Shared Decision-Making Principles in Healthcare
Introduction, benefits of shared decision making, principles of shared decision making.
Shared decision making is an essential component of patient-centered healthcare. It is the process in which patients and health professionals work together to select treatments and healthcare plans and make decisions that balance the risks and expected outcomes with patients’ preferences and values (Bae, 2017). To provide effective care, healthcare workers need to understand the concepts relevant to shared decision making and follow the basic principles stipulated in the following bulletin.
Shared decision making provides a number of benefits to both patients and health care professionals.
- It increases patient satisfaction and leads to better health outcomes (Agency for Healthcare Research and Quality 2020).
- Patients who are involved in choosing their treatment experience less anxiety and depression, quicker recovery, and increased compliance with treatment regimens (Agency for Healthcare Research and Quality 2020).
- Greater patient involvement leads to the reduction of healthcare costs (Bae 2017).
- It improves the quality of patient-physician communication, allowing people receiving and delivering care to understand what is important for other person, which improves both patients’ and doctors’ satisfaction (Agency for Healthcare Research and Quality 2020).
For effective shared decision making, a number of principles need to be observed. First, patients need to be given extensive information about the possible choices. Many patients experience frustration and dissatisfaction with their care because they do not feel like they have adequate input into the decisions that their doctors make about their health (Agency for Healthcare Research and Quality 2020). They do not understand the evidence behind the decisions and do not have enough knowledge to evaluate the available treatment options. The solution is to share with the patients all available information about their care and make sure that they accurately understand it. Patient decision aids are instruments used to explain the issues fairly and, explain the pros and cons of each option, and provide support for patients require it.
Second, healthcare providers should be supportive of patient involvement in the decision-making process. Currently, some health professionals do not approve of patient involvement, while others support the concept but do not know how to put it into practice (Agency for Healthcare Research and Quality 2020). Relevant education should be provided to doctors and nurses to ensure that they can effectively communicate with patients and encourage them to make informed healthcare decisions (Bae 2017). They need to learn to ask questions corresponding to individual patient’s characteristics, extract relevant patient information from various sources, and collaborate with other health specialists to ensure effective care.
The third recommendation for efficient decision making pertains to end-of-life and palliative care. When treating patients with late-stage terminal diseases, health professionals need to choose between fighting to prolong their lives or giving up and keeping a patient comfortable ( Talks at Google 2017). Dealing with mortality means to not giving a patient a good death but a good life up until the end, and the most important thing for health professionals is to find a compromise between quantity and quality of care.
The most important thing in providing end-of-life care is to determine a patient’s priorities and focus on them. Healthcare specialists usually give the utmost attention to prolonging an individual’s life without caring about what is important for them ( Talks at Google 2017). Involving other goals besides surviving into the healthcare process includes providing palliative care to patients from the early stages of terminal illnesses.
Palliative care deals with improving the patient’s quality of life and focuses on goals rather than options. The studies show that the patients who started palliative care at the early stages of disease generally produce better outcomes. They are 90% less likely to be on chemotherapy in the last two weeks of their lives, and 50% less likely to start chemo during the last three months of their lives ( Talks at Google 2017). They spend more time at home and are less likely to die in the hospital. They experience less suffering, including depression and anxiety, and, as a result, live 25% longer than patients who do not receive palliative care. The same principles can be applied to treating regular patients—pay more attention to their needs, values, and priorities to ensure effective care.
The practice of shared decision making is based on several principles that should be implemented by doctors and nurses in healthcare facilities to provide effective care. The first is giving patients all possible information about available treatment options and ensuring that they fully understand them. The second is being supportive of patient involvement in the decision-making process. The third is focusing on an individual’s priorities and quality of life rather than on general surviving. These principles are particularly important in end-of-life care that generally gives more attention to options rather than goals. Listening to patients, determining their life priorities, and considering them facilitates shared decision making, increases patient satisfaction, and provides better health outcomes.
Agency for Healthcare Research and Quality. 2020. “Strategy 6I: Shared decisionmaking.” Web.
Bae, Jong-Myon. 2017. “Shared decision making: Relevant concepts and facilitating strategies.” Epidemiology and Health 39. Web.
Talks at Google. 2020. Being Mortal: Medicine and What Matters in the End. Atul Gawande. Talks at Google.” Web.
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Decision-making in Nursing 3000 words degree level
Decision Making in District Nursing
The aim of this assignment is to discuss and analyze a decision made in practice. All nurses make clinical decisions; they make clinical judgments about the need of patients in their care.
Nursing clinical decision can be referred to as clinical reasoning, clinical judgment, inference and diagnostic reasoning (Thompson, 2004).
It is an ability of a practicing nurse to correctly identify, define and solve problems which are uniquely nursing in origin.
Nurses’ clinical decisions and actions are evidence-based practices, and involve the nurse using scientific knowledge and nursing processes (assessment, diagnosis, planning, implementation and documentation) to consider a client care situation and then make judgments about what to do in that situation. The clinical judgments and decisions about actions underpinning the care are essential for the outcome and quality of care.
WHY DO CLINCAL DECISIONS MATTER TO PATIENTS
The patient is the direct receiver of the intervention resulting from a nursing decision. The client should receive well planned individualized intervention, and participate in all steps of the process of decision making and he is assured of continuity of care through well written planned care. Thus to some extent he could feel confidence in this form of caring unlike the one he could receive elsewhere from technical ancillary staff with no plan (Warr, J (2006))
The use of nursing decisions does not only benefit the clients who receive the care; they also benefit the nurses who provide the care, because it provides an increasing autonomy in nursing practices, helping nurses identify their independent practice domain. The use of nursing decisions provides a common referencing system, and common terminology to serve as a base for improving clinical practices. Most importantly, it serves as a framework through which quality of care can be evaluated.
Other health care institutions also benefit from nursing decisions, the nursing process through better resource utilization, and increased client satisfaction and improved documentation of care.
This case will analyze a 44 year old man who had an accident and was been referred to district nurses from the care team. For the purpose of identity and in accordance with (NMC, 2004) code of professional conduct of confidentiality, the name of the patient shall not be revealed.
The patient had an abscess developed on his hip, had a history of diabetes Type 2, drug misuse and aggression. The nurses visit the patient and assess him. The patient is in a very distressed situation and was not allowing anybody to move him from his bed. His personal hygiene was very poor and the nurses found it very difficult to move him around to do the dressings. Different nurses in the team offered help to change his clothing and position, but he doesn’t like them to do that. Even though the patient didn’t want to let others check his pressure area, the district nurse took the decision to check his pressure area anyway. First of all, the patient denied access to her to check his pressure area, but the District Nurse (DN) was very assertive and tried to persuade him and make him understand that the need of pressure area check, care and prevention, and she gained consent eventually.
DN conducted an assessment of the patient with Pressure Ulcer Risk Assessment Tool (PURAT) by following the trust policy. While checking physically the patient had already developed a pressure sore of Grade II on his sacral area. Based on the assessment DN coordinated with the medical equipment team to have a hospital bed with pressure relieving (air-flow) mattress, hoist and slide sheet and a treatment plan then agreed upon. Usually factors such as mobility impaired, diabetes, incontinence etc, are risk factors to pressure ulcer (Lesley, 2006)
During an informal conversation with the patient, he expresses his depression over his chronic condition, incontinence and impaired mobility, resulting in his feeling of worthlessness. He claimed to have given up on himself to seek any further medical treatment. Patient feelings are not possible to detect unless verbalized by the patient, Andrew (2004). From this reason, it becomes imperative to rely on patient response. In order to protect him from harming himself more, this decision was agreed upon by DN and inter professional team.
HOW PRIORITY WAS DECIDED
The priority was decided based on the assessment of the risk; priority is given to risks that pose immediate danger to patient. In this case immobility and patient history of diabetes is considered as a priority to make the aforementioned decision. According to the National institute for health and clinical excellence (NICE) (NHS) quick reference guide (2005) distributed to health professional in NHS across England, the key priorities were mentioned. It is said patient should receive an initial and ongoing risk assessment in the first episode of care (within 6 hours). Research suggests that hourly turn and using of ripped mattress are the main intervention for pressure ulcer (NICE Clinical Guideline No. 7).
All those who are vulnerable to pressure ulcer should as a minimum be placed on a high specification foam mattress. The pressure relieving devices should be choose on the risk assessment, location and causes of the pressure ulcer if present and skin assessment. A registered nurse must act to identify and minimize the risk to the patient. NMC (2004)
TOOLS AND SERVICES USED
The tool that was helpful in making this decision is called Pressure Ulcer Risk Assessment Tool (PURAT). This is completed on the patient first visit and regularly re-assessed. This assists registered health care professionals to assess the patient. Any form of tools that gives an opportunity to carry out assessment on various risk factors as priority before making a decision could be considered adequate. The rational model approach is based around cognitive judgments of pros and cons of various options. It is organized around selecting the most logical and sensible alternative that will have desired effect.
Forms of service had being set up to govern and manage pressure ulcers in accordance with National institute of health and clinical excellence (2005), such as European Pressure ulcer advisory panel guidelines (EPUAP, 2010). Safeguarding Vulnerable Adults policy (Wiltshire, 2008)
ROLE OF KNOWLEDGE, SKILLS AND EXPERIENCE IN DECISION MAKING
Effective clinical decision-making is a vital and essential component of professional nursing practices. In every human activity, including nursing, there is always a risk of errors of judgment or faulty reasoning: that is human error.
Jane Coiffed, a researcher, manages to illustrate the complex interplay between clinical experience, judgment tasks and accuracy. Nurses’ competency is a key factor in clinical decision making, and this could only come from their personal knowledge, skills and experiences according to Bakalis (2006).
Decisions are drawn from a variety of sources of information and this requires knowledge and skills. Being able to weigh up merit of evidence from number of sources and apply a systemic approach to determine conclusions upon which to make course of actions is the essence of acquired skills. The personal knowledge that a nurse brought to the diagnostic task play an important role in the way the problem will be interpreted. This could affect the outcome for the patient, which depends on the nurse interpretation.
In every institution, people makes decisions and it is no different in the case of nursing clinical decisions; however, the emphasis is being placed upon knowledge and experience gained over an extended period of time through clinical practice (war ,2006). Such knowledge and skills are necessary to help in making clinical decisions about the patient, with expected positive outcomes.
DECISION MAKING USING INTUITION APPROACH
Addressing the fundamental of problem identification, ideas flows only when a person is able to identify a problem and communicate with others. When making decisions, nurses, like all people, are subject to uncertainty, error and heuristic short-cuts (Dowding and Thompson 2004). It was further proved that these heuristics are fallible and can introduce unhelpful bias into decision making. Although there are differences in the way a novices and expert make decisions, the finding according to Benner (2008), has it that experts often used less information in making a more accurate diagnosis and generating more alternative actions, more specifically in evaluating alternative actions and developing better nursing plan information than the novice. However, there is potential of intuitive capability. Nurses in whichever setting are articulating significant questions; moreover, they may themselves develop personal theories about patient care.
Partricia Berner (1987) explains nurses decision making along the intuition approach, intuition being the immediate and almost instinctive knowing of something without the conscious use of reasoning or rational thought processes. Some nurses practitioners may not have being aware of the significance of the phenomenon they observed, or the relationship of their ‘hunch’ about a situation. In addition, they may not communicate this to others well if at all – for instance, in the case of the observation of a nurse in a medical setting where a decision is made within a few short minutes. One good example is a nurse interacting with patients who comes in weekly for dialysis. The observation of such nurses, who are consistently able to decide within few minutes of interaction with patient, may contribute to a decision as to whether these patients’ daily dialysis will be completed efficiently and effectively without complication. This is uncertain and rather evolves out of outcome criteria that are more predictive. Nurses as health practitioners sometimes appear intuitive to outside observers and feels internalized within the practice. Clinical knowledge could be communicated; this will be a step to further development of conceptual ideas.
On the other hand, the analytical approach uses information process theory (hypothetical-deductive approach ), which examines how nurses and doctors reason when making judgment and decision and this approach can be demonstrated to others if necessary. Orielly (1993) confirmed that experience and knowledge are two major factors affecting decision making, and that this will in turn affect the outcome. War (2006) reports that the model each nurse uses for decisions depends on the task and context of the situation, but not the level of knowledge and experiences.
The weakness in the intuition types of approach is the lack of inability to formulate questions about an important phenomenon where that could warrant conceptualization of an important aspect of care. Intuition types of approach is an unconscious types of decision making, as such it does not give rooms to linear thinking. Notwithstanding, this approach has the advantage of being very relevant in the situation where carrying out an emergency action becomes a priority.
According to Nordgren (2006), describing the informative approach of decision making observed that human conscious minds has limited ability to understand information, thus supporting collecting information and investigating it before making a final decision. The outcome of decision could be predicted in informative approach theory. Another advantage of this is that it could be applied to solve complex matters. Scientifically based rules can aid formative (hypothetical –deductive approach) theory. Going by the hypothetical-deductive approach may be rewarding, research suggests that an individual goes through a number of phrases in their reasoning process: the cue acquisition, hypothesis, interpretation and evaluation. This provides enough information about the patient as well as enabling nurses to communicate the situation with the patient. In a scenario such as an emergency situation, the choice of using the hypothetical-deductive approach may not be realistic.
DIFFICULTIES AND DEFICITS AFFECTING DECISION MAKING
Multifarious social, political and economic changes have had a dramatic effect on health and nursing. Numerous factors influence clinical the decision making process, such as:
CRITICAL THINKING. Problem solving and decision making are predicted on individuals ability to think critically. Critical thinking is defined by the National council for excellence in critical thinking instruction (Nordgren (2006)) to be an intellectually disciplined process of actively and skilfully conceptualizing, applying, analyzing, synthesizing or evaluating information gathered from or generated by observation, experience, reflection, reasoning or communication as a guide to belief and action. This ability is manifested whenever nurse practitioners could ask why, what or how. A nurse who asks why a patient is restless is engaging a critical thinking. This avoids making any assumptions, but is rather the investigating the possible causes through a decision making process.
This is an essential criterion for the generation of option or solution. Creative individuals are able to conceptualize new and innovative approaches to a problem or issues by being more flexible and independent in their thinking. There is a relationship between the clinical judgment, decision making, creativity and critical thinking.
Situation that leads to stress can sometimes be unbearable situations. An individual perceives a stressful environment as being demanding and threatening to their personal well being. Those who have internal locus of control view life as challenging and have motives of having influence on the outcome of stressful life events. Those with internal locus are able to deal with stress more effectively than those without it. Therefore, it could be said that because stress interferes with a person’s concept of self efficacy, extreme stress can have negative impact affecting thinking and decision making.
Deficient performance could be observed in shift workers principally because of circadian rhythm disruptions (Bakalis, 2006). Performance and cognitive functioning are influenced by circadian rhythms: natural rhythms of day and night in a 24 hour day. Shift workers are prone to alertness as well as performance problem as a result of altered circadian rhythm; this could result in impaired attention, judgment, accuracy and safety. This suggests shift working sometimes to be a barrier to the effective nursing decision process.
ETHICAL AND LEGAL CONSIDERATIONS. The large number of ethical issues facing nurses in clinical practice makes the established codes of ethics for nurses critical to the moral and ethical decision making process. The ICN Code of Ethics for nurses (2006) helps guide nurses in setting priorities, making judgments and taking action when faced with ethical dilemmas in clinical practices. Beliefs, practices, habits, likes, customs and rituals are all forms of ethical consideration that could affect the decision making process in nursing practice.
KNOWLEDGE AND EXPERIENCE. According to Banner (1984), nursing practice does not require knowledge alone for an individual to be a perfect practitioner or to be able to make good clinical decision; clinical experience is also an important tool for good clinical practice and performances.
This is another aspect that contributes to decision making clinical decision, and is a social activity involving health care team members and the patient. One of significant influence for nurses involves their relationship with the physician. Haddad, Stein (1967) saw the communicating pattern used by physician and nurses as a nurse-doctor game.
The principle is that overt disagreement must be avoided; in order to obey the rules, nurses must communicate their recommendations without appearing to make recommendations (Porter, Haddad 1991). According to an observation by Joseph (1985), experienced nurses are less likely to feel that nurses should assume responsibility, and this reluctance to assume responsibility creates a barrier to effective clinical decision making.
In this aspect, competence is a major factor: nurses’ personal intelligence and knowledge brings about belief in one’s ability. Perception of being less intelligent, competent or educated brings about the feelings which could result in relinquished authority to those perceived as being better (Joseph1985:22). The extent to which a person believes they can control events and outcome relies on level of self efficacy as well as any self concept.
Sometimes inadequate number of staff for the task required could affect the decision making process; likewise, this inadequacy could be related to the skill index as well. For instance, in a situation where novice nurses were being added or replaced experienced staff, experienced nurses encountered the additional effort of educating, advising and supporting inexperience nurses. Young and inexperienced nurses require more supervisory and coping support than their older counterparts. The performance of a task for the first time as novices staff nurse and the presence of highly skilled people, are all factors that can increase anxiety and alter the decision making process.
Why these difficulties arise could be as a result of differing factors: increasing diversity in employment settings (especially in the NHS), types of health care providers, hospital policy and governance, cost of effective results, people’s sexual orientation, believes and cultures, races/ethnicities and customs.
Clinical decision making is a complex process. It is necessarily an integral part of the nursing profession to make decision about their patients, and it is the responsibility of every nurse to make judgments about the need of the patients in their care. It therefore really matters how nurses make decisions, and how careful should they be before making them. Nursing is a noble profession and has the obligation to reduce the risk to patients to the absolute minimum possible, and thus provide safe treatment. The decision nurses made must be explicable and defensible; therefore, it becomes necessary to follow a set of clinical guideline and base their actions on evidenced based practices.
The demanding nature of nursing practice involves the making of clinical decisions that are informed by the most relevant and valid evidence available. This becomes necessary in order to have a safe practice, and also as necessary protection against legal action, for individuals and institutions. A number of policies and professionals today have been in place to ensure every clinical practice has checks and balances. A great many agencies and bodies across the country are responsible for regulating health care services in order to maintain, as well as upgrade, the standard of the services: bodies such as the NHS, the Nursing medical council-NMC UK, the National institute of health and clinical guidance etc.
In the UK and western world generally, great emphasis is placed on the need for health care professionals to account for all decisions they make when caring for the patient – with or on behalf of their client. The national library of guidelines based on guidelines produced by the NHS has been produced in the UK specifically for the systemic review of evidence and to have extensive consultation with clinicians, patient and – where relevant – the profession itself.
The World Health Organization has initiated recent innovation and improvement by recently publishing, in international journals, articles about quality care, and has launched performance assessment tools for quality improvement in hospitals. This was specifically aimed at assessing, as well as improving, the performance of clinical work in every hospital worldwide. It can therefore be deducted that the nursing practitioner as well as health care cannot just make decisions: they have to be based on real clinical evidence.
Moreover, nurses can ensure making the best possible decision they can by combining knowledge from various sources, including personal knowledge, experience, theoretical and evidence based practices. As long as a decision is based on the best evidence, information and clinical judgment available, it will be best decision that can be made at the time with knowledge available at the time – though that does not mean it will always be always be the ‘best’ decision, in retrospect: life – and decision-making – will never be perfect.
Nurses’ use a range of information to make clinical judgments and always have; but whatever the outcome, competency and knowledge as well as firsthand experience increase the cognitive resources available for interpretation of data, resulting in more accurate – and better – decision making to the benefit of all.
Andrew Gray and Stephen Harrison (2004), Journal of Social Policy
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Introduction to Evidence-Based Practice in Nursing and Healthcare By Kathy Malloch, Timothy Porter-O’Grady. Copyright 2010
Leading and managing in nursing 7 th edition 2002 By Patricia S. Yoder-Wise
Describing critical thinking
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Shared Decision-Making for Nursing Practice: An Integrative Review
1 Pace University, College of Health Professions, Lienhard School of Nursing 861 Bedford Road Pleasantville, NY 10570, USA
Jason T. Slyer
2 Clinical Assistant Professor, Pace University, College of Health Professions, Lienhard School of Nursing 163 William Street, 5 th Floor New York, NY 10036, USA
Supplementary material is available on the publisher’s web site along with the published article.
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.
To understand shared decision-making as a comprehensive process from the perspective of the patient and provider in all healthcare settings.
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.
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.
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.
Shared decision-making (SDM) has received national and international attention from providers, educators, researchers, and policy makers [ 1 - 5 ]. Shared decision-making has been described as taking place in a relationship where there is a partnership between the provider and the patient characterized by a collaborative bi-directional mutual exchange of information and discussion involving negotiation leading to a shared decision [ 6 ]. Shared decision-making, therefore, takes place in a relationship that is participatory, collaborative, open, and respectful. The relationship is one in which there are at least two participants: the nurse, as the provider, and the patient. Trust and respect between providers and patients has also been described as foundational for SDM [ 7 - 10 ].
The literature on SDM is extensive. These works describe the individual components of SDM, including the facilitators and barriers to the achievement of SDM [ 10 - 14 ]. Provider SDM competencies have also been explored in the literature [ 15 - 17 ] along with the context of the provider and patient relationship such as the need for resources, including time [ 6 , 18 - 29 ]. Research has also been conducted to examine the effect of SDM on patient outcomes with regard to chronic and acute illnesses [ 20 , 27 , 30 , 31 ]; treatment adherence [ 31 ]; patient coping [ 32 , 33 ]; knowledge attainment and empowerment [ 34 , 35 ]; autonomy and self-determination [ 22 , 36 , 37 ]; and, patient satisfaction [ 26 , 38 , 39 ]. Despite this research, the overall evidence as to the effect of SDM leading to positive patient outcomes is inconclusive [ 40 , 41 ].
Nurses develop relationships and work with individuals, families, communities and populations across diverse healthcare settings. Hildegard E. Peplau [ 42 ] provided a framework for the nursing professions’ understanding of the nurse-patient helping relationship as the nexus from which there is growth. Millard, Hallett and Luker [ 43 ] saw the importance of the nurse-patient relationship as the vehicle for the exchange of information necessary for SDM and suggested that there is a need for nurses to “pay attention to the quality and nature of the relationships they have with their patient” [ 43 ]. Furthermore, Clark, et al. [ 40 ] examined the nurse-patient dyad as an intervention necessary to both sustain the relationship and facilitate SDM towards care management.
The focus on SDM has been on the dyad relationship and the individual components of SDM rather than describing and explaining the process taking place within the relationship. Gulbrandsen [ 44 ] noted that the contemporary literature’s portrayal of SDM does not do an adequate job of illustrating the processes of SDM. A comprehensive understanding of SDM as a process would be meaningful for nurses as they work with patients towards shared decisions about care management.
The aim of this integrative review is to understand the comprehensive process of SDM from the perspective of the patient and provider in all healthcare settings. Understanding the process will create a common language and appreciation of SDM for meaningful nursing practice [ 45 ].
This integrative review applied the comprehensive and systematic approach described by Whittemore and Knafl [ 46 ] consisting of the literature search, data evaluation, and data analysis. This method facilitated the gathering of information and research from a variety of methodologies (quantitative, qualitative, and theoretical) supporting an integrative approach allowing for a comprehensive depiction of the process of SDM.
3.1. Inclusion Criteria
Articles considered for inclusion were qualitative or quantitative research articles or theoretical literature that addressed SDM taking place within a relationship between the patient and the provider. Patients needed to be 18 years of age or older and providers could represent any healthcare field. Only articles published in English were considered. Articles were excluded if they solely addressed intervention strategies such as education to enhance SDM competencies in providers or decision aids as an intervention to assist patients in their shared decision rather than a focus on the process of SDM taking place in a relationship. Articles focusing on shared decision-making in psychiatric or mental health settings were excluded because of the unique issues within this patient population pertaining to SDM.
3.2. Search Strategy
A comprehensive literature search was applied in PubMed, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO. Diverse literature available in English was searched from 1970 through January 2016, including quantitative designs (both experimental and non-experimental), qualitative designs, and theoretical papers. Three searches were conducted in each database in order to identify literature related to SDM inclusive of the patient, the provider, and the environment. (Table 1 1 ) depicts these basic search strategies along with the key terms used.
Basic search term strategies used across all databases.
3.3. Data Evaluation
Articles that met the inclusion criteria were evaluated for methodological quality. The standardized critical appraisal instruments for experimental, observations, quantitative descriptive, qualitative, and expert opinion/theoretical works from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI) were used for this assessment [ 47 ]. This stage reduced the possibility of bias and errors by including only papers deemed reliable/dependable and valid/credible [ 47 ]. Any disagreements between the reviewers were resolved through discussion until consensus was reached. Supplemental (Table S1 ) contains the results of the critical appraisals for all included studies.
3.4. Data Analysis
Data analyses were carried out through the application of an inductive content analysis process that involved creating categories and abstractions [ 48 ]. The categories were then further grouped under higher order headings [ 48 , 49 ]. The synthesis process involved creating categories that describes all of the aspects of the SDM process leading to a new representation of facts offering a visual representation of SDM as a guide for nursing practice [ 50 ].
Upon completion of the initial searches, 4,674 potentially relevant titles were identified. Duplicates were removed, leaving 1,562 articles for review. After reviewing the titles and abstracts, 1,340 articles were excluded for not meeting the inclusion criteria. After full text review, an additional 166 articles were excluded for not meet the inclusion criteria, leaving 55 articles for critical appraisal. Three articles were excluded for methodological weaknesses in the research and limited results sections (Fig. 1 1 ) [ 51 - 53 ].
PRISMA Flow Diagram [ 54 ].
Fifty-two articles published between 1997 and 2016 were included in this review. Supplemental Table ( S2 ) contains an overview of the included articles. Twenty-three of the articles originated from the United States, six from the United Kingdom, five from Germany, nine from Canada, two from the Netherlands, and one each from Australia, Denmark, Norway, Italy, and France. Two articles originated from multiple countries. Sixteen of the articles were quantitative designs, 19 were qualitative, one was mixed method, and 16 were conceptual.
The analysis of this integrative review and the articles retained from data analysis generated three categories: (a) communication/relationship building; (b) working towards a shared decision; and (c) action for SDM, each containing sub-themes that depict the process of SDM. (Table 2 2 ) outlines the three categories and sub-categories along with the corresponding articles informing each category. These categories and sub-categories were further contextualized into a visual representation of the shared decision-making process seen in Fig. ( 2 2 ).
A visual representation for shared decision-making in practice.
Shared decision-marking categories and subcategories.
4.1. Communication and Relationship
Communication and relationship building is the first general category and is foundational for the SDM process. The three sub-themes within this theme are: relationship building—trust and respect; information exchange— communication; and context.
4.1.1. Relationship Building—Trust and Respect
Individuals enter into the relationship and must work towards building a trusting and respectful relationship where SDM is invited and encouraged. The work begins as the patient identifies a need or question. This need and/or question influences the patient’s quest for answers [ 76 ]. The relationship is the vehicle by which providers and patients “act in a relational way” and the individuals are “actively seeking a personal connection with each other” [ 65 ]. The relationship is a partnership where there is collaboration and a sharing of power [ 30 , 34 ]. With the sharing of power, there is mutual responsibility toward one another [ 16 ]. The relationship is strengthened over time leading to bi-directional trust and respect [ 58 , 67 ]. Patients who feel trusted and respected are more open and share information with their provider thereby facilitating communication for SDM [ 13 ].
4.1.2. Information Exchange—Communication
Information exchange via interpersonal and intrapersonal communication sustains the relationship. The interpersonal process of communication is bi-directional between the provider and the patient when there is a mutual exchange of information [ 6 , 19 , 22 , 23 , 25 , 38 , 67 , 70 , 72 ]. The exchange of information also involves active listening [ 29 , 63 , 69 ]. Emotions such as fear, anger, and anxiety can interfere with a patient’s readiness to communicate [ 12 , 14 ]. Furthermore, a provider’s readiness and receptiveness to explore a patient’s feelings and preferences is important [ 65 ]. For example, the emotional tone the provider creates facilitates an atmosphere of compassion and caring that enhances open communication [ 11 , 71 ]. In situations where this emotional tone is not created the patient is less likely to feel compassion or care and may perceive the provider’s approach as “authoritarian.” This perception may prompt the patient’s reluctance to communicate and establishing a “shield” –creating a barrier to SDM [ 21 ].
The intrapersonal process of communication also plays a role in the achievement of SDM taking place within the provider and patient through the process of reflection [ 73 ]. The reflection process takes place at two levels. Mutual reflection takes place when the provider and the patient reflect together via communication, exchanging thoughts about decisions, and clarifying the patient’s perspective [ 73 ]. Individual reflection takes place autonomously within the individual provider or patient [ 73 ]. For example, during an individual reflective moment a provider may identify “blind spots” in a patient’s perception of an experience which may be limiting the patient’s insight about an issue [ 73 ]. During the corresponding mutual reflection, the provider uses communication skills to challenge the patient verbally and non-verbally while encouraging the patient to also engage intrapersonal self-reflection. The mutual reflection process, therefore, encourages patients to engage in their own independent reflections that helps them recognize “a new decision or a new position on the difficulty or challenge on which they had been reflecting” [ 73 ]. Furthermore, providers and patients continually reflect upon their relationship and communication over time known as post-decision deliberation. These deliberations offer an opportunity for reconsideration of past decisions illustrating the on-going process of decision-making [ 68 ].
The provider and the patient work within a particular healthcare context that either facilitates or creates barriers for SDM. From the patient’s perspective, the context includes the patient’s family, friends, and home, including community supports and networks [ 24 , 29 ]. For example, patients who are accompanied by family members to healthcare encounters are more likely to engage in SDM [ 21 , 26 , 27 ]. The context of the provider’s work environment also influences their ability to integrate SDM into practice [ 20 , 22 , 23 , 28 ]. Time and access to resources are facilitators for SDM [ 6 , 18 , 25 , 52 ]. Organizational models and systems that facilitate patients’ access to their provider(s) and/or healthcare team reduce fragmentation and improve collaboration, coordination, and SDM [ 25 ]. Technology capable of tracing patients’ progress through the SDM process is a valuable resource [ 19 , 21 ]. Shared decision-making is prominent in the thoughts of healthcare providers within the larger healthcare system; however, so too are evidence-based practice (EBP) and clinical practice guidelines. The challenge for providers is to ensure that the realities of clinical practice are addressed along with the patient’s preferences [ 25 ].
4.2. Work Toward Shared Decision-Making
Communication and relationship building are foundational for the initiation of SDM. Shared decision-making, however, requires dedicated ongoing work. The second general category, work towards SDM, has four sub-categories: assessment, teaching-learning, finding balance, and decision.
The work towards SDM begins with an assessment. The assessment of the individual is foundational as the provider must “come to know one’s patient” [ 29 ] and the patient’s specific preferences [ 35 ]. Understanding the individual patient characteristics begins with an awareness of the patient’s age, gender, race, spiritual and cultural beliefs, education, and life experiences. All of these characteristics influence the patient’s beliefs about SDM and the value placed on SDM [ 35 , 63 ]. For example, the assessment will reveal whether patients see themselves as sharing in decision-making, or whether they prefer the provider to be the primary decision maker? The role a patient chooses to play may change over time, depending on the situation for which the patient is seeking assistance [ 74 ]. Furthermore, as the work towards the shared decision takes place, there will be moments when the provider’s expertise will warrant that they take the lead in the encounter and other moments when the patient will take the lead [ 74 ]. Race too may influence a patient’s behavior if an individual decides not to share information for reasons of racially inspired mistrust [ 58 , 59 ]. Age may influence behaviors as research has shown that younger individuals choose to engage in SDM compared to older adults [ 26 , 28 ]. This is also true of individuals with higher levels of education and literacy [ 14 , 25 , 60 ].
The assessment continues as the provider asks questions about the reasons the patient is seeking assistance. How SDM unfolds varies depending upon the acuity or chronicity of illness [ 27 , 28 , 73 , 75 ]. Acute illness may foster a provider-led approach to SDM. Conversely, chronic illness fosters a patient-led approach with patients who are responsible for the self-management of their illness over time in their own home/community, often with the support of family or friends [ 27 , 29 , 39 ]. Gathering information about social support and social networks, therefore, is a part of the assessment [ 29 ] as these networks have been found to facilitate a patient’s ability to be active and engaged in SDM [ 6 , 26 ]. Ultimately, the assessment offers the provider an opportunity to know the patient, the patient’s family, and home/community, building a practice based on facts and evidence not assumptions.
Shared decision-making warrants that patients have the necessary information that they need to know so that they can share in the decision-making process [ 78 ]. Providers, therefore, will need to teach and provide their patients with this information. What providers teach to support learning depends on the assessment [ 27 , 28 , 33 , 74 ]. For example, the provider needs to consider the readiness of the patient and the amount and type of information that needs to be taught and how to best teach that information for a specific patient [ 21 ]. This is vital in today’s EBP-driven healthcare environment. The EBP process involves sharing information with the patient about diagnosis and treatment, educating the patient about the disease and treatment options, and informing the patient about the strength of the evidence, as well as the risks, benefits, and possible outcomes [ 68 ]. Information gathered during the assessment guides providers so that they are mindful of a patient’s age, literacy, language, and culture in the development and delivery of educational information. Patient-centered education applies specific teaching strategies for specific patients, such as culturally appropriate decision aids, which both guide patient learning and facilitate the patient’s understanding of information [ 15 , 27 , 29 , 60 , 68 , 77 ].
4.2.3. Finding Balance
Providers and patients come together due to identified needs/issues. A need/issue causes uncertainty [ 76 ] and challenges providers and patients to find a resolution through SDM. Part of the work of SDM is achieving balance necessary to arrive at a shared decision [ 20 , 37 ]. This is especially relevant with regard to EBP. For example, in a clinical practice scenario when there is evidence that there may be alternative best practice choices, the provider’s competence in the use of equipoise in the search for a balanced shared decision is sought. The concept of equipoise is exemplified by “talk” where there is the presentation of information, portrayal of options and exploitation of alternatives, as well as deliberation [ 15 ].
What happens, however, in situations where there is no documented evidence for best practice or there is only one best practice choice that a patient considers unacceptable because of personal ideas, values, or beliefs? These encounters invoke the ethics of practice, including the principles of autonomy and beneficence. The provider and the patient together seek to achieve balance between these principles through the application of skills such as talking, openness, and information provision [ 28 , 31 , 36 , 77 ]. Furthermore, part of the work in finding balance requires deliberation and negotiation leading to consensus about the decision [ 6 , 37 , 65 , 69 ].
4.2.4. The Decision
Communication and relationship building, assessment, teaching and learning and the seeking of balance are all part of the SDM process leading to consensus about the decision. The work is individual for every patient and facilitates care that is patient-centered [ 6 , 20 , 35 , 65 , 69 , 74 ]. Ultimately, the shared decision is not the end point but signals the need for the patient to take action and carry out the decision.
4.3. Action for Shared Decision-Making
This third theme, action for SDM, contains two sub-themes: Takes action or no action.
4.3.1. Takes Action
Shared decision-making does not end with the decision. Once the provider and patient come to a shared decision there needs to be action by the patient. The process of SDM, therefore, moves beyond the decision point as the patient engages in the steps necessary to take action to see the decision through [ 73 ]. For example, patients return to their homes/communities where they attempt to carry out their decisions. During this process, the implementation of the decision may be seamless, the patient is satisfied, and the issue or question is addressed. There may be, however, times when patients find the action challenging or the actions that are required are not what was expected. In these situations, the patient may not be satisfied resulting in an unresolved issue or questions prompting the patient to return to the provider to re-evaluate the decision [ 13 , 19 , 21 , 27 , 63 , 68 , 73 ].
4.3.2. No Action
No action occurs when patients return to their homes/communities; however, once in their familiar environment, they chose not to initiate the steps and actions to see their decisions through. For example, patients may feel pressured by the perceived power imbalance they experienced with their provider and as a result found themselves aligning with a particular decision favored by the provider [ 21 , 34 ]. As a result, when patients return to their homes/communities they choose not to act. This realization may trigger the need to return to the provider or in some cases a patient may choose not to return for further care [ 13 , 19 , 21 , 27 , 63 , 68 , 73 ].
The significance of this integrative review is noted in the presentation of the ongoing process of SDM. Box ( 1 1 ) below provides a case study that exemplifies this ongoing process. This process takes place in practice between a nurse and patient during a healthcare encounter where there is an identified need/issue or question. The relationship is one of a partnership where both parties are collaborating. The relationship that develops is one where trust and respect is fostered by the communication between the nurse and the patient. Communication is both interpersonal and intrapersonal. Interpersonal communication between the nurse and patient takes place during the healthcare encounter. Intrapersonal communication takes place during the encounter when the nurse and patient think about— via reflection —what they are saying, doing, and observing at the moment they are actively engaged [ 79 ]. For example, a nurse may reflect on a patient’s non-responsiveness to a conversation. Nurses who are knowledgeable about communication and skillful in the application of communication techniques will use strategic questioning where options are explored and listening to facilitate a patient’s insight into the presiding issue [ 80 ]. Reflection also continues after the interaction as nurses and patients reflect upon past SDM healthcare encounters. During these moments, patients may have questions and/or decide that the initial decision is no longer acceptable and wish to return to their nurse. This review highlights relationship building and communication in nursing practice that is foundational for SDM and signals that communication is complex, requiring nurses to be ever vigilant about what they are saying and doing, as well as the patient’s response. Being aware of one’s own reflections as well as one’s skills to assist patients in their own self-reflection facilitates a practice based in SDM. In addition, this review highlights the need for a practice environment that fosters relationships and communication by establishing practice models where ongoing connections between the nurse and patient are consistent and continuous, thereby supporting and sustaining SDM.
A case study of shared decision-making.
Flexibility in the nurse-patient relationship is identified as significant in this review and takes place as nurses and patients work together, alternating who takes the lead during SDM. There may be times when the nurse takes the lead to educate the patient about best practices while considering patient characteristics and the patient’s response to the information. As the work continues, the patient may take the lead, being the expert in his/her own life experiences. Flexibility in the SDM process also takes place in the bi-directional communication between the nurse and the patient as discussions take place about EBP. These discussions are a give and take of ideas about EBP and choices about treatments; when balance is achieved, a shared decision can be reached.
This review also highlights the need for nurses to be continually aware of the importance of context in the form of family/friends, community, organization, and the greater healthcare system. For example, practice models that are intra and interprofessionally based will enhance patients’ access to available organizational providers in the event they need to return to re-evaluate a past decision. These practice models also enrich the support, guidance, teaching, and mentoring of patients [ 23 , 25 , 27 , 29 ]. Resources that foster and facilitate SDM such as time, consultation services, reliable and valid decision aids that are culturally appropriate, and clinical information systems that track a patient’s progress in the achievement of shared decisions are necessary. These examples suggest policy changes at the organizational level. At the healthcare system level, the development of standards of practice based in evidence, while beneficial, have been viewed as a challenge by others as there may be the potential for “fewer choices being offered to patients by healthcare providers” [ 25 ].
Education initiatives that enhance the nurse’s ability to integrate SDM into their practice are significant. Competencies need to be achieved in the area of reflective practice, the nurse-patient relationship, communication and strategic questioning, assessment, teaching and learning, ethics, and the role of social supports and social networks within a community. Part of this educational endeavor also includes nurses examining their own comfort levels about SDM. For example, nurses may express positive beliefs about SDM; however, these beliefs may not manifest in practice as the nurse may be ambivalent about a partnership with a patient due to a lack of trust in a patient’s ability [ 16 , 64 ]. Patents too will need to be competent in order to be active and engaged in the SDM process. Their competency, however, is centered around the information that they need to know to participate in SDM. This means that the SDM encounter will require that nurses provide support, guidance, mentoring, coordination, and education to patients throughout the entire SDM process. Nurses, therefore, will need to assume a diverse set of roles beyond caregiver as they adjust to the flexible nature of SDM. For example, the shared decision may require a course of action in which the patient needs to access community resources. Nurses will educate patients on what community resources are available, offer advice and support patients as they access services, and advocate when a patient has difficulty connecting with these services.
The visual representation of SDM Fig. ( 2 2 ) offered in this review provides nurses with a guide for practice and also for research. Contemplating the guide offers cues for hypothesis generation and the raising of qualitative questions that will add to the body of nursing knowledge. For example, there is limited information in the literature about patients returning to their home/communities as they attempt to take the necessary steps and carry out the actions for the shared decision. The development of qualitative descriptive studies to describe what happens as patients attempts to initiate shared decisions once they leave a healthcare encounter would provide valuable evidence for nurses as they address needed practice changes to facilitate SDM.
Shared decision-making has received attention in the recent years, however, this attention has focused on the individual components of SDM rather than a comprehensive process. An understanding of SDM that captures this comprehensive process would facilitate SDM in practice, research, and the development of educational programs for nurses and other healthcare providers that embrace all aspects of the process. To this end, an integrative review was conducted applying the systematic approach described by Whittemore and Knafl [ 46 ]. The outcome of this integrative review provides an understanding of SDM as a comprehensive process that takes place between the nurse and the patient. It provides an opportunity to consider the complexity of SDM as an on-going process that does not end with the decision. The visual representation is a guide that depicts the processes of SDM taking place during the healthcare encounter with implications for the shared decision over time in the event a patient needs to return to the nurse to reconsider earlier decisions.
LIST OF ABBREVIATIONS
Consent for publication.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
Shared Decision-Making at Medical Institution Essay
I’d love to point suggest some changes the institution has to make regarding patient-centered treatment, evidence-based care, and the theory of preference-sensitive care. I understand that the code of medical ethics requires practitioners to exactingly respect the principle of informed consent. Practitioners must explain to the patients the medical facts accurately and then give professional opinions or make recommendations that can be used to address a certain medical condition as per the ‘good medical practice’ doctrine. The principle of shared decision making (SDM) has its basis on this premise. At this institution, we need to create an atmosphere that will allow patients to have a chance to assess options and make decisions according to personal values, and preferences.
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SDM process has a chance of improving patient-centered care that can greatly improve the quality and efficacy of the healthcare delivery system. Patients will be better contented and will be comfortable with their choice. Furthermore, the increased involvement of patients in decision making, allowing them to take responsibility for their health in developing the healthcare delivery regimes will increase adherence and long-term results cut down extravagant expenditure. When patients engage in SDM, they tend to develop more realistic expectations of the health outcomes and the implications of the treatment.
The SDM strategy will also reduce patient-doctor tensions thus reduce the feeling by patients that the physician may have made a wrong treatment option particularly when the outcome is unsatisfactory or unanticipated. There will be reduced conflict when it comes to making critical decisions, the patients will have a greater knowledge of treatment alternatives, more patients will be decisive rather than undecided and there will be conformity between patient values and the available option.
The facility should give decision aids which will help patients to be able to clarify their preferences, attitudes, and values then can choose which one is important about the perceived benefits or damage. This institution must give patients evidence-based medical information regarding certain health conditions, the alternative, and the benefits related to them, the harms, and the probabilities of every alternative. We institution will need to develop decision guidance in the steps of a decision-making process, by sequential questions that profile the preferences of the patients. Physicians should give the patients truthful advice as per the best healthcare options available.
Many obstacles will come in the way as we try to implement SDM policy. I highlighted just a few. Patients can easily opt for alternative treatments that are not evidence-based for various personal reasons. For instance, the cost, family decisions, the quality of life, uncertainty, and lifestyle.
Considering that physicians are usually held responsible for health-related issues from quality of care, patient adherence, to patient preference for non-standard treatment, physicians often fear lower reimbursements or low-quality ratings.
Competent adult patients often claim their right of choice even when they are making a decision that does not meet healthcare guidelines or and demand the physician to incorporate such choices in their treatment plans.
The process of SDM has to comply with the following aspects;
- Offer explicit information about medical conditions, treatment alternative, and the expected outcomes
- Provide the decision aid of tools to assist patients in identifying and articulating their values and priorities when making medical decisions and alternatives
- There has to be structured guidance to assist patients to integrate the clinical aspects and personal values to settle on informed treatment decision
The management of the institution should support the development of projects that increase knowledge and understanding of the SDM process. Even though the needs of the patients and the quality or the standard of healthcare delivery can conflict, physicians should take responsibility for giving sound advice based on the best available treatment options regardless of the consequences.
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