Consideration of shared decision making in nursing: a review of clinicians' perceptions and interventions

The perceptions and experiences of community nurses and patients towards shared decision-making in the home setting: An integrative review

AIM

To explore patients' and community nurses' perceptions and experiences of shared decision-making in the home.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, British Nursing Index, Psycinfo, Medline and Social Services Abstracts were searched for qualitative, quantitative and mixed methods papers published between 1 December 2001 and 31 October 2023.

REVIEW METHODS

A systematic search of electronic databases was undertaken using defined inclusion criteria. The included papers were appraised for quality using the Joanna Briggs Institute critical appraisal checklist for qualitative research. Relevant data were extracted and thematically analysed.

RESULTS

Fourteen papers comprising 13 research studies were included. Patients attached great importance to their right to be involved in decision-making and noted feeling valued as a unique individual. Communication and trust between the patient and nurse were perceived as fundamental. However, shared decision-making does not always occur in practice. Nurses described tension in managing patients' involvement in decision-making.

CONCLUSION

The findings demonstrate that although patients and community nurses appreciate participating in shared decision-making within the home, there are obstacles to achieving a collaborative process. This is especially relevant when there are fundamentally different perspectives on the decision being made. More research is needed to gain further understanding of how shared decision-making plays out in practice and to understand the tensions that patients and nurses may experience.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This paper argues that shared decision-making is more than the development of a relationship where the patient can express their views (though of course, this is important). Shared decision-making requires acknowledgement that the patient has the right to full information and should be empowered to choose between options. Nurses should not assume that shared decision-making in community nursing is easy to facilitate and should recognize the tensions that might exist when true patient choice is enabled.

IMPACT

This paper demonstrates how the idea of shared decision-making needs to be explored in the light of everyday practice so that challenges and barriers can be overcome. In particular, the tensions that arise when patients and nurses do not share the same perspective. This paper speaks to the potential of a gap surrounding shared decision-making in theory and how it plays out in practice.

REPORTING METHOD

The reporting of this review was guided by the 2020 guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

This review was carried out as part of a wider study for which service users have been consulted.

How the current non-significant effects of person-centred care on nurses' outcomes could be abated by the WE-CARE roadmap enablers: A discursive paper

AIM

To describe the non-significant results in nurses' outcomes after the implementation of person-centred care (PCC) and discuss if and how enablers of the WE-CARE roadmap for implementing PCC could abate the non-significant results.

DESIGN

In this paper, an innovative framework of enablers in the WE-CARE Roadmap is explained in relation to increased PCC and nurses' job satisfaction.

METHOD

Findings from a scoping review and published material provided how PCC and nurses' outcomes connect. The WE-CARE roadmap entails five enablers: Information technology, Quality measures, Infrastructure, Incentive systems and contracting strategies.

RESULTS

The WE-CARE roadmap was described and each enabler in the WE-CARE roadmap is discussed concerning PCC and the nurses' job satisfaction. Thus far, the effects of PCC on nurses' outcomes have been non-significant. The WE-CARE roadmap enablers can be implemented to ensure an increased PCC implementation and higher nurses' job satisfaction.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perceptions of physicians, medical and nursing students concerning shared decision-making: a cross-sectional study

Objective: The purpose of this study was to evaluate the attitudes of Flemish physicians and medical/nursing trainees regarding shared decision-making (SDM) and to determine possible differences based on sex, age, rank, occupation and specialty. Methods: A cross-sectional study was conducted between June and September 2017 in which the Patient-Practitioner Orientation Scale (PPOS) was translated and administered. Higher scores on the six-point scale indicate a patient-centered respondent. Independent t-tests, One and Two-way ANOVA and multivariate regression analysis with the variables sex, age, occupation and specialty were performed. Results: 266 responses from 93 physicians, 147 medical and 26 nursing students were analyzed. Mean sharing scores were 4,24 ± 0,64; 4,30 ± 0,61; and 4,30 ± 0,67, respectively. In the regression model, female sex (p < 0,10) and employment (p < 0,05) in general practice or internal medicine is predictive for higher sharing among physicians. Bivariate analysis revealed significant differences between specialisms (p < 0,05): pediatricians (4,79 ± 0,69), psychiatrists (4,74 ± 0,47), obstetricians/gynecologists (4,40 ± 0,38) and general practitioners (4,31 ± 0,59) scored higher on the PPOS than surgeons (3,84 ± 0,58). Conclusion: Flemish providers and trainees are disease-centered. Physicians' attitudes vary depending on their specialism, presumably due to prolonged exposure to the specific clinical context. Additionally, academic-trained nurses share the belief that the physician should decide and the patient should rely on his knowledge rather than his own. There is an urgent need for health policy and educational institutions to facilitate an environment in which SDM is supported.

Parent/Carer-Reported Experience of Shared Decision Making at Child and Adolescent Mental Health Services: A Multilevel Modelling Approach

Background and Objective: Shared decision making (SDM) has been associated with positive outcomes at child and adolescent mental health services (CAMHS). However, implementing SDM is sometimes challenging. Understanding the factors associated with parent/carer experience of SDM could provide empirical evidence to support targeted efforts to promote SDM. This study aimed to explore the frequency of parent/carer-reported experience of SDM and examine possible associations between SDM and clinician's perceptions of the (a) children's and young people's psychosocial difficulties, (b) additional complex problems, and (c) impact of the psychosocial difficulties. Methods: Secondary analysis was conducted on administrative data collected from CAMHS between 2011 and 2015. The sample was composed of 3,175 cases across 58 sites in England. Frequencies were recorded and associations were explored between clinician-reported measures and parent/carer-reported experiences of SDM using a two-level mixed-effect logistic regression analytic approach. Results: Almost 70% of parents/carers reported experiencing higher levels of SDM. Individual-level variables in model one revealed statistically significant (p <0.05) associations suggesting Asian parents/carers (OR = 1.95, 95% CI [1.4, 2.73]) and parents/carers having children with learning difficulties (OR = 1.45, 95% CI [1.06, 1.97]) were more likely to report higher levels of SDM. However, having two parents/carers involved in the child's care and treatment decisions (OR = 0.3, 95% CI [0.21, 0.44]) and being a parent/carer of a child or young person experiencing conduct problems (OR = 0.78, 95% CI [0.63, 0.98]) were associated with lower levels of SDM. When adjusting for service level data (model two) the presence of conduct problems was the only variable found to be significant and predicted lower levels of SDM (OR = 0.29, 95% CI [0.52, 0.58]). Conclusion: Multilevel modelling of CAMHS administrative data may help identify potential influencing factors to SDM. The current findings may inform useful models to better predict and support SDM.

Manipulation and free will in shared decision making

In recent years, there has been an increased focus on patient involvement in treatment planning in the health care system. To reduce the risk of the clinician moving towards paternalism, various methods have been introduced-shared decision making, among others. The goal of shared decision making is for the clinician and patient to share available evidence on the best treatment and to raise awareness on the needs and preferences of the patient as to make a genuinely informed choice. However, in the present article, we discuss to which degree paternalism can be avoided in light of the clinician's role as an authority with certain knowledge and expertise. Through the philosophical theory of reasons-responsiveness, we discuss to which extend free will and control applies to the patient. Through theoretical analysis, we come to suggest that the clinician has a role as an ally rather than manipulator.

Exploring healthcare professionals' knowledge, attitudes and experiences of shared decision making in rheumatology

OBJECTIVES

To explore physicians' and nurses' knowledge, attitudes and experiences of shared decision making (SDM) in rheumatology, to identify barriers and facilitators to SDM, and to examine whether physicians' and nurses' perspectives of SDM differ.

METHODS

A cross-sectional, exploratory, online survey was used. Besides demographic characteristics, healthcare professionals' knowledge, attitudes and experiences of SDM in rheumatology were assessed. Barriers and facilitators to SDM were identified from healthcare professionals' answers. Descriptive statistics were computed and differences between physicians' and nurses' perspectives of SDM were examined with a t-test or Fisher's exact test, as appropriate.

RESULTS

Between April and June 2019, 77 physicians and 70 nurses completed the survey. Although most healthcare professionals lacked a full conceptual understanding of SDM, almost all physicians (92%) and all nurses had a (very) positive attitude toward SDM, which was most frequently motivated by the belief that SDM improves patients' treatment adherence. The majority (>50%) of healthcare professionals experienced problems with the application of SDM in clinical practice, mostly related to time constraints. Other important barriers were the incompatibility of SDM with clinical practice guidelines and beliefs that patients do not prefer to be involved in decision making or are not able to take an active role. Modest differences between physicians' and nurses' perspectives of SDM were found.

CONCLUSIONS

There is a clear need for education and training that equips and empowers healthcare professionals to apply SDM. Furthermore, the commitment of time, resources and financial support for national, regional and organisational initiatives is needed to make SDM in rheumatology a practical reality.

Multiple health literacy dimensions are associated with physicians' efforts to achieve shared decision-making

OBJECTIVES

Shared decision-making (SDM) in health care is widely encouraged. However, for SDM to occur patients need to be able to obtain, understand and apply medical information. Our aim was to assess the relationship between health literacy (HL), numeracy and SDM (using French translations of validated measures).

METHODS

A cross-sectional survey using a self-administered online questionnaire was proposed to all members of the Seintinelles association. Several scales were used to measure HL (FCCHL and 3HLQ/SILS), numeracy (SNS-3), the SDM process (CollaboRATE) and explore their inter-relationships.

RESULTS

Data from 2 299 respondents (96.7% women, 46.1% with a history of cancer) were analysed. All measurement scales showed adequate psychometric properties. Functional HL, communicative HL and numeracy were positively associated with SDM while no significant relation was observed between critical HL and SDM. Furthermore, perceived difficulties in asking physicians' questions and deprivation were negatively associated with SDM.

CONCLUSION

Patient support to reach SDM requires high levels of HL, particularly in the functional and communicative domains. Efforts must be made to improve access and understanding of health information.

PRACTICE IMPLICATIONS

Brief self-reported measures could be used to screen for low levels of health literacy, tailor information accordingly and improve patient involvement in healthcare decision-making.

Patient experience of treatment decision making for wet age-related macular degeneration disease: a qualitative study in China

OBJECTIVES

This study aimed to investigate the experience of patients with wet age-related macular degeneration (wAMD) in treatment decision-making process.

DESIGN

A descriptive qualitative study was designed by using semistructured interviews, and the data analysis was conducted with the thematic analysis approach.

PARTICIPANTS AND SETTING

A convenient and purposive sample of 21 participants diagnosed with wAMD was recruited from May 2018 to September 2018. The study was conducted in the Eye Clinic of Southwest Hospital of Army Medical University in Chongqing located in the southwest of China.

RESULTS

The mean age of the participants was 64.48 years (ranging 50-81 years), and the duration of the disease ranged from 6 months to 48 months. Four major themes were identified from the original data analysis. These themes included facing the darkness (choosing from light and darkness and living in pain), constraints on decision making (doctor-oriented decision making, inadequacy of options and time), weighing alternatives (family influence, financial burden and maintaining social function) and decision-making support (professional decision-making assistance and peer support).

CONCLUSION

This is a qualitative study attempting to explore the patient experience of treatment decision making for wAMD disease in China. Previous literature has focused on treatment effect and symptoms, rather than the individual experience and the wide contexts from a sociocultural perspective. Further studies, such as cross-sectional studies, can be used to describe the status and determine the influencing factors of decision0making process, so as to develop an impact factor model of decision making and to formulate an intervention for patients with wAMD.

Patients' and Caregivers' Conceptualisations of Pressure Ulcers and the Process of Decision-Making in the Context of Home Care

Background: Although the addition of patients in the process of shared decision-making can improve their recovery, there is a lack of knowledge about patients’ and caregivers’ perceptions on the management of pressure ulcers at home. Objectives: To explore the conceptualisations of patients with pressure ulcers and their caregivers on the barriers and facilitators for their involvement in home care and in the process of shared decision-making regarding the care provided. Methods: A qualitative study based on grounded theory in a theoretical sample of 10 patients with pressure ulcers and 15 main caregivers from the health district of Puertollano (Spain). The data were based on semi-structured interviews, analysed using a coding process and the constant comparative method. Results: According to the participants, personal motivation and the involvement of primary care professionals facilitated their participation in the process of shared decision-making and generated feelings of positivity. In contrast, older age, having disabling pathologies, a low educational level or health paternalism were perceived as barriers for their involvement. Conclusions: A non-paternalistic care model and personal motivation facilitate the process of shared decision-making in the care of people with pressure ulcers. Further studies are required to deepen the understanding of this phenomenon and examine the barriers and facilitators for the involvement of patients and caregivers in the management of these injuries in other contexts.

Improving shared health decision making for children and adolescents with chronic illness: A narrative literature review

OBJECTIVE

This review aims to increase understanding of health decision-making by children and adolescents with chronic illnesses and offer suggestions for improving shared decision-making with healthcare professionals.

METHODS

Using cross-disciplinary publication databases, we surveyed literature on children's and adolescents' health decision-making from psychology, health sciences, and neuroscience.

RESULTS

Several factors influencing health decision-making were identified. Considering neurobiological aspects, children lack functionality in the frontal lobe resulting in lesser cognitive control and higher risk-taking compared to adults. Additionally, adolescents' generally higher arousal of socioemotional systems demonstrates neurological underpinnings for reward-seeking behaviours. Psychological investigations of children's health decision-making indicate important age-dependent differences in risk-taking, locus of control, affect and cognitive biases. Furthermore, social influences, particularly from peers, have a large, often negative, effect on individual decision-making due to desire for peer acceptance.

CONCLUSION

Acknowledging these factors is necessary for optimising the process of shared decision-making to support minors with chronic illnesses during healthcare consultations.

PRACTICE IMPLICATIONS

Doctors and other healthcare professionals may need to counteract some adolescents' risk-taking behaviours which are often spurred by peer pressure. This can be achieved by highlighting the patient's control over health outcomes, emphasising short-term benefits and long-term consequences of risky behaviours, and recommending peer support networks.

US-based cross-sectional survey of clinicians' knowledge and attitudes about shared decision-making across healthcare professions and specialties

OBJECTIVE

In this study, we aim to compare shared decision-making (SDM) knowledge and attitudes between US-based physician assistants (PAs), nurse practitioners (NPs) and physicians across surgical and family medicine specialties.

SETTING

We administered a cross-sectional, web-based survey between 20 September 2017 and 1 November 2017.

PARTICIPANTS

272 US-based NPs, PA and physicians completed the survey. 250 physicians were sent a generic email invitation to participate, of whom 100 completed the survey. 3300 NPs and PAs were invited, among whom 172 completed the survey. Individuals who met the following exclusion criteria were excluded from participation: (1) lack of English proficiency; (2) area of practice other than family medicine or surgery; (3) licensure other than physician, PA or NP; (4) practicing in a country other than the US.

RESULTS

We found few substantial differences in SDM knowledge and attitudes across clinician types, revealing positive attitudes across the sample paired with low to moderate knowledge. Family medicine professionals (PAs) were most knowledgeable on several items. Very few respondents (3%; 95% CI 1.5% to 6.2%) favoured a paternalistic approach to decision-making.

CONCLUSIONS

Recent policy-level promotion of SDM may have influenced positive clinician attitudes towards SDM. Positive attitudes despite limited knowledge warrant SDM training across occupations and specialties, while encouraging all clinicians to promote SDM. Given positive attitudes and similar knowledge across clinician types, we recommend that SDM is not confined to the patient-physician dyad but instead advocated among other health professionals.

Age, gender, and current living status were associated with perceived access to treatment among Canadians using a cross sectional survey

Background

Access, particularly timely access, to care is the Canadian public’s most important healthcare concern. The drivers of perceived appropriateness of access to care among patients with at least one chronic health condition (CHC) are not, however, well defined. This study evaluated whether personal characteristics, self-reported health status and care received were associated with patients’ perception of effective access in managing a chronic illness.

Methods

The study population (n = 619) was drawn from a representative sample of the adult Canadian population who reported having ≥1 CHC in the 2013–2014 Health Care in Canada survey. Ordinal regression, with the continuation ratio model, was used to evaluate association of perceived level of access to treatment with socio-demographic factors, perceived health status and care utilization experience.

Results

Factors most closely associated with patients’ satisfaction with care access were: age, sex, current cohabitation, care affordability, and availability of support and information to help manage their CHCs. Individuals, particularly females, < 35 years, currently living alone, with poor access to professional support or information and who feel affordability of care has worsened over the past five years were more likely to report a poorer level of treatment access.

Conclusions

Individuals living alone, who are younger, and women may be especially susceptible to lower perceived access to care of CHCs and a sense of pessimism about things not getting better. Further evaluation of the reasons behind these findings may help develop effective strategies to assist these populations to access the care they need.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3215-6) contains supplementary material, which is available to authorized users.

Shared Decision-Making for Nursing Practice: An Integrative Review

BACKGROUND

Shared decision-making has received national and international interest by providers, educators, researchers, and policy makers. The literature on shared decision-making is extensive, dealing with the individual components of shared decision-making rather than a comprehensive process. This view of shared decision-making leaves healthcare providers to wonder how to integrate shared decision-making into practice.

OBJECTIVE

To understand shared decision-making as a comprehensive process from the perspective of the patient and provider in all healthcare settings.

METHODS

An integrative review was conducted applying a systematic approach involving a literature search, data evaluation, and data analysis. The search included articles from PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and PsycINFO from 1970 through 2016. Articles included quantitative experimental and non-experimental designs, qualitative, and theoretical articles about shared decision-making between all healthcare providers and patients in all healthcare settings.

RESULTS

Fifty-two papers were included in this integrative review. Three categories emerged from the synthesis: (a) communication/ relationship building; (b) working towards a shared decision; and (c) action for shared decision-making. Each major theme contained sub-themes represented in the proposed visual representation for shared decision-making.

CONCLUSION

A comprehensive understanding of shared decision-making between the nurse and the patient was identified. A visual representation offers a guide that depicts shared decision-making as a process taking place during a healthcare encounter with implications for the continuation of shared decisions over time offering patients an opportunity to return to the nurse for reconsiderations of past shared decisions.

Views of general practice staff about the use of a patient-oriented treatment decision aid in shared decision making for patients with type 2 diabetes: A mixed-methods study

Background

Decision aids can be used to support shared decision making (SDM). A patient‐oriented treatment decision aid (DA) was developed for type 2 diabetes but its use by general practice staff appeared to be limited.

Objectives

To explore views of practice staff towards SDM and the DA.

Design

A mixed‐methods study within the Dutch PORTDA‐diab trial.

Setting and participants

Included were 17 practices with staff members who were responsible for routine diabetes care and had worked with the DA, and 209 of their patients.

Methods

Interviews were conducted focusing on applicability, usefulness and feasibility of the DA. Interviews were tape‐recorded, transcribed verbatim and subjected to content analysis for identifying and classifying views. Patient‐reported data about the use of the DA were collected. Associations between specific views and use of the DA were tested using Pearson point‐biserial correlation.

Results

The majority of practice staff expressed positive views towards SDM, which was associated with making more use of the DA. Most of the staff expressed that the DA stimulated a two‐way conversation. By using the DA, several became aware of their paternalistic approach. Some staff experienced a conflict with the content of the DA, which was associated with making less use of the DA.

Conclusions

The DA was considered useful by practice staff to support SDM. A positive view towards SDM was a facilitator, whereas experiencing a conflict with the content of the DA was a barrier for making use of the DA.

Health care as perceived by persons with inflammatory bowel disease - a focus group study

AIMS AND OBJECTIVES

The aim of this study was to explore the perceptions of health care among persons living with inflammatory bowel disease.

BACKGROUND

The quality of care plays an important role in the life of persons with a chronic disease. To define what persons with inflammatory bowel disease perceive as high-quality care, greater focus must be placed on the individual's own perspective of living with the condition.

DESIGN

A qualitative exploratory study was conducted based on focus groups.

METHODS

Five focus groups were conducted with adult persons living with inflammatory bowel disease, 14 men and 12 women aged 19-76 years. The interviews were performed between January-June 2014.

RESULTS

The perceptions of health care from the perspective of persons living with inflammatory bowel disease were summarised in two categories: 'professional attitudes of healthcare staff' and 'structure of the healthcare organisation'. Persons with inflammatory bowel disease want to be encountered with respect, experience trust and obtain information at the right time. They also expect shared decision-making, communication and to encounter competent healthcare professionals. Furthermore, the expectations on and perceptions of the structure of the healthcare organisation comprise access to care, accommodation, continuity of care, as well as the pros and cons of specialised care.

CONCLUSION

The findings show the importance of establishing a respectful and trusting relationship, facilitating healthcare staff and persons with inflammatory bowel disease to work as a team in fulfilling individual care needs - but there is room for improvement in terms of quality of care.

RELEVANCE TO CLINICAL PRACTICE

A person-centred approach, which places the individual and her/his family at the centre, considering them experts on their own health and enabling them to collaborate with healthcare staff, seems important to reach a high-quality healthcare organisation for patients with Inflammatory bowel disease.

Lymphoma Therapy and Adverse Events: Nursing Strategies for Thinking Critically and Acting Decisively

BACKGROUND

Multiple treatment options, combined with disease heterogeneity, have created nursing challenges in the management of adverse events (AEs) during antilymphoma therapy. Testing has revealed that less than half of participating nurses correctly graded peripheral neuropathy and neutropenia related to antilymphoma regimens.

OBJECTIVES

This article identifies nursing challenges in the management of AEs associated with therapy for lymphomas and describes how strategies in critical thinking can help meet those challenges.

METHODS

A comprehensive literature search in oncology nursing, nursing education, and critical thinking was conducted; participant responses to pre- and post-tests at nursing education programs were evaluated; and a roundtable meeting of authors was convened.

FINDINGS

Oncology nurses can cultivate critical thinking skills, practice thinking critically in relation to team members and patients, leverage information from the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events, and manage workflow to allow more opportunity for critical thinking.

Shared Decision Making: Through the Patient's Eyes

Birth is an intimate moment in a woman's life, and healthcare providers play a pivotal role in pregnant women having safe and memorable birth experiences. Utilizing the shared decision-making model during the prenatal period involves listening to the voices of identified high-risk patients and giving them options for care during labor and birth. "Through the Patient's Eyes" is an innovative program that evolved from the care planning process for these identified high-risk obstetric patients who are invited back postpartum to describe to the team birth through "their" eyes. Through this program, the team learned that compassionate care comes from truly listening to pregnant women and their families and that nurses play a pivotal role as educators and advocates. Sharing birth stories with the staff who cared for them not only had a positive effect on the staff but also many women described profound healing afterward.

Breast reconstruction in older patients: A literature review of the decision-making process

AIM

Women not undergoing breast reconstruction after mastectomy tend to be older. This review aims to aid in effective, evidence-based choices regarding breast reconstruction in an older population, appraising the influencing patient factors described in the literature and those directing the reconstructive surgeon. This may refute current misconceptions and ensure surgical decisions are made based on evidence without ageist assumptions. The review forms the basis of an evidence-based algorithm addressing each step of the decision-making process.

METHOD

A literature search was conducted using PubMed, Medline, Evidence.nhs.uk and the Cochrane database. Search terms initially were breast reconstruction, mastectomy, elderly, older, decision, reasons and rationale. A separate literature search was performed for each of the individual 'steps' in the decision-making process.

RESULTS

Overall, 44 papers were obtained. For each section of the decision-making process, titles and abstracts were screened for relevance. Only English language papers were included.

CONCLUSION

If reconstruction is oncologically plausible and co-morbidities and frailty formally assessed, older women should be actively informed about breast reconstruction, receive support and engage in 'shared decision-making'. The older patient is less likely to do research independently. Amongst other factors, body image, cancer fears, employment and carer responsibilities play a part in the decision. With adequate preoperative and frailty assessment and early involvement of the geriatrician and anaesthetist, microsurgical reconstruction is safe. Autologous reconstruction has better long-term outcomes than implant-based reconstructions in this age group, correlating with improved survival and longevity of reconstruction. Age alone should not be considered a contraindication to breast reconstruction.

Promoting participation in healthcare situations for children with JIA: a grounded theory study

Children's right to participate in their own healthcare has increasingly become highlighted in national and international research as well as in government regulations. Nevertheless, children's participation in healthcare is unsatisfactorily applied in praxis. There is a growing body of research regarding children's participation, but research from the children's own perspective is scarce. The aim of this study was thus to explore the experiences and preferences for participation in healthcare situations among children with juvenile idiopathic arthritis (JIA) as a foundation for creating strategies to promote their participation in pediatric healthcare. Twenty children, aged 8 to 17 years, with JIA were interviewed individually and in focus groups. In order to increase the children's opportunities to express their own experiences, different interview techniques were used, such as draw-and-tell and role play with dolls. The analysis was conducted with a constructivist grounded theory. The result explores children's perspective of influencing processes promoting their participation in healthcare situations. The core category that emerged was, "Releasing fear and uncertainty opens up for confidence and participation," and the categories related to the core category are, "surrounded by a sense of security and comfort," and "strengthened and supported to become involved." In conclusion, the knowledge gained in this study offers new insights from the perspective of children themselves, and can constitute a valuable contribution to the understanding of necessary conditions for the development of specific interventions that promote participation among children in healthcare situations.

Shared Decision-Making in Oncology - A Qualitative Analysis of Healthcare Providers' Views on Current Practice

BACKGROUND

Despite an increased awareness of shared decision-making (SDM) and its prominent position on the health policy agenda, its implementation in routine care remains a challenge in Germany. In order to overcome this challenge, it is important to understand healthcare providers' views regarding SDM and to take their perspectives and opinions into account in the development of an implementation program. The present study aimed at exploring a) the attitudes of different healthcare providers regarding SDM in oncology and b) their experiences with treatment decisions in daily practice.

MATERIAL AND METHODS

A qualitative study was conducted using focus groups and individual interviews with different healthcare providers at the University Cancer Center Hamburg, Germany. Focus groups and interviews were audio-recorded, transcribed and analyzed using conventional content analysis and descriptive statistics.

RESULTS

N = 4 focus groups with a total of N = 25 participants and N = 17 individual interviews were conducted. Attitudes regarding SDM varied greatly between the different participants, especially concerning the definition of SDM, the attitude towards the degree of patient involvement in decision-making and assumptions about when SDM should take place. Experiences on how treatment decisions are currently made varied. Negative experiences included time and structural constraints, and a lack of (multidisciplinary) communication. Positive experiences comprised informed patients, involvement of relatives and a good physician-patient relationship.

CONCLUSION

The results show that German healthcare providers in oncology have a range of attitudes that currently function as barriers towards the implementation of SDM. Also, their experiences on how decision-making is currently done reveal difficulties in actively involving patients in decision-making processes. It will be crucial to take these attitudes and experiences seriously and to subsequently disentangle existing misconceptions in future implementation programs.

Shared Decision Aids: Increasing Patient Acceptance of Long-Acting Reversible Contraception

Unintended pregnancies are an important public health issue. Long-acting reversible contraceptive methods (LARCs) are reliable, safe, highly effective methods for most women; however they are underutilized in the United States. Shared decision aids were added to usual care in five public health family planning clinics in the Southeastern United States, staffed by advance practice nurses and registered nurses. All five sites showed an increase in the use of LARCs during the time period that shared decision aids were used (results statistically significant to p < 0.001). It is important for women to make informed choices about contraception, and shared decision aids can be utilized to support this decision making. This resource has been adopted for statewide use in all public health clinics, and implications for practice suggest that the use of shared decision aids is an effective method to support informed patient decision making and acceptance of LARC methods of contraception.

Exploration of the e-patient phenomenon in nursing informatics

The availability of health information on the Internet has equalized opportunities for knowledge between patients and their health care providers, creating a new phenomenon called the e-patient. E-patients use technology to actively participate in their health care and assume higher levels of responsibility for their own health and wellness. This phenomenon has implications for nursing informatics research related to e-patients and potential collaboration with practitioners in developing a collective wisdom. Nursing informatics can use the data, information, knowledge, and wisdom (DIKW) framework to understand how e-patients and clinicians may achieve this collective wisdom. Nurse informaticists can use constructivism and Gadamerian hermeneutics to bridge each stage of this framework to illustrate the fundamentals of patient and clinician interactions and commonality of language to achieve a collective wisdom. Examining the e-patient phenomenon will help nurse informaticists evaluate, design, develop, and determine the effectiveness of information systems used by e-patients. The Internet can facilitate a partnership between the patient and clinician and cultivate a collective wisdom, enhanced by collaboration between nurse informatics and e-patients.

Realizing empowerment in difficult diabetes care: a guided self-determination intervention

Although health professionals advocate empowerment in patient care, they often fail to realize it in practice. Through grounded theories we previously explained why barriers to empowerment were seldom overcome in diabetes care. Zoffmann used these theories as a basis for developing a decision-making and problem-solving method called guided self-determination (GSD). To realize empowerment, health professionals need detailed knowledge of the barriers, their own roles in these barriers, ways to overcome them, and recognizable evidence of having succeeded. Through theory-driven, qualitative evaluation, the previously developed grounded theories helped us recognize changes consistent with empowerment in dyads of nurses and patients with poorly controlled type 1 diabetes. By completing GSD reflection, patients remarkably improved their ability to identify, express, and share unique and unexpected difficulties related to living with diabetes. As signs of empowerment, patients and health professionals accomplished shared decision making, resolved life-disease conflicts, and established meaningful and effective relationships.

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared-decision making for adult patients and health care providers in all health care settings.The specific questions to be answered are: BACKGROUND: Patient-centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients' Organizations (IAOP) who describe patient-centered healthcare as care that is aimed at addressing the needs and preferences of patients. The IAOP presents five principles which are foundational to the achievement of patient-centered healthcare: respect, choice, policy, access and support, as well as information. These five principles are further described as:Within the description of these five principles the idea of shared decision-making is clearly evident.The concept of shared decision-making began to appear in the literature in the 1990s. It is defined as a "process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient-centered care." The details of the shared decision-making process are complex and consist of a series of steps including:Three overall representative decision-making models are noted in contemporary literature. These three models include: paternalistic, informed decision-making, and shared decision-making. The paternalistic model is an autocratic style of decision-making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision-making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement. Finally, the shared decision-making model is representative of a sharing and a negotiation towards treatment decisions. Thus, these models represent a range with patient non-participation at one end of the continuum to informed decision making or a high level of patient power at the other end. Several shared decision-making models focus on the process of shared decision-making previously noted. A discussion of several process models follows below.Charles et al. depicts a process model of shared decision-making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included:This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker. This model also depicts the need to take steps to participate in the shared decision-making process. To take steps means that there is an agreement between and among all involved that shared decision-making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision-making and the actuality of shared decision-making in practice is not strong. Research concerning patients and patient preferences on shared decision-making points to variations depending on age, education, socio-economic status, culture, and diagnosis. Healthcare providers may also hold preferences for shared decision-making; however, research in this area is not as comprehensive as is patient focused research. Elwyn et al. explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision-making process. An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines. This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.The notion of information sharing as a prerequisite to shared decision-making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision-making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision-making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al. portrays shared decision-making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the "test of a shared decision (as distinct from the decision-making process) is if both parties agree on the treatment option."Towle and Godolphin developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision-making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision-making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include:Patient competencies include:This model illustrates the shared decision-making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model. This model, however, gives greater emphasis to the process of the co-participation of the healthcare provider and the patient. The co-participation depicts a mutual partnership with mutual responsibilities that can be seen as "reciprocal relationships of dialogue." For this to take place the relationship between and among the participants of the shared decision-making process is important along with other internal and external influences such as communication, trust, mutual respect, honesty, time, continuity, and commitment. Cultural, social, and age group differences; evidence; and team and family are considered within this model.Elwyn et al. presents yet another model that depicts the shared decision-making process; however, this model offers a view where the healthcare provider holds greater responsibility in this process. In this particular model the process focuses on the healthcare provider and the essential skills needed to engage the patient in shard decisions. The competencies outlined in this model include:The healthcare provider must demonstrate knowledge, competencies, and skills as a communicator. The skills for communication competency require the healthcare provider to be able to elicit the patient's thoughts and input regarding treatment management throughout the consultation. The healthcare provider must also demonstrate competencies in assessment skills beyond physical assessment that includes the ability to assess the patient's perceptions and readiness to participate. In addition, the healthcare provider must be able to assess the patient's readiness to learn the information that the patient needs to know in order to fully engage in the shared decision-making process, assess what the patient already knows, what the patient does not know, and whether or not the information that the patient knows is accurate. Once this assessment is completed the healthcare provider then must draw on his/her knowledge, competencies, and skills necessary to teach the patient what the patient needs to know to be informed. This facilitates the notion of the tailor-made information noted previously. The healthcare provider also requires competencies in how to check and evaluate the entire process to ensure that the patient does understand and accept with comfort not only the plan being negotiated but the entire process of sharing in decision-making. In addition to the above, there are further competencies such as competence in working with groups and teams, competencies in terms of cultural knowledge, competencies with regard to negotiation skills, as well as, competencies when faced with ethical challenges.Shared decision-making has been associated with autonomy, empowerment, and effectiveness and efficiency. Both patients and health care providers have noted improvement in relationships and improved interactions when shared decision-making is in evidence. Along with this improved relationship and interaction enhanced compliance is noted. Additional research points to patient satisfaction and enhanced quality of life. There is some evidence to suggest that shared decision-making does facilitate positive health outcomes.In today's healthcare environment there is greater emphasis on patient-centered care that exemplifies patient engagement, participation, partnership, and shared decision-making. Given the shift from the more autocratic delivery of care to the shared approach there is a need to more fully understand the what of shared decision-making as well as how shared decision-making takes place along with what internal and external influences may encourage, support, and facilitate the shared decision-making process. These influences are intervening variables that may be of significance for the successful development of practice-based strategies that may foster shared decision-making in practice. The purpose of this qualitative systematic review is to identify internal and external influences on shared decision-making in all health care settings.A preliminary search of the Joanna Briggs Library of Systematic Reviews, MEDLINE, CINAHL, and PROSPERO did not identify any previously conducted qualitative systematic reviews on the meaningfulness of internal and external influences on shared decision-making.

The next of kin of older people undergoing haemodialysis: a discursive perspective on perceptions of participation

AIM

This paper is a report of a study conducted to explore how the family members of older people who will undergo haemodialysis treatment for the rest of their lives perceive participation.

BACKGROUND

The rights of families to participate in treatment and health care are supported by international law, and by national law in Norway since 1999.

METHOD

This study, which employed an explorative qualitative approach, was carried out in Norway in 2008. Data were derived from transcribed interviews with seven family members underwent critical discourse analysis.

FINDINGS

Three discourse practices about the next of kin perception of participation were found: (1) to care and take control, (2) to struggle for involvement, and (3) to be forgotten and powerless. The next of kin said that they had no dialogue with the healthcare team, and some fought to be included in the decision-making process.

CONCLUSION

The dominant part of the discourse as expressed by the next of kin seems to be a paternalistic ideology. Thus, finding ways to enable the next of kin to participate in the decision-making process seems to be a major challenge for the healthcare team in the dialysis units.

Perceptions of patient participation amongst elderly patients with end-stage renal disease in a dialysis unit

AIM

A patient's right to influence treatment and health care has been guaranteed by Norwegian law since 1999. The aim of this study was to explore how elderly patients with end-stage renal disease who are undergoing treatment with haemodialysis for the rest of their lives perceive patient participation in a dialysis unit.

METHODS

This study, which was inspired by critical discourse analysis, drew on data derived from transcribed interviews with 11 patients.

FINDINGS

Two discourses related to patient participation were identified. The first and dominant discourse was called the health-care team's power and dominance. Both environmental conditions and the team's practice exercised power and control over the patients. The patients trusted the health-care team, but some felt powerless and were afraid of what might happen if they refused to follow the instructions. The health-care team owned the knowledge and decided what the patients needed to know. Most of all the patients wanted dialogue about the future. After years of treatment, patient identity seemed to be threatened by this situation. The second discourse is called the patients struggling for shared decision-making. Some patients struggled to be involved in decision-making about 'dry weight', diet, blood access and time of treatment when these factors threatened their well-being and the quality of their daily lives.

CONCLUSIONS

The elderly patients' right to participate in their haemodialysis treatment did not seem to be well incorporated into the social practices of haemodialysis units. Changing the social practices in the dialysis units from a paternalistic ideology to an ideology of participation will require consideration of the context, the dialogue and the process of shared decision-making with the patient.