS

The ODST is an inexpensive and widely accessible intervention that can be used to educate healthcare providers about SDM and decision support.

Interventions for increasing the use of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review.

OBJECTIVES

To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs.

AUTHORS' CONCLUSIONS

It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Comparative impact of two continuing education activities targeted at COPD educators on educational outcomes: protocol for a non-randomized controlled study using mixed methods

Background

Therapeutic patient education (TPE) improves quality of life and reduces health care utilization among patients with chronic obstructive pulmonary disease (COPD). However, benefits from TPE might depend on the performance of the educators and training is needed to ensure the effective delivery of TPE interventions. Based on the framework by Moore et al. (J Contin Educ Health Prof 29:1-15, 2009), we will compare the impact of two continuing education (CE) activities on TPE in regard to the following educational outcomes: (1) learning, (2) self-report of competence, (3) performance of the educators, and (4) outcomes of COPD patients who will meet the newly trained educators for TPE.

Methods

We will conduct a non-randomized controlled study using mixed methods. Educators will first participate in a CE activity on TPE that will include a role-playing simulation (experimental group) or in a lecture on TPE (comparison group) and then will perform TPE in COPD patients. Among educators, we will assess: (1) learning, by measuring knowledge about TPE, and (2) self-report of competence using self-administered questionnaires before and after the activity. Then, after the CE activity, we will assess (3) educators’ performance levels in delivering TPE by rating a videotaped TPE intervention. In COPD patients who will meet the newly trained educators for TPE after either CE activity, we will assess (4) quality of life and resource utilization using interviewer-administered questionnaires, before and after TPE. Statistical analyses will compare the experimental group against the comparison group using multivariate models. Using a semi-structured interview guide, we will conduct interviews with educators and perform content analysis. Results will be integrated in order that qualitative results further explain the quantitative ones.

Discussion

To the best of our knowledge, this is the first controlled mixed methods study to compare the impact of two CE activities on TPE in regard to four educational outcomes. We believe this study will serve as a model for evaluating CE activities on TPE. Results from this study could increase educators’ performance levels in delivering effective TPE interventions, and, in turn, COPD patient outcomes.

Trial registration

The study was registered on https://clinicaltrials.gov/ (NCT02870998) on March 15, 2016.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3284-6) contains supplementary material, which is available to authorized users.

The Effect of Communication Skills Training for Generalist Palliative Care Providers on Patient-Reported Outcomes and Clinician Behaviors: A Systematic Review and Meta-analysis

CONTEXT

As most end-of-life care is provided by health care providers who are generalists rather than specialists in palliative care, effective communication skills training for generalists is essential.

OBJECTIVES

To determine the effect of communication training interventions for generalist palliative care providers on patient-reported outcomes and trainee behaviors.

METHODS

Systematic review from searches of 10 databases to December 2015 (MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, CENTRAL, Web of Science, ICTRP, CORDIS, and OpenGrey) plus hand searching. Randomized controlled trials of training interventions intended to enhance generalists' communication skills in end-of-life care were included. Two authors independently assessed eligibility after screening, extracted data, and graded quality. Data were pooled for meta-analysis using a random-effects model. PRISMA guidelines were followed.

RESULTS

Nineteen of 11,441 articles were eligible, representing 14 trials. Eleven were included in meta-analyses (patients n = 3144, trainees n = 791). Meta-analysis showed no effect on patient outcomes (standardized mean difference [SMD] = 0.10, 95% CI -0.05 to 0.24) and high levels of heterogeneity (chi-square = 21.32, degrees of freedom [df] = 7, P = 0.003; I² = 67%). The effect on trainee behaviors in simulated interactions (SMD = 0.50, 95% CI 0.19-0.81) was greater than in real patient interactions (SMD = 0.21, 95% CI -0.01 to 0.43) with moderate heterogeneity (chi-square = 8.90, df = 5, P = 0.11; I² = 44%; chi-square = 5.96, df = 3, P = 0.11; I² = 50%, respectively). Two interventions with medium effects on showing empathy in real patient interactions included personalized feedback on recorded interactions.

CONCLUSIONS

The effect of communication skills training for generalists on patient-reported outcomes remains unclear. Training can improve clinicians' ability to show empathy and discuss emotions, at least in simulated consultations. Personalized feedback on recorded patient interactions may be beneficial.

REGISTRATION NUMBER

CRD42014014777.

Milestones, barriers and beacons: Shared decision making in Canada inches ahead

Canada's approach to shared decision making (SDM) remains as disparate as its healthcare system; a conglomerate of 14 public plans - ten provincial, three territorial and one federal. The healthcare research funding environment has been largely positive for SDM because there was funding for knowledge translation research which also encompassed SDM. The funding climate currently places new emphasis on patient involvement in research and on patient empowerment in healthcare. SDM fields have expanded from primary care to elder care, paediatrics, emergency and critical care medicine, cardiology, nutrition, occupational therapy and workplace rehabilitation. Also, SDM has reached out to embrace other health-related decisions including about home care and social care and has been adapted to Aboriginal decision making needs. Canadian researchers have developed new interprofessional SDM models that are being used worldwide. Professional interest in SDM in Canada is not yet widespread, but there are provincial initiatives in Alberta, British Columbia, Ontario, Quebec and Saskatchewan. Decision aids are routinely used in some areas, for example for prostate cancer in Saskatchewan, and many others are available for online consultation. The Patient Decision Aids Research Group in Ottawa, Ontario maintains an international inventory of decision aids appraised with the International Patient Decision Aid Standards. The Canada Research Chair in SDM and Knowledge Translation in Quebec City maintains a website of SDM training programs available worldwide. These initiatives are positive, but the future of SDM in Canada depends on whether health policies, health professionals and the public culture fully embrace it.

Patient-Clinician Communication About End-of-Life Care in Patients With Advanced Chronic Organ Failure During One Year

CONTEXT

Patient-clinician communication is an important prerequisite to delivering high-quality end-of-life care. However, discussions about end-of-life care are uncommon in patients with advanced chronic organ failure.

OBJECTIVES

The aim was to examine the quality of end-of-life care communication during one year follow-up of patients with advanced chronic organ failure. In addition, we aimed to explore whether and to what extent quality of communication about end-of-life care changes toward the end of life and whether end-of-life care communication is related to patient-perceived quality of medical care.

METHODS

Clinically stable outpatients (n = 265) with advanced chronic obstructive pulmonary disease, chronic heart failure, or chronic renal failure were visited at home at baseline and four, eight, and 12 months after baseline to assess quality of end-of-life care communication (Quality of Communication questionnaire). Two years after baseline, survival status was assessed, and if patients died during the study period, a bereavement interview was done with the closest relative.

RESULTS

One year follow-up was completed by 77.7% of the patients. Quality of end-of-life care communication was rated low at baseline and did not change over one year. Quality of end-of-life care communication was comparable for patients who completed two year follow-up and patients who died during the study. The correlation between quality of end-of-life care communication and satisfaction with medical treatment was weak.

CONCLUSION

End-of-life care communication is poor in patients with chronic organ failure and does not change toward the end of life. Future studies should develop an intervention aiming at initiating high-quality end-of-life care communication between patients with advanced chronic organ failure and their clinicians.

Implementation of a cystic fibrosis lung transplant referral patient decision aid in routine clinical practice: an observational study

Background

The decision to have lung transplantation as treatment for end-stage lung disease from cystic fibrosis (CF) has benefits and serious risks. Although patient decision aids are effective interventions for helping patients reach a quality decision, little is known about implementing them in clinical practice. Our study evaluated a sustainable approach for implementing a patient decision aid for adults with CF considering referral for lung transplantation.

Methods

A prospective pragmatic observational study was guided by the Knowledge-to-Action Framework. Healthcare professionals in all 23 Canadian CF clinics were eligible. We surveyed participants regarding perceived barriers and facilitators to patient decision aid use. Interventions tailored to address modifiable identified barriers included training, access to decision aids, and conference calls. The primary outcome was >80% use of the decision aid in year 2.

Results

Of 23 adult CF clinics, 18 participated (78.2%) and 13 had healthcare professionals attend training. Baseline barriers were healthcare professionals’ inadequate knowledge for supporting patients making decisions (55%), clarifying patients’ values for outcomes of options (58%), and helping patients handle conflicting views of others (71%). Other barriers were lack of time (52%) and needing to change how transplantation is discussed (42%). Baseline facilitators were healthcare professionals feeling comfortable discussing bad transplantation outcomes (74%), agreeing the decision aid would be easy to experiment with (71%) and use in the CF clinic (87%), and agreeing that using the decision aid would not require reorganization of the CF clinic (90%). After implementing the decision aid with interventions tailored to the barriers, decision aid use increased from 29% at baseline to 85% during year 1 and 92% in year 2 (p < 0.001). Compared to baseline, more healthcare professionals at the end of the study were confident in supporting decision-making (p = 0.03) but continued to feel inadequate ability with supporting patients to handle conflicting views (p = 0.01).

Conclusion

Most Canadian CF clinics agreed to participate in the study. Interventions were used to target identified modifiable barriers to using the patient decision aid in routine CF clinical practice. CF clinics reported using it with almost all patients in the second year.

Interventions for improving the adoption of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) can reduce overuse of options not associated with benefits for all and respects patient rights, but has not yet been widely adopted in practice.

OBJECTIVES

To determine the effectiveness of interventions to improve healthcare professionals' adoption of SDM.

SEARCH METHODS

For this update we searched for primary studies in The Cochrane Library, MEDLINE, EMBASE, CINAHL, the Cochrane Effective Practice and Organisation of Care (EPOC) Specialsied Register and PsycINFO for the period March 2009 to August 2012. We searched the Clinical Trials.gov registry and the proceedings of the International Shared Decision Making Conference. We scanned the bibliographies of relevant papers and studies. We contacted experts in the field to identify papers published after August 2012.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies evaluating interventions to improve healthcare professionals' adoption of SDM where the primary outcomes were evaluated using observer-based outcome measures (OBOM) or patient-reported outcome measures (PROM).

DATA COLLECTION AND ANALYSIS

The three overall categories of intervention were: interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. Studies in each category were compared to studies in the same category, to studies in the other two categories, and to usual care, resulting in nine comparison groups. Statistical analysis considered categorical and continuous primary outcomes separately. We calculated the median of the standardized mean difference (SMD), or risk difference, and range of effect across studies and categories of intervention. We assessed risk of bias.

MAIN RESULTS

Thirty-nine studies were included, 38 randomised and one non-randomised controlled trial. Categorical measures did not show any effect for any of the interventions. In OBOM studies, interventions targeting both patients and healthcare professionals had a positive effect compared to usual care (SMD of 2.83) and compared to interventions targeting patients alone (SMD of 1.42). Studies comparing interventions targeting patients with other interventions targeting patients had a positive effect, as did studies comparing interventions targeting healthcare professionals with usual care (SDM of 1.13 and 1.08 respectively). In PROM studies, only three comparisons showed any effect, patient compared to usual care (SMD of 0.21), patient compared to another patient (SDM of 0.29) and healthcare professional compared to another healthcare professional (SDM of 0.20). For all comparisons, interpretation of the results needs to consider the small number of studies, the heterogeneity, and some methodological issues. Overall quality of the evidence for the outcomes, assessed with the GRADE tool, ranged from low to very low.

AUTHORS' CONCLUSIONS

It is uncertain whether interventions to improve adoption of SDM are effective given the low quality of the evidence. However, any intervention that actively targets patients, healthcare professionals, or both, is better than none. Also, interventions targeting patients and healthcare professionals together show more promise than those targeting only one or the other.

Efficacy of advance care planning: a systematic review and meta-analysis

OBJECTIVE

To systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations.

DESIGN

Systematic review and meta-analyses.

DATA SOURCES

Medline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists.

STUDY SELECTION

Randomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English.

DATA EXTRACTION AND SYNTHESIS

Fifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: 'advance directives' and 'communication.'

MAIN OUTCOMES AND MEASURES

Primary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms.

RESULTS

Interventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication.

CONCLUSIONS

ACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.

Coaching and guidance with patient decision aids: A review of theoretical and empirical evidence

BACKGROUND

Coaching and guidance are structured approaches that can be used within or alongside patient decision aids (PtDAs) to facilitate the process of decision making. Coaching is provided by an individual, and guidance is embedded within the decision support materials. The purpose of this paper is to: a) present updated definitions of the concepts "coaching" and "guidance"; b) present an updated summary of current theoretical and empirical insights into the roles played by coaching/guidance in the context of PtDAs; and c) highlight emerging issues and research opportunities in this aspect of PtDA design.

METHODS

We identified literature published since 2003 on shared decision making theoretical frameworks inclusive of coaching or guidance. We also conducted a sub-analysis of randomized controlled trials included in the 2011 Cochrane Collaboration Review of PtDAs with search results updated to December 2010. The sub-analysis was conducted on the characteristics of coaching and/or guidance included in any trial of PtDAs and trials that allowed the impact of coaching and/or guidance with PtDA to be compared to another intervention or usual care.

RESULTS

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients in the process of thinking about a decision and in communicating their values/preferences with others. In 98 randomized controlled trials of PtDAs, 11 trials (11.2%) included coaching and 63 trials (64.3%) provided guidance. Compared to usual care, coaching provided alongside a PtDA improved knowledge and decreased mean costs. The impact on some other outcomes (e.g., participation in decision making, satisfaction, option chosen) was more variable, with some trials showing positive effects and other trials reporting no differences. For values-choice agreement, decisional conflict, adherence, and anxiety there were no differences between groups. None of these outcomes were worse when patients were exposed to decision coaching alongside a PtDA. No trials evaluated the effect of guidance provided within PtDAs.

CONCLUSIONS

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients to participate in decision making. However, there are few randomized controlled trials that have compared the effectiveness of coaching used alongside PtDAs to PtDAs without coaching, and no trials have compared the PtDAs with guidance to those without guidance.

Supportive and palliative care for metastatic breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced-stage disease. While cure is not a realistic outcome, site-specific interventions, supportive care, and palliative care can achieve meaningful outcomes and improve quality of life. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three resource-stratified tables: health system resource allocations, resource allocations for organ-based metastatic breast cancer, and resource allocations for palliative care. These tables illustrate how health systems can provide supportive and palliative care services for patients at a basic level of available resources, and incrementally add services as more resources become available. The health systems table includes health professional education, patient and family education, palliative care models, and diagnostic testing. The metastatic disease management table provides recommendations for supportive care for bone, brain, liver, lung, and skin metastases as well as bowel obstruction. The third table includes the palliative care recommendations: pain management, and psychosocial and spiritual aspects of care. The panel considered pain management a priority at a basic level of resource allocation and emphasized the need for morphine to be easily available in LMICs. Regular pain assessments and the proper use of pharmacologic and non-pharmacologic interventions are recommended. Basic-level resources for psychosocial and spiritual aspects of care include health professional and patient and family education, as well as patient support, including community-based peer support.

Classroom-based and distance learning education and training courses in end-of-life care for health and social care staff: a systematic review

BACKGROUND

Staff from a range of health and social care professions report deficits in their knowledge and skills when providing end-of-life and palliative care, and education and training has been advocated at a range of levels.

AIMS

To review the literature related to classroom-based and distance learning education and training initiatives for health and social care staff in end-of-life and palliative care, in terms of their target audience, extent, modes of delivery, content and teaching and learning strategies, and to identify the most effective educational strategies for enhancing care.

DESIGN

A systematic review of the literature evaluating classroom-based and distance learning education and training courses for health and social care staff in end-of-life and palliative care.

DATA SOURCES

Online databases CINAHL, MEDLINE, EMBASE and PSYCHINFO between January 2000 and July 2010. Studies were selected that discussed specific education and training initiatives and included pre-and post-test evaluation of participants' learning.

RESULTS

30 studies met eligibility criteria. The majority reported successful outcomes, though there were some exceptions. Level of prior experience and availability of practice reinforcement influenced learning. Participative and interactive learning strategies were predominantly used along with discussion of case scenarios. Multi-professional learning was infrequently reported and service user and carer input to curriculum development and delivery was reported in only one study.

CONCLUSIONS

Classroom-based education and training is useful for enhancing professionals' skills and perceived preparedness for delivering end-of-life care but should be reinforced by actual practice experience.

Evaluation of nurses' perceptions on providing patient decision support with cardiopulmonary resuscitation

The decision whether to receive cardiopulmonary resuscitation (CPR) is a decision in which the personal values of the patient must be considered along with information about the risks and benefits of the treatment. A decision aid can be used to provide patient decision support to a patient who is seriously ill and needs to consider CPR options. The goal of this project was to identify the barriers and facilitators to using a CPR decision aid, through evaluating nursing perceptions on providing patient decision support. Using a needs assessment, it was determined that implementing a patient decision aid for CPR status in the Acute Monitor Area (AMA) of The Ottawa Hospital would be an excellent quality improvement project. The nurses who chose to participate were given an education session regarding patient decision support. Questionnaires were distributed to evaluate their views of patient decision support and decision aids before and after the education session and implementation of the CPR decision aid. Questionnaire results did not indicate a significant change between before or after education session and decision aid implementation. Qualitative reports did indicate that nurses generally have positive attitudes toward patient decision support and decision aids. The nurses identified specific barriers and facilitators in their commentaries. This clinically relevant data supports the idea that patient decision support should be integrated into daily nursing practice.

Training health professionals in shared decision-making: an international environmental scan

OBJECTIVE

To identify and analyze training programs in shared decision-making (SDM) for health professionals.

METHODS

We conducted an environmental scan looking for programs that train health professionals in SDM. Pairs of reviewers independently analyzed the programs identified using a standardized data extraction sheet. The developers of the programs validated the data extracted.

RESULTS

We identified 54 programs conducted between 1996 and 2011 in 14 countries and 10 languages. Thirty-four programs targeted licensed health professionals, 10 targeted pre-licensure health professionals, and 10 targeted both. Most targeted only the medical profession (n=32); six targeted more than one health profession. The five most frequently mentioned teaching methods were case-based discussion, small group educational session, role play, printed educational material, and audit and feedback. Thirty-six programs reported having evaluated their impacts but evaluation data was available only for 17.

CONCLUSIONS

Health professional training programs in SDM vary widely in how and what they deliver, and evidence of their effectiveness is sparse.

PRACTICE IMPLICATIONS

This study suggests there is a need for international consensus on ways to address the variability in SDM training programs. We need agreed criteria for certifying the programs and for determining the most effective types of training.

Decision Coaching to Prepare Patients for Making Health Decisions

Background. Decision coaching is individualized, nondirective facilitation of patient preparation for shared decision making. Purpose. To explore characteristics and effectiveness of decision coaching evaluated within trials of patient decision aids (PtDAs) for health decisions. Data Sources. A subanalysis of trials included in the 2011 Cochrane Review of PtDAs. Study Selection. Eligible trials allowed the effectiveness of decision coaching to be compared with another intervention and/or usual care. Data Extraction. Two reviewers independently screened 86 trials, extracted data, and appraised quality. Data Synthesis. Ten trials were eligible. Decision coaching was provided by genetic counselors, nurses, pharmacists, physicians, psychologists, or health educators. Coaching compared with usual care ( n = 1 trial) improved knowledge. Coaching plus PtDA compared with usual care ( n = 4) improved knowledge and participation in decision making without reported dissatisfaction. Coaching compared with PtDA alone ( n = 4) increased values-choice agreement and improved satisfaction with the decision-making process without any difference in knowledge or participation in decision making. Coaching plus PtDA compared with PtDA alone ( n = 4) had no difference in knowledge, values-choice agreement, participation in decision making, or satisfaction with the process. Decision coaching plus PtDA was more cost-effective compared with PtDA alone or usual care ( n = 1). Limitations. Methodological quality, number of trials, and description of decision coaching. Conclusions. Compared with usual care, decision coaching improved knowledge. However, the improvement in knowledge was similar when coaching was compared with PtDA alone. Outcomes for other comparisons are more variable, some trials showing positive effects and other trials reporting no difference. Given the small number of trials and variability in results, further research is required to determine the effectiveness of decision coaching.