Factors influencing patients' preferences and perceived involvement in shared decision-making in mental health care

Patient Participation in Mental Health Care - Perspectives of Healthcare Professionals and Patients: A Scoping Review

AIM

This scoping review aims to synthesize findings from fourteen selected articles to provide a comprehensive understanding of patient participation in mental healthcare.

METHOD

The review analyzed articles employing various qualitative methodologies, including interviews and observations, to explore patient and healthcare professional perspectives. Articles were selected based on their relevance to the topic of patient participation in mental health care.

RESULTS

The analysis revealed diverse perspectives on patient participation. Patients' preferences varied, with some preferring shared decision-making while others preferred minimal involvement. Barriers to shared decision-making included fear of judgment and substance misuse concerns. Strategies to manage disagreements and foster trusting relationships were identified. Challenges in implementing patient and public involvement in mental health services were noted, including stigma and inadequate professional training. Interprofessional collaboration was deemed fundamental, although fragmented care pathways and communication breakdowns persisted. Structural conditions and professional expectations significantly influenced patient participation, with a paternalistic approach perpetuating power imbalances.

CONCLUSION

Despite challenges, the findings underscored the importance of empowering patients in treatment decision-making, promoting collaborative relationships, and addressing barriers to enhance patient-centered care in mental health settings. Insights from this review contribute to the discourse on patient-centered care, emphasizing the need for holistic approaches prioritizing patient dignity and well-being.

Informed Consent and Surrogate Interference at the Initiation of Community-Based Palliative Care Services

Community-based palliative care (CBPC) clinicians sometimes contend with an ethically charged scenario when they encounter patients for the first time: The patient's spouse, or other loved one or caregiver, revokes the patient's valid informed consent to initiate care. While surrogates are usually motivated by protective instincts, there are other situations where surrogates act out of self-interest. This article considers whether it is ever ethically justified for an adult to revoke another adult's valid informed consent to initiate palliative care services. The article examines this scenario from three perspectives: the patient's capacity to give or relinquish informed consent, the surrogate's intent and use of substituted judgment or best interest, and the clinician's duty to provide clinical care. This ethical analysis argues that CBPC clinicians have an ethical responsibility to provide palliative care services for patients who have given valid informed consent for those services even when a surrogate acts as an interfering or oppositional force.

Concordance in the healthcare context: A concept analysis

Background

The concept of concordance and its usage are indicative of patient-centered healthcare, which encourages an equitable collaboration between patients and clinicians. However, there is a lack of clarity in understanding concordance, and an analysis of this concept is warranted.

Objective

This paper seeks to explore the essence of the concordance concept in the healthcare context.

Methods

Walker and Avant's eight-step method of concept analysis was applied. A literature search was conducted using concordance AND concord as keywords on CINAHL, MEDLINE, PubMed, ProQuest, Cochrane database, and ScienceDirect databases, published between 2006 and 2022.

Results

The attributes of concordance include communication process, therapeutic partnership, and agreement on treatment regimens. Antecedents of concordance comprise provider-patient relationship, patients' beliefs, healthcare providers' characteristics, and complexity of treatment plans. Consequences are improved adherence and compliance, improved clinical outcomes, and better quality of life.

Conclusion

This paper offers clarification of concordance by presenting its antecedents, attributes, and consequences. The findings serve as a basis for developing assessments and nursing interventions to promote patient concordance. Nurses can use the findings to encourage concordance by establishing a trusty relationship during health encounters that respects patients' beliefs and effectively communicating to improve patients' understanding in dealing with complex treatment plans.

Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.

Patient Activation of Persons With Opioid Use Disorder in Intensive Outpatient Treatment

BACKGROUND

High patient activation is associated with a variety of positive health outcomes. Although increasing patient activation in persons with opioid use disorder (OUD) in intensive outpatient treatment (IOT) programs may increase engagement and improve outcomes, little is known about how patient activation is manifested in these programs.

AIMS

To describe types of instances in which persons play an active role in their IOT or show self-determination in their recovery generally (patient activation) and types of instances in which they play a passive role in their IOT or have recovery directed by others (patient nonactivation).

METHODS

A qualitative descriptive study using data from a larger grounded theory study was conducted. Interviews were completed with 14 persons with OUD who attended an IOT program within a large health care system in the Midwest. Content analysis was used to create a typology of instances of patient activation or nonactivation in participants' IOT experiences.

RESULTS

Six types of instances were identified: (1) making and enacting one's own treatment decisions, (2) actively collaborating with staff, (3) self-determining one's disclosure in groups, (4) making a commitment to treatment, (5) taking responsibility for one's recovery, and (6) taking actions to avoid return to use.

CONCLUSIONS

Patient activation is multidimensional and plays a salient role in IOT experiences. IOT staff should engage patients as active participants in their treatment and encourage mutual goal-setting and shared-decision but should be aware that some approaches used too early in treatment may impede recovery.

Healthcare Professionals' Experiences of Recovery-Oriented Collaboration Between Mental Health Centres and Municipalities: A Qualitative Study

Collaboration within mental health centres and with municipalities in Western European healthcare has presented challenges due to structural and cultural disparities. The Danish healthcare system faces obstacles that impact mental healthcare services, particularly in cross-sectorial cooperation. Our aim was to investigate healthcare professionals' experiences of recovery-oriented collaboration within a mental healthcare setting across hospitals and municipalities to gather a deeper understanding of this issue. Twenty-four employees were purposively sampled from mental health centres in Copenhagen and focus group interviews were conducted to explore their perceptions of working together. Inductive content analysis was used to analyse the data and identify themes and categories. The participants emphasised challenges in communication and coordination to improve collaboration within across the two sectors. This study can contribute to a greater understanding of collaboration between mental health centres and municipalities. It aims to inspire improvements in communication, coordination, and the optimisation of mental health service delivery across sectors.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Ethical considerations in evaluating discharge readiness from the intensive care unit

Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients' readiness can conflict with perceptions of what readiness means for patients, families, and healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families.

The Practice of Shared Decision-Making Among Physiotherapists and Patients with Musculoskeletal Conditions

Purpose

Shared decision-making (SDM) may be interpreted as a set of core values rather than as a consensus definition. This study aimed to explore how SDM between patients and physiotherapists may lead to patient satisfaction.

Patients and Methods

A cross-sectional study was conducted to examine the relationship between SDM and patient satisfaction. The study targeted physiotherapists and patients with musculoskeletal pain or disorders. A structured questionnaire (the nine-item Shared Decision-Making Questionnaire) was developed to show the extent to which patients felt involved in the process by scoring nine items from 0 to 5 on a six-point scale. t-tests were performed to estimate differences in SDM perceptions between patients and physiotherapists, and regression analyses were performed to estimate the best predictors of SDM.

Results

The questionnaire was completed by a total of 106 patients and nine physiotherapists. The demographic information of the samples was presented with frequency analysis. This study's findings demonstrate no variations in the final SDM perceptions between patients and physiotherapists, but when SDM was contrasted step-by-step (as items), many variances were discovered. These distinctions reinforce the notion that regardless of the end outcome, the process of reaching a consensus has a distinct profile depending on the type of medical care. Therapists emphasize the first steps, possibly because there is sufficient evidence to make a therapeutic decision. However, patients highlight the final steps, perhaps because the moment for a decision based on the consultation's nature is approaching.

Conclusion

This study demonstrates that SDM is a complex process that must be examined in multiple stages. However, in physiotherapy contexts, this process exhibits extremely different patterns, reflecting a significantly different perspective of the decision-making process.

Associations between perceptions of shared decision making and health among hysterectomy patients: A prospective observational study

OBJECTIVE

To investigate patient and clinical factors that are associated with perceptions of shared decision making between hysterectomy patients and surgeons and to evaluate associations between shared decision making and postoperative health.

METHODS

This study is based on a prospective cohort scheduled for hysterectomy for benign conditions in Vancouver, Canada. Validated patient-reported outcomes assessed shared decision making, pelvic health, depression, and pain. Regression analyses measured the association between perceptions of shared decision making with patient and clinical factors. Then, associations between shared decision making with postoperative pelvic health, pain and depression were evaluated using regression analysis and adjusted for patient and clinical factors.

RESULTS

In this study, 308 participants completed preoperative measures, and a subset of 146 participants also completed the postoperative measures. More than 50% of participants reported less than optimal shared decision making scores. No significant associations were identified between patients' perceptions of shared decision making with patients' age, comorbidities, socioeconomic factors, indication for surgery, or preoperative depression and pain. Regression analyses found that higher/better self-reported shared decision making scores were associated with fewer postoperative pelvic organ symptoms (P = 0.01).

CONCLUSION

Many patients' reporting lower than optimal scores on the shared decision making instrument highlight the opportunity to improve surgeon-patient communication in this surgical cohort. Strengthening shared decision making between surgeons and their patients may be associated with improved self-reported postoperative health.

Patient-related characteristics considered to affect patient involvement in shared decision making about treatment: A scoping review of the qualitative literature

OBJECTIVE

To identify patient-related characteristics considered to affect patient involvement in shared decision making (SDM) about treatment.

METHODS

We conducted a scoping review of qualitative studies. We searched for literature across seven databases until March 2022, and included qualitative studies that focused on associations between patient-related characteristics and SDM about treatment in adults. We analyzed studies using an inductive thematic approach.

RESULTS

The search yielded 5948 articles, of which 70 were included. We identified many different patient-related characteristics, which we grouped into four categories related to: (1) the individual who is facing the decision, (2) the decision, (3) the relationship between the patient and the clinician and others involved in the decision, and (4) the healthcare context.

CONCLUSIONS

Studies report a variety of patient-related characteristics that may affect patient involvement in SDM. Amongst others, patients may need to feel informed, to understand their role in SDM, and be able to communicate. Involvement may be challenging with characteristics such as perceived time pressure, poor patient-clinician relationships, emotional distress, and severe illness.

PRACTICE IMPLICATIONS

In order to truly involve patients in SDM, we might need to focus on characteristics such as patient emotions and relationship building, besides information provision and values clarification.

Drivers of shared decision making in inpatient psychiatry: An exploratory survey of patients' and multi-disciplinary team members' perspectives

OBJECTIVE

To assess the prevalence and predictors of Shared Decision Making (SDM) in an adult, inpatient psychiatric setting.

METHOD

Multi-disciplinary clinician focus groups and patient pre-testing informed the development of a survey on 4 SDM and 11 factors hypothesized to interfere with SDM. The survey was administered to 89 adult inpatients (80% response rate) and their treatment team psychiatrists, nurses, and social workers (n = 338 ratings, 95% response rate). Group differences and predictors were estimated using t and F-tests.

RESULTS

Patients' mean SDM score (n = 64, standardized Cronbach alpha = 0.858) was 3.35 ± 1.13 (5 = highest agreement), and correlated with overall satisfaction with care (n = 61, r = 0.399, p = 0.001). Patients' disagreement with clinician's diagnosis (44% of patients) correlated with lower SDM ratings by patients (t = 2.55, df = 62, p = 0.013) and by clinicians (t = 2.99, df = 69, p = 0.004). Psychotic diagnoses were not a significant determining factor for SDM. Overall, clinicians rated SDM more favorably than patients (t = -5.43, df = 63, p < 0.001), with nurses and social workers rating SDM higher than physicians (p < 0.001).

CONCLUSIONS

Diagnostic agreement / disagreement is a key predictor of SDM for patients and clinicians, while presence of psychosis is not. SDM was rated higher by clinicians than patients. SDM ratings vary significantly between clinical disciplines.

Mental health service users' experiences and perspectives of family involvement in their care: a systematic literature review

Background: The importance of engaging families in mental health care is recognised and endorsed by governments worldwide, however service users' perspectives of family involvement are not well understood.Aims: This study sought to summarise the literature regarding how service users view the involvement of family in their engagement with services and care.Methods: A search was conducted within the following databases for manuscripts published in the last 10 years: PsycINFO, CINAHLPlus, PubMed and Scopus. Of the 4251 eligible papers 17 met the inclusion criteria for review and were subjected to quality appraisal using the RATS (relevance, appropriateness, transparency, soundness) qualitative research review guidelines.Results: Thematic analysis identified four primary themes: family involvement can be positive and negative; barriers to family involvement; family involvement is variable; and communication and collaboration among stakeholders.Conclusions: Identifying the barriers to family involvement and heterogeneity among service users' views were key findings of this review. Despite the widely reported benefits of including families in mental health care it does not always occur. A clearer and more nuanced understanding of service users' needs and preferences for family involvement is required.

Implementation and staff understanding of shared decision-making in the context of recovery-oriented care across US Veterans Health Administration (VHA) inpatient mental healthcare units: a mixed-methods evaluation

OBJECTIVES

To examine the understanding and practice of shared decision-making (SDM) within the context of recovery-oriented care across Veterans Health Administration (VHA) inpatient mental healthcare units.

DESIGN

VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient Scale (RAIN). Scores on the RAIN item for medication SDM were used to rank each site from lowest to highest. The top 7 and bottom 8 sites (n=15) were selected for additional analyses using a mixed-methods approach, involving qualitative interviews, observation notes and quantitative data.

SETTING

34 VHA inpatient mental health units located in every geographical region of the USA.

PARTICIPANTS

55 treatment team members.

RESULTS

Our results identified an overarching theme of 'power-sharing' that describes participants' conceptualisation and practice of medication decision-making. Three levels of power sharing emerged from both interview and observational data: (1) No power sharing: patients are excluded from treatment decisions; (2) Limited power sharing: patients are informed of treatment decisions but have limited influence on the decision-making process; and (3) Shared-power: patients and providers work collaboratively and contribute to medication decisions. Comparing interview to observational data, only observational data indicating those themes differentiate top from bottom scoring sites on the RAIN SDM item scores. All but one top scoring sites indicated shared power medication decision processes, whereas bottom sites reflected mostly no power sharing. Additionally, our findings highlight three key factors that facilitate the implementation of SDM: inclusion of veteran in treatment teams, patient education and respect for patient autonomy.

CONCLUSIONS

Implementation of SDM appears feasible in acute inpatient mental health units. Although most participants were well informed about SDM, that knowledge did not always translate into practice, which supports the need for ongoing implementation support for SDM. Additional contextual factors underscore the value of patients' self-determination as a guiding principle for SDM, highlighting the role of a supporting, empowering and autonomy-generating environment.

Respect in the Eyes of Non-Urban Elders: Using Qualitative Interviews to Distinguish Community Elders' Perspective of Respect in General and Healthcare Services

This study aimed to describe the connotation of respect for community elders in daily situations, and discuss the elderly's views on respect for healthcare services. A qualitative research design was conducted to interview elders from a non-urban area in Changhua, Taiwan. Study sites were Lukang and Ershui. A total of 52 people were interviewed, with an average age of 75 years old. Based on Grounded theory, the thematic analysis method was used to analyze data. This study found that respect from the perspective of the elderly can be divided into three categories: (1) verbal expression, (2) non-verbal behavior, and (3) behavior combined with appropriate language. We found that elders use the performance of healthcare service providers to discuss respect in the field of healthcare services. Respect can also be shown in the physical environment in healthcare settings. This study found that, for the community elders, respect is an individual's subjective feelings regarding the process of interpersonal interaction. Compared to daily life, the respect of the elderly for the healthcare setting has increased the element of the environment. In addition, it was found that elderly people have lower expectations and requirements for respect in healthcare settings.

Task-Specific Patient Preferences for Shared Decision-Making in Hand Surgery

BACKGROUND

Shared decision-making for surgery can increase patient engagement, satisfaction, and clinical outcomes. However, the level of involvement that patients desire at each step of the decision-making process is unknown.

METHODS

The authors surveyed patients at an academic hand surgery clinic to examine the preferred role in decision-making using validated questionnaires (i.e., Control Preference Scale, Problem-Solving Decision-Making Scale, and General Self-Efficacy Scale). The Control Preference Scale assesses general treatment preferences, whereas the Problem-Solving Decision-Making Scale distinguishes between problem-solving tasks (e.g., making diagnoses, calculating risks/benefits) and decision-making tasks. Patients' self-beliefs and perceived ability to handle difficult situations were assessed with the General Self-Efficacy Scale. The authors used linear regression models and ordinal logistic regression to examine the relationship between self-efficacy and patients' preferred role in treatment decision-making.

RESULTS

Patients overall preferred an equal share of decision-making responsibility with the surgeon (mean Control Preference Scale score, 3.3 ± 0.7). Specifically, for problem-solving tasks, however, 81 percent of patients wanted to "hand over" the responsibility and 19 percent preferred shared decision-making. In contrast, for decision-making tasks, 54 percent of patients preferred shared decision-making. Each point increase in General Self-Efficacy Scale score correlated with 12 percent greater odds of preferring to retain the responsibility (OR, 1.12; 95 percent CI, 1.05 to 1.21; p = 0.001). However, self-efficacy did not show a significant effect for problem-solving tasks.

CONCLUSIONS

The authors found that patients prefer surgeons to provide expert knowledge for problem-solving tasks but desire equal share of responsibility in decision-making tasks. The authors' findings support the current shift away from the paternalistic model of surgical decision-making, and provide an effective strategy to tailor shared decision-making to align care delivery with patient preferences.

Perceived involvement in health care decisions among US adults: Sociodemographic and medical condition correlates

OBJECTIVE

To explore factors associated with how often US adults perceived that they were "always" involved in decisions about health care to the degree that they desired.

METHODS

We examined cross-sectional, nationally representative data from the 2018 Health Information National Trends Survey. There were 3504 responses in the full HINTS dataset; 2499 remained after eliminating respondents with missing data for any factor of interest. Sociodemographic factors included age, gender, race/ethnicity, and education. Medical conditions included diabetes, hypertension, heart disease, lung disease, arthritis, cancer, and depression. Participants were asked to think about communication with health professionals during the last 12 months and how often health professionals involved them in decisions about health care.

RESULTS

In univariate analyses, Asian and Hispanic race were associated with lower odds of always being involved in decisions about health care; whereas higher education and a history of cancer were associated with higher odds of "always" being involved in decisions about health care, p < 0.05. In multivariate analyses, race and education both remained significant; however, history of cancer did not.

CONCLUSION

Differences by race/ethnicity and educational attainment exist regarding perceived involvement in decisions about health care.

PRACTICE IMPLICATIONS

Findings may inform future shared decision making interventions.

Implementing online patient feedback in a 'special measures' acute hospital: A case study using Normalisation Process Theory

Objective

Online patient feedback is becoming increasingly prevalent on an international scale. However, limited research has explored how healthcare organisations implement such feedback. This research sought to explore how an acute hospital, recently placed into ‘special measures’ by a regulatory body implemented online feedback to support its improvement journey.

Methods

Semi-structured interviews were conducted with eleven key stakeholders involved in the implementation and/or use of online patient feedback. Data was analysed using deductive thematic analysis with Normalisation Process Theory used as the analytical framework. Research findings are translated into the Engage, Support and Promote (ESP) model, a model of rapid feedback adoption.

Results

Participants viewed the implementation of online feedback as an opportunity to learn, change and improve. Factors found to facilitate implementation were often linked to engagement, support and promotion. Although less frequently described, barriers to implementation included staff anxieties about time pressures, moderation processes and responding responsibilities. Such anxieties were often addressed by activities including the provision of evidence based responder training. Overall, staff were overwhelmingly positive about the value of online feedback with 24 impacts identified at an individual and organisational level, including the ability to boost staff morale, resilience and pride.

Conclusions

The rapid implementation of online patient feedback can be achieved in a ‘special measures’ organisation. However, the difficulties of implementing such feedback should not be underestimated. In order to embed online feedback, staff members need to be engaged and feel supported, with opportunities to provide, respond and invite patient feedback frequently promoted to both patients and staff members.

Clinicians' experiences on patients' demands and shared decision making in Finnish specialized mental health care

PURPOSE

Psychiatric patients' awareness of treatments options and their possibilities to influence their care has increased. For the clinicians, the management of evidence-based care, as well as organizational and resource aspects, set different goals for the clinical encounter. In this article we are focusing on the clinicians' experiences and ask: How do the clinicians view situations in which there is a conflict between patients' individual needs and goals and other aspects in decision-making?

MATERIALS AND METHODS

We implemented a qualitative study of 13 thematic semi-structured interviews with clinicians working in psychiatry. We used discourse analysis to investigate how the clinician view the doctor-patient interaction.

RESULTS

We identified three discources which were termed the medical standpoint, the psychodynamic standpoint and the standpoint of the patient's experience.

CONCLUSIONS

In their talk, the clinicians use the three discources to make sense of the diverse expectations from both the patient and the mental health care system. The three discources also reflect different aspects in psychiatric treatment cultures, such as evidence-based medicine, the ideal of patient-centeredness, therapeutic interaction and organizational requirements.

Computerized Conjoint Analysis of the Weight Treatment Preferences of Individuals With Schizophrenia

OBJECTIVE

Innovative approaches are needed for assessing treatment preferences of individuals with schizophrenia. Conjoint analysis methods may help to identify preferences, but the usability and validity of these methods for individuals with schizophrenia remain unclear. This study examined computerized conjoint analysis for persons with schizophrenia and whether preferences for weight management programs predict service use.

METHODS

A computerized, patient-facing conjoint analysis system was developed through iterative consultation with 35 individuals with schizophrenia enrolled at a community mental health clinic. An additional 35 overweight participants with schizophrenia then used the system to choose among psychosocial weight management programs varying in four attributes: location (community or clinic), delivery mode (Internet or in person), leader (clinician or layperson), and training mode (individual or group). A multilevel logit model with partial preference data determined contributions of each attribute to groupwide preferences. Associations were studied between preferences and use of a psychosocial weight management group.

RESULTS

Conjoint analysis system usability was rated highly. Groupwide preferences were significantly influenced by location (p<0.001; clinic was preferred), leader (p=0.02; clinician was preferred), and training mode (p<0.001; group was preferred) but not delivery mode (p=0.68). Preferences did not correlate with age, gender, body mass index, illness severity, or subsequent program use. Participants described barriers to program attendance, including transportation, scheduling, privacy, psychiatric illness, and lack of motivation.

CONCLUSIONS

Computerized conjoint analysis can produce valid assessments of treatment preferences of persons with schizophrenia and inform treatment development and implementation. Although preferences may affect treatment use, they are one of multiple factors.

Complex skin cancer treatment requiring reconstructive plastic surgery: an interview study on the experiences and needs of patients

To provide patient-centered care, it is essential to explore what patients consider important and to adjust care accordingly. This may specifically be relevant for patients with complex skin cancer, for whom the care process is often more complicated and psychological and social problems may play a larger role. The objective was to explore the experiences and needs of patients who had undergone surgical treatment by a dermatologist for a complex skin cancer with a subsequent reconstruction by a plastic surgeon. An interview study was conducted among 16 patients who had undergone surgical treatment by a dermatologist and reconstruction by a plastic surgeon for basal cell carcinoma, cutaneous squamous cell carcinoma, or lentigo maligna. The interviews focused on patients’ experiences and needs regarding care using a predefined topic list. All interviews were audio-taped, transcribed verbatim and inductively analyzed using Atlas.ti. Patients reported a need for a skilled and friendly physician who tailors information and communication to their individual situation. A need for continuity of care and improved collaboration between healthcare providers was also emphasized. Furthermore, patients experienced complications and unmet expectations and expressed a need for shared decision-making at various steps throughout the treatment process (depending on age). Patients also considered completeness of tumor removal, follow-up visits with multiple specialists to be planned the same day and recognition of the psychological impact of the disease on the partner important. To improve patient-centered care for complex skin cancer patients, more efforts should be directed towards improving continuity of care and collaboration. Furthermore, it is advocated for physicians to be sensitive to the individual needs of patients and their partner and adjust information, communication and (supportive) care accordingly.

The Shared Decision-Making Process in the Pharmacological Management of Depression

Shared decision making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. There is an international consensus across medicine about the importance of SDM interventions, which have raised great interest in mental healthcare over the last decade. Yet SDM is not widely adopted, particularly in the field of psychiatry. The purpose of the present article is to examine, from a patient and physician perspective, the importance of SDM in the management of healthcare with a focus on mental health; it reviews the enablers and barriers (and how to overcome them) to implementing a SDM process in psychiatric practice. SDM models have been developed recently for involving patients with depression in the decision-making process, which could result in augmenting the proportion of patients who adhere to their antidepressant or other treatments for a duration that complies with the current recommendations. To implement this approach, more physicians need training in the SDM approach and access to appropriate tools that help engage in collaborative deliberation, and practice generally needs to be reorganized around the principles of patient engagement.

Shared decision-making between health care providers and patients at a tertiary hospital diabetic Clinic in Tanzania

Background

Patients’ participation in decision making regarding their treatment is defined in ethical, legal and human rights standards in the provision of care that concerns health providers and the entire community. This study was conducted to document experiences of patients and health care providers on shared decision making.

Methods

This study employed a phenomenological study design using in-depth interview technique. Study participants were diabetic patients visiting the clinic and healthcare providers working at Muhimbili National Hospital. Data was collected using the semi-structured interview guide with open-ended questions using an audio digital recorder. Content analysis method was used during analysis whereby categories were reached through the process of coding assisted by Nvivo 12 software.

Results

Participants in this study expressed the role of shared decision-making in the care of patients with diabetes, with report of engagement of patients by health care providers in making treatment decisions. Participants reported no use of decision-making aids; however, health education tools were reported by participants to be used for educating patients. Limited time, patient beliefs and literacy were documented as barriers of effective engagement of patients in decision making by their healthcare providers.

Conclusion

Engagement of patients in decision-making was noted in this study as experienced by participants of this study. Time, patient beliefs and patient literacy were documented as barriers for patients engagement, therefore diabetic clinic at Muhimbili National Hospital need to devise mechanisms for ensuring patients involvement in treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06041-4.

The OPTION Scale: Measuring Patients' Perceptions of Shared Decision-Making in the Kingdom of Saudi Arabia

Background

Involving patients in the decision-making process is now widely accepted as appropriate and ethical during consultations, particularly when several options are available. The aim of this study is to measure the patients’ perceptions of shared decision-making practices during clinical encounters in Saudi Arabia.

Methods

This study employs a quantitative cross-sectional design. The OPTION scale was translated to Arabic. The questionnaire’s content validity was assessed using an expert panel review. The questionnaire was then administered to 291 participants through online recruitment.

Results

Participants reported positive perceptions of shared decision-making practices in Saudi Arabia. The lowest perceived shared decision-making scores were from patients who visited the internal medicine department (f = 2.163, P = 0.009). Participants who received care from female physicians reported significantly higher levels of involvement in the shared decision-making process compared to male physicians (t = −2.732, P = 0.007). Although the majority of the participants in the study were from Eastern Province, this province documented the lowest mean perceived decision-making score by the patients compared to other provinces within Saudi Arabia (f = 3.613, P = 0.007). Female participants in the study had a higher shared decision-making score than the male participants (t = −3.644, P < 0.0001).

Conclusion

Generally, the study results confirmed that shared decision-making in the Saudi health system includes significant patient involvement. Interventions that enhance the culture of shared decision-making in Saudi Arabia are necessary to ensure better adherence to treatment plans and thus better health outcomes.

I am the person who knows myself best: Perception on shared decision-making among hospitalized people diagnosed with schizophrenia in China

Shared decision-making is related to better health outcomes in serious mental illness. It is not well addressed in non-Western cultures, for example Chinese culture. Chinese could be influenced by both paternalism and familism when making treatment decisions. However, this is unexplored. The study purpose is to explore shared decision-making from perspectives of inpatients diagnosed with schizophrenia in China. This study adopted qualitative descriptive approach. Through semi-structured interviews, twelve participants from the psychiatry department of a tertiary hospital shared their perceptions of shared decision-making. An inductive thematic approach was used to analyse the transcripts. Primary results included three main themes with nine subthemes: (1) Having a positive attitude: i) wanting my voice to be heard, ii) needing my family to be involved, and iii) preferring the psychiatrist to decide; (2) Feeling excluded: i) having limited financial capacity, ii) lacking interactive communication, iii) too few psychiatrists, and iv) being unsatisfied with informed consent process; and (3) Self-motivation in decision-making by: i) easing the burden on the family and ii) actively collecting health information. In this context, patients have fewer treatment options and a limited role in SDM. Yet, they have preference for SDM, actively seeking health information from mental health professionals particularly nurses.

Shared decision making for adults with severe mental illness: A concept analysis

AIM

Shared decision making for adults with severe mental illness has increasingly attracted attention. However, this concept has not been comprehensively clarified. This review aimed to clarify a concept of shared decision making for adults with severe mental illness such as schizophrenia, depression, and bipolar disorder, and propose an adequate definition.

METHODS

Rodgers' evolutionary concept analysis was used. MEDLINE, PsychINFO, and CINAHL were searched for articles written in English and published between 2010 and November 2019. The search terms were "psychiatr*" or "mental" or "schizophren*" or "depression" or "bipolar disorder", combined with "shared decision making". In total, 70 articles met the inclusion criteria. An inductive approach was used to identify themes and sub-themes related to shared decision making for adults with severe mental illness. Surrogate terms and a definition of the concept were also described.

RESULTS

Four key attributes were identified: user-professional relationship, communication process, user-friendly visualization, and broader stakeholder approach. Communication process was the densest attribute, which consisted of five phases: goal sharing, information sharing, deliberation, mutual agreement, and follow-up. The antecedents as prominent predisposing factors were long-term complex illness, power imbalance, global trend, users' desire, concerns, and stigma. The consequences included decision-related outcomes, users' changes, professionals' changes, and enhanced relationship.

CONCLUSIONS

Shared decision making for adults with severe mental illness is a communication process, involving both user-friendly visualization techniques and broader stakeholders. The process may overcome traditional power imbalance and encourage changes among both users and professionals that could enhance the dyadic relationship.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

OBJECTIVES

Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.

METHODS

We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.

RESULTS

Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.

CONCLUSION

Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.

PRACTICE IMPLICATIONS

We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

'I have anxiety, but I have values and preferences' Experiences of users with generalized anxiety disorder: A qualitative study

To understand the experience and perceptions of people diagnosed with generalized anxiety disorder, along the whole process and their role through the decision-making process for their treatment. A qualitative study through focus groups composed of people diagnosed with generalized anxiety disorder was carried out. Content analysis was carried out to explore the most representative issues. Five thematic categories were identified: onset of the disorder, symptoms and course; daily life with the disorder; coping with the disorder; demand of healthcare for anxiety, and treatment options and decision-making. Most of the patients reported physical symptoms of anxiety. The majority of participants perceived little social support from their environment and occupational interferences. Coping seems to differ among participant that have recovered or not recovered. The involvement of users with generalized anxiety disorder was scarce, and pharmacological treatment was always the first option offered. There is scarce orientation to elicit preferences and values of patients across the process of care for people with generalized anxiety disorder. The consequence is a biased predisposition of the healthcare system to provide pharmacological treatment as the first option and ignore the perspective of patients on how to cope with their illness.

Perceptions of shared decision-making in severe mental illness: An integrative review

WHAT IS KNOWN ABOUT SHARED DECISION-MAKING?: There is increasing evidence of the positive impact of shared decision-making on health outcomes. There has been little exploration of shared decision-making regarding people diagnosed with serious mental illness from the perspectives of key stakeholders including consumers, families and mental health professionals. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Consumers show variability in the preference for their involvement. Most stakeholders acknowledge the importance of family involvement. MHPs should share the responsibility and right to facilitate consumer involvement. There is bidirectional association between shared decision-making and therapeutic relationships. The practice of shared decision-making is related to multiple factors, and one main perceived barrier is time. The majority of studies are from Western countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Elicit consumer preferences and establish a collaborative therapeutic relationship. Encourage and engage families in treatment decision-making. Inter-professional collaboration should be integrated into shared decision-making. It might require lengthier consultation time. Studies in non-Western countries are needed to fully understand the impact of culture on shared decision-making. Abstract Introduction Shared decision-making (SDM) has been broadly advocated in health services and constitutes an important component of patient-centred care and relationship-based care. Aim To review available literature related to perceptions of key stakeholders about shared decision-making in serious mental illness. Method An integrative review was conducted through a search of four online databases from January 2012 to June 2019. Results Forty-six articles were included. Six themes were generated from the data analysis: (a) dynamic preferences for SDM, (b) various stakeholders are rarely involved, (c) SDM is not routinely implemented, (d) multiple facilitators and barriers to SDM, (e) SDM and therapeutic relationships interact, (f) SDM has a promising impact on health outcomes. Discussion Overall, most stakeholders have recognized the importance and flexibility of SDM in serious mental illness, although it is not routine in mental health service. Consumer preferences show variability in their involvement. Most stakeholders acknowledged the importance of family involvement to treatment decision-making. There are several significant challenges to practice SDM. It may require extended consultation times and increasing empirical evidence regarding the SDM outcomes, as well as integrating inter-professional collaboration into SDM. Most studies were conducted in Western culture. Implications for practice Mental health nurses should elicit consumer preferences and establish a collaborative therapeutic relationship. Encourage and engage families in treatment decision-making when consumers prefer their families to be involved. Inter-professional collaboration should be integrated into shared decision-making. The practice of shared decision-making might need extended consultation time and more robust evidence about the outcome of shared decision-making. Studies in non-Western cultures are needed to fully understand cultural issues of shared decision-making.

Beyond pros and cons - developing a patient decision aid to cultivate dialog to build relationships: insights from a qualitative study and decision aid development

BACKGROUND

An individualized approach using shared decision-making (SDM) and goal setting is a person-centred strategy that may facilitate prioritization of treatment options. SDM has not been adopted extensively in clinical practice. An interprofessional approach to SDM with tools to facilitate patient participation may overcome barriers to SDM use. The aim was to explore decision-making experiences of health professionals and people with diabetes (PwD), then develop an intervention to facilitate interprofessional shared decision-making (IP-SDM) and goal-setting.

METHODS

This was a multi-phased study. 1) Feasibility: Using a descriptive qualitative study, individual interviews with primary care physicians, nurses, dietitians, pharmacists, and PwD were conducted. The interviews explored their experiences with SDM and priority-setting, including facilitators and barriers, relevance of a decision aid for priority-setting, and integration of SDM and a decision aid into practice. 2) Development: An evidence-based SDM toolkit was developed, consisting of an online decision aid, MyDiabetesPlan, and implementation tools. MyDiabetesPlan was reviewed by content experts for accuracy and comprehensiveness. Usability assessment was done with 3) heuristic evaluation and 4) user testing, followed by 5) refinement.

RESULTS

Seven PwD and 10 clinicians participated in the interviews. From interviews with PwD, we identified that: (1) approaches to decision-making were diverse and dynamic; (2) a trusting relationship with the clinician and dialog were critical precursors to SDM; and, (3) goal-setting was a dynamic process. From clinicians, we found: (1) complementary (holistic and disease specific) approaches to the complex patient were used; (2) patient-provider agendas for goal-setting were often conflicting; (3) a flexible approach to decision-making was needed; and, (4) conflict could be resolved through SDM. Following usability assessment, we redesigned MyDiabetesPlan to consist of data collection and recommendation stages. Findings were used to finalize a multi-component toolkit and implementation strategy, consisting of MyDiabetesPlan, instructional card and videos, and orientation meetings with participating patients and clinicians.

CONCLUSIONS

A decision aid can provide information, facilitate clinician-patient dialog and strengthen the therapeutic relationship. Implementation of the decision aid can fit into a model of team care that respects and exemplifies professional identity, and can facilitate intra-team communication.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.

Veterans Affairs Providers' Beliefs About the Contributors to and Responsibility for Reducing Racial and Ethnic Health Care Disparities

Purpose: Providers' beliefs about the causes of disparities and the entities responsible for addressing these disparities are important in designing disparity-reduction interventions aimed at providers. This secondary analysis of a larger study is aimed at evaluating perceptions of providers regarding the underlying causes of racial health care disparities and their views of who is responsible for reducing them. Methods: We surveyed 232 providers at 3 Veterans Affairs (VA) Medical Centers. Results: Sixty-nine percent of participants believed that minority patients in the United States receive lower quality health care. Most participants (64%) attributed differences in quality of care for minority patients in the VA health care system primarily to patients' socioeconomic status, followed by patient behavior (43%) and provider behaviors (33%). In contrast, most participants believed that the VA and other health care organizations (75%) and providers (70%) bear the responsibility for reducing disparities, while less than half (45%) believed that patients were responsible. Among provider-level contributors to disparities, providers' poor communication was the most widely endorsed (48%), while differences in prescribing of medications (13%) and in provision of specialty referrals (12%) were the least endorsed. Conclusions: Although most providers in the study did not believe that providers contribute to disparities, they do believe that they, along with health care organizations, have the responsibility to help reduce them. Interventions might focus on directly offering providers concrete ways that they can help reduce disparities, rather than focusing on simply raising awareness about disparities and their contributions to them.

Implementation and Use of a Client-Facing Web-Based Shared Decision-Making System (MyCHOIS-CommonGround) in Two Specialty Mental Health Clinics

Electronic shared-decision making programs may provide an assistive technology to support physician-patient communication. This mixed methods study examined use of a web-based shared decision-making program (MyCHOIS-CommonGround) by individuals receiving specialty mental health services, and identified qualitative factors influencing adoption during the first 18 months of implementation in two Medicaid mental health clinics. T-tests and χ2 analyses were conducted to assess differences in patient use between sites. Approximately 80% of patients in both clinics created a MyCHOIS-CommonGround user profile, but marked differences emerged between clinics in patients completing shared decision-making reports (79% vs. 28%, χ2(1) = 109.92, p < .01) and average number of reports (7.20 vs. 3.60, t = - 3.64, p < .01). Results suggest high penetration of computer-based programs in specialty mental health services is possible, but clinic implementation factors can influence patient use including leadership commitment, peer staff funding to support the program, and implementation strategy, most notably integration of the program within routine clinical workflow.

Psychometric properties of the Arabic version of the 9-item Shared Decision-Making Questionnaire: the entire process from translation to validation

OBJECTIVE

To translate the German 9-item Shared Decision-Making Questionnaire (SDM-Q-9) to Arabic and assess its psychometric properties for measuring Arabic-speaking patients' perceptions of the shared decision-making (SDM) process.

DESIGN

Multicentre cross-sectional study.

SETTING

Secondary healthcare settings; outpatient clinics of 10 major hospitals were selected in four emirates in the United Arab Emirates (Abu Dhabi, Dubai, Sharjah and Umm Al Quwain).

PARTICIPANTS

Patients with chronic diseases who attended outpatient clinics of participating hospitals.

MEASUREMENTS

The original German SDM-Q-9 was translated to Arabic. International multiphase translation guidelines and the process of cross-cultural adaptation of self-reported measures were used. Various psychometric properties were assessed, including reliability (internal consistency), and construct validity (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA]).

RESULTS

The final Arabic version of the SDM-Q-9 was tested among 516 secondary care patients. Internal consistency yielded a Cronbach's alpha of 0.929 for the whole scale. EFA showed a one-factorial solution, Kaiser-Meyer-Olkin measure of sampling adequacy was 0.907 and Bartlett's test of sphericity was significant (χ2=3413.69, df=36, p<0.0005). For the CFA, two different models were tested; Model 1 included the nine items and Model 2 was monofactorial that included items 2-9 and thus excluded item 1. Both models were adequate as they produced similar indices.

CONCLUSIONS

The Arabic version of SDM-Q-9 showed excellent reliability and acceptable validity parameters among secondary care patients. The newly translated Arabic questionnaire is the first psychometrically tested tool that can be used in the 22 member states of the Arab league to assess patients' perspectives on the SDM process.

Shared Decision Making in Psoriasis: A Systematic Review of Quantitative and Qualitative Studies

BACKGROUND

Patients with psoriasis face numerous treatment and self-management decisions. Shared decision making is a novel approach where patients' preferences and values are considered in cooperation with healthcare professionals before making treatment decisions.

OBJECTIVE

The objective of this systematic review was to explore what is illuminated in psoriasis research regarding shared decision making, and to estimate the effects of shared decision-making interventions in this context.

METHODS

Qualitative, quantitative, and mixed-methods studies were eligible for inclusion. We searched six electronic databases up to January 2018. Two reviewers independently applied inclusion and quality criteria. The SPIDER framework was used to identify eligibility criteria for study inclusion. Narrative and thematic syntheses were utilized to identify prominent themes emerging from the data.

RESULTS

A total of 23 studies were included in the review. Of these, we included 18 studies (19 papers) to describe what was illuminated with regard to shared decision making in psoriasis research. Four major themes emerged: interpersonal communication; exchange of competence and knowledge; different world view; and involvement and preference, organized under two analytical themes; "Co-creation of decisions" and "Organization of treatment and treatment needs". For shared decision-making effects, we included four controlled studies. These varied in scope and interventional length and showed limited use of shared decision making-specific outcome measures, reflecting the early stage of the literature. Because of study heterogeneity, a meta-synthesis was not justified.

CONCLUSIONS

There appears to be a need to strengthen the relationship between medical doctors and patients with psoriasis. The evident lack of knowledge about each other's competence and the lack of self-efficacy for both patients and providers challenges the basic principles of shared decision making. The effects of shared decision making in psoriasis are inconclusive, and more research appears necessary to determine the possible benefits of shared decision-making interventions.

Effectiveness of a multi-facetted blended eHealth intervention during intake supporting patients and clinicians in Shared Decision Making: A cluster randomised controlled trial in a specialist mental health outpatient setting

OBJECTIVE

To investigate the effectiveness of a multi-facetted blended eHealth intervention, called SDM-Digital Intake (SDM-DI), in which patients and clinicians are supported in Shared Decision Making during the intake process.

METHODS

The study is a two-arm matched-paired cluster Randomised Controlled Trial in a specialist mental health outpatient setting with two conditions: SDM-DI and Intake As Usual (IAU). Four intake teams were allocated to each arm. All patients who followed an intake, were asked to participate if they were capable to complete questionnaires. Decisional Conflict (DC), referring to patients' engagement and satisfaction with clinical decisions, was the primary outcome. Secondary outcomes were patient participation, applying Shared Decision Making (SDM), working alliance, treatment adherence and symptom severity. Effects were measured at two weeks (T1) and two months (T2) after intake. Multilevel regression and intention-to-treat analyses were used. Additionally, the influence of subgroups and intervention adherence on DC were explored.

RESULTS

At T1, 200 patients participated (47% intervention, 53% control), and at T2 175 patients (47% intervention, 53% control). At T1 and T2, no differences were found between conditions on DC. Subgroup analyses showed that effects of SDM-DI on DC were not modified by primary diagnoses mood, anxiety and personality disorders. Compared to IAU, at T2, patients reported positive effects of SDM-DI on SDM (β 7.553, p = 0.038, 95%CI:0.403-14.703, d = 0.32) and reduction of symptoms (β -7.276, p = 0.0497, 95%CI:-14.544--0.008, d = -0.43). No effects were found on patient participation, working alliance and treatment adherence. Exploratory analyses demonstrated that if SDM was applied well, patients reported less DC (β = -0.457, p = 0.000, 95%CI:-0.518--0.396, d = -1.31), which was associated with better treatment outcomes.

CONCLUSION

Although, this trial fails to demonstrate that SDM-DI by itself is sufficient to reduce DC, the results are encouraging for further efforts in improving and implementing the SDM intervention.

Implementing shared decision making in routine mental health care

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non-maleficence. It is argued that SDM is "polyvalent", a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high-quality decision support tools; integrating SDM with other recovery-supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes - social marketing and the hospitality industry - are identified.

A digital intake approach in specialized mental health care: study protocol of a cluster randomised controlled trial

BACKGROUND

Enhancing patient participation is becoming increasingly important in mental health care as patients use to have a dependent, inactive role and nonadherence to treatment is a regular problem. Research shows promising results of initiatives stimulating patient participation in partnership with their clinicians. However, few initiatives targeting both patients' and clinicians' behaviour have been evaluated in randomised trials (RCT). Therefore, in GGz Breburg, a specialized mental health institution, a digital intake approach was developed aimed at exploring treatment needs, expectations and preferences of patients intended to prepare patients for the intake consultations. Subsequently, patients and clinicians discuss this information during intake consultations and make shared decisions about options in treatment. The aim of this trial is to test the efficacy of this new digital intake approach facilitated by Routine Outcome Monitoring (ROM), peer support and training of clinicians as compared to the intake as usual. The primary outcome is decisional conflict about choices in treatment. Secondary outcomes focus on patient participation, shared decision making, working alliance, adherence to treatment and clinical outcomes.

METHODS

This article presents the study protocol of a cluster-randomised controlled trial in four outpatient departments for adults with depression, anxiety and personality disorders, working in two different regions. Randomisation is done between two similar intake-teams within each department. In the four intervention teams the new intake approach is implemented. The four control teams apply the intake as usual and will implement the new approach after the completion of the study. In total 176 patients are projected to participate in the study. Data collection will be at baseline, and at two weeks and two months after the intake.

DISCUSSION

This study will potentially demonstrate the efficacy of the new digital intake approach in mental health care in terms of the primary outcome the degree of decisional conflict about choices in treatment. The findings of this study may contribute to the roll out of such eHealth initiatives fostering patient involvement in decision making about their treatment.

TRIAL REGISTRATION

Trial registration: Dutch Trial Register NTR5677 . Registered 17th January 2016.

Aggression in psychiatric hospitalizations: a qualitative study of patient and provider perspectives

BACKGROUND

When the people hospitalized in psychiatric units demonstrate aggression, it harms individuals and creates legal and financial issues for hospitals. Aggression has been linked to inpatient, clinician and environmental characteristics. However, previous work primarily accessed clinicians' perspectives or administrative data and rarely incorporated inpatients' insights. This limits validity of findings and impedes comparisons of inpatient and clinician perspectives.

AIMS

This study explored and compared inpatient and clinician perspectives on the factors affecting verbal and physical aggression by psychiatric inpatients.

METHODS

This study used an interpretive theoretical framework. Fourteen inpatients and 10 clinicians were purposefully sampled and completed semi-structured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Six themes were identified at personal and organizational levels. The three person-level themes were major life stressors, experience of illness and interpersonal connections with clinicians. The three organization-level themes were physical confinement, behavioural restrictions and disengagement from treatment decisions.

CONCLUSIONS

Aggression is perceived to have a wide range of origins spanning personal experiences and organizational policies, suggesting that a wide range of prevention strategies are needed.

Families and medication use and adherence among Latinos with schizophrenia

BACKGROUND

Medication nonadherence among Latinos with schizophrenia represents a significant treatment obstacle. Although some studies have examined patient and family perceptions of adherence, few have examined these perceptions together. However, such knowledge can provide a deeper understanding of how family processes may contribute to or impede adherence among underserved groups such as Latinos.

AIMS

This study explored perceptions of medication and adherence among Latinos with schizophrenia and key family members.

METHOD

Purposive sampling was used to collect data from 34 participants: 14 patients with schizophrenia receiving community-based mental health services in an urban public setting and 20 key family members. Informed by grounded theory, semistructured interviews were analyzed by bilingual-bicultural team members.

RESULTS

Salient themes emerged indicating facilitators of and obstacles to medication use. Specifically, challenges centered on medication side effects, autonomy and choice, and illness insight, whereas facilitators focused on family support and holistic views of treatment and empowerment.

CONCLUSIONS

Because the majority of Spanish-speaking Latinos with schizophrenia live with family, it is important to examine family factors that may influence medication use. Findings suggest that patient and family perceptions of medication should be examined as part of the treatment process, particularly regarding issues of autonomy and choice.

From providing a service to being of service: advances in person-centred care in mental health

PURPOSE OF REVIEW

This review explores the concept of person-centred care, giving particular attention to its application in mental health and its relationship to recovery. It then outlines a framework for understanding the variety of approaches that have been used to operationalize person-centred care, focusing particularly on shared decision-making and self-directed care, two practices that have significant implications for mental health internationally.

RECENT FINDINGS

Despite growing recognition of person-centred care as an essential component of recovery-orientated practice, the levels of uptake of shared decision-making and self-directed care in mental health remain low. The most significant barrier appears to be the challenge presented to service providers by one of the key principles of person-centred care, namely empowerment.

SUMMARY

Shared decision-making and self-directed support, two practices based upon the principles of person-centred care, have the potential for being effective tools for recovery. Full engagement of clinicians is crucial for their successful uptake into practice. More research is needed to address both outcomes and implementation.

Shared decision making in Swedish community mental health services - an evaluation of three self-reporting instruments

BACKGROUND

Despite the potential impact of shared decision making on users satisfaction with care and quality in health care decisions, there is a lack of knowledge and skills regarding how to work with shared decision making among health care providers.

AIM

The aim of this study was to evaluate the psychometric properties of three instruments that measure varied dimensions of shared decision making, based on self-reports by clients, in a Swedish community mental health context.

METHOD

The study sample consisted of 121 clients with experience of community mental health care, and involved in a wide range of decisions regarding both social support and treatment. The questionnaires were examined for face and content validity, internal consistency, test-retest reliability and construct validity.

RESULTS

The instruments displayed good face and content validity, satisfactory internal consistency and a moderate to good level of stability in test-retest reliability with fair to moderate construct correlations, in a sample of clients with serious mental illness and experience of community mental health services in Sweden.

CONCLUSIONS

The questionnaires are considered to be relevant to the decision making process, user-friendly and appropriate in a Swedish community mental health care context. They functioned well in settings where non-medical decisions, regarding social and support services, are the primary focus. The use of instruments that measure various dimensions of the self-reported experience of clients, can be a key factor in developing knowledge of how best to implement shared decision making in mental health services.

Engaging African-American Veterans in Mental Health Care: Patients' Perspectives

Despite growing interest in patient engagement, the concept remains poorly defined. Moreover, patients' perspectives on engagement are lacking, particularly those of minority patients. A better understanding of patients' views and what influences their engagement in health services will facilitate better patient education and implementation practices to enhance patient participation in health care. This article addresses patients' perspectives of facilitators and barriers to engagement in outpatient mental health services. Forty-nine African-American veterans with mental illness receiving routine medication management visits were interviewed. Qualitative data analysis was guided by a constructivist grounded theory approach. Participants identified several barriers and facilitators to engagement in mental health services, including patient as well as provider-related factors. Results emphasize the role of providers in facilitating sustained involvement of patients in their own care. Based on the findings, the authors offer a preliminary framework for patient engagement that encompasses patient and provider factors.

Non-helpful relationships with professionals - a literature review of the perspective of persons with severe mental illness

BACKGROUND

The relationship with professionals has proved to be important with regard to outcome for persons with severe mental illness (SMI). The understanding of non-helpful relationships is important complementary knowledge to that regarding helpful relationships.

AIM

To review the available qualitative research providing knowledge of non-helpful relationships from the perspective of persons with SMI.

METHOD

A review of qualitative studies, based on an earlier systematic search, analyzed through thematic analysis.

RESULTS

The main themes were "non-helpful professionals", "organization versus relation" and "the consequences of non-helpful relationships with professionals". Examples of professionals described as non-helpful were pessimistic and uncaring professionals who were paternalistic and disrespectful. Discontinuity, insufficient time and coercion were some of the contextual factors described as non-helpful. These sorts of relationships were non-helpful because they hindered helpful relationships from developing and contributed to further suffering, instilling hopelessness and hindering personal growth.

CONCLUSIONS

Non-helpful relationships with professionals can be understood as impersonal relationships that contain no space for negotiation of the relationship nor of the support and treatment provided through it. It is important that organizations provide professionals with favorable conditions to negotiate the organizational framework and to treat persons with SMI as whole human beings.