Barriers and facilitators to shared decision-making in neonatal medicine: A systematic review and thematic synthesis of parental perceptions

ObjectivesSystematically review parental perceptions of shared decision-making (SDM) in neonatology, identifying barriers and facilitators to implementation.MethodsElectronic database (Medline, PsycINFO, CINAHL and Scopus) and follow-up searches were conducted to identify qualitative studies. Data were extracted, thematically analysed and synthesised.ResultsSearches yielded 2445 papers, of which 25 were included. Thematic analysis identified six key themes. Key barriers included emotional crises experienced in the NICU setting, lack of medical information provided to parents to inform decision-making, inadequate communication of information, poor relationships with caregivers, lack of continuity in care, and perceived power imbalances between HCPs and parents. Key facilitators included clear, honest and compassionate communication of medical information, caring and empathetic caregivers, continuity in care, and tailored approaches that reflected parent’s desired level of involvement.ConclusionThe highly specialised environment, and the emotional crises experienced by parents impact significantly on their perceived capacity to engage in surrogate decision-making.Practice ImplicationsComplex and multi-factorial interventions that address the training needs of HCPs, and the emotional, informational and decision support needs of parents are needed. SDM skills training, improved information delivery, and integrated emotional and decisional support could help parents to become more involved in SDM for their infant.     

Shared decision-making among non-physician healthcare professionals: Enhancing patient involvement in women’s reproductive health in community healthcare settings

ObjectiveShared decision-making (SDM) is an important approach to patient-centered care in women’s reproductive healthcare. This study explored SDM experiences and perceptions among non-physician healthcare professionals.MethodsWe completed 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women’s reproductive healthcare. Interviews were audio-recorded, transcribed, and analyzed using an expanded grounded theory framework. Constant comparative analysis identified emergent themes.ResultsProfessionals noted community-based healthcare required contextualized decision-making approaches. Results identified listening, decisional ownership, and engagement strategies that enhanced SDM involvement. Findings suggested outcome-oriented SDM concepts, including decisional ownership and investigative listening to enhance SDM. Providers redefined ‘challenging’ patients as engaged in their healthcare and discussed ways SDM improved healthcare experience beyond one visit.ConclusionFindings offered insight into actionable and practical strategies for enhancing SDM in community-based women’s reproductive healthcare. The findings offer strategies to improve SDM by addressing barriers and facilitators among professionals. This extends SDM beyond the patient-physician dyad and supports broader application of SDM.Practice implicationsIncorporating professionals’ experiences into SDM concepts can enhance SDM in community-based women’s healthcare practice, offering opportunities to support a culture of SDM across settings.     

Development of an adjective-selection measure evaluating clinicians’ attitudes towards using patient decision aids: The ADOPT measure

BackgroundThe implementation of shared decision-making and patient decision aids (PDAs) is impeded by clinicians’ attitudes.ObjectiveTo develop a measure of clinician attitude towards PDAs.MethodsTo develop the ADOPT measure, we used four stages, culminating in measure responses by medically qualified clinicians, 25 from each of the following specialties: emergency medicine, family medicine, oncology, obstetrics and gynaecology, orthopaedics, and psychiatry. To assess validity, we also posed three questions to assess the participants’ attitudinal and behavioural endorsement of PDAs. Allocating a point per adjective, we calculated the sum as well as positive and negative scores. We used univariate logistic regression to determine associations between the scores and attitudinal or behavioural endorsements.Results152 clinicians completed the measure. ‘Time-saving’ (39%) and ‘easy’ (34%) were the most frequently selected adjectives. ‘Time-consuming’ and ‘unfamiliar’ were the most frequently selected negative adjectives (both 19%). The sum scores were significantly associated with behavioural endorsement of PDAs.DiscussionClinicians were able to respond to adjective-selection methods and the ADOPT measure could help assess clinician attitudes to PDAs. Validation will require further research.Practice implicationsThe ADOPT measure could help identify the extent and source of attitudinal resistance.     

Shared decision-making and the implementation of treatment recommendations for depression

ObjectiveThis study aimed to examine the relationship between shared decision-making (SDM) and the implementation of treatment recommendations amongst outpatients at a specialist Depression Clinic.MethodsA total of 110 adult outpatients in a specialist Depression Clinic in Sydney, Australia, completed an online survey examining their experiences of shared decision-making (SDM) during their psychiatrist consultation and the extent to which they later implemented Depression Clinic treatment recommendations.ResultsThe odds of implementing treatment recommendations were over four times higher in patients who reported a high level of SDM in their consultation, compared to those who reported a low level of SDM. Further, three elements of patient-rated SDM were significantly associated with an increased likelihood of implementing depression treatment recommendations. These three elements were: i) being given the opportunity to ask questions or voice concerns; ii) being asked about any problems or side effects from previous treatments; and iii) being involved in deciding their treatment plan.ConclusionsSDM was significantly associated with an increased likelihood of implementing psychiatrists’ treatment recommendations at a specialist Depression Clinic.Practice implications: We recommend that clinicians be informed of the potential benefits of SDM and adopt SDM when developing treatment plans with patients living with depression.     

Identifying residents’ educational needs to optimising postgraduate medical education about shared decision-making

ObjectiveTo investigate how to optimise resident engagement during workplace learning of shared decision-making (SDM) by understanding their educational needs.MethodsA qualitative multicentre study was conducted using video-stimulated interviews with 17 residents in General Practice. Video recordings of residents’ recent clinical encounters were used to facilitate reflection on their educational needs.ResultsData analysis resulted in five themes regarding residents’ educational needs for learning SDM: acquiring knowledge and skills needed to perform SDM; practising SDM; reflection and feedback; longitudinal and integrated training; and awareness and motivation for performing SDM.ConclusionResidents expressed a need for continuous attention to be paid to SDM during postgraduate medical education. That would help them engage in two parallel learning processes: acquiring the knowledge and skills necessary to perform SDM, and practising SDM in the clinical workplace. Alignment between the educational curriculum, workplace learning and resident learning activities is essential to operationalise SDM attitude, knowledge and skills into clinical performance.Practice ImplicationsThe identified educational needs provide ingredients for fostering the development of SDM proficiency. The findings suggest that residents and clinical supervisors need parallel training to bridge the gap between education and clinical practice when learning SDM.     

Making shared decisions in relation to planned caesarean sections: What are we up to?

ObjectiveTo map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women’s experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.MethodsUsing a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.Results34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.ConclusionMany women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.Practice implications: Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.     

Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements

ObjectiveTo explore how physicians bring up patient preferences, and how it aligns with assessments of shared decision-making.MethodsQualitative conversation analysis of physicians formulating hypotheses about the patient’s treatment preference was compared with quantitative scores on SDM and ‘patient preferences’ using OPTION(5) and MAPPIN’SDM.ResultsPhysicians occasionally formulate hypotheses about patients’ preferences and then present a treatment option on the basis of that (“if you think X + we can do Y”). This practice may promote SDM in that the decisions are treated as contingent on patient preferences. However, the way these hypotheses are formulated, simultaneously constrains the patient’s freedom of choice and exerts a pressure to accept the physician’s recommendation. These opposing effects may in part explain cases where different assessment instruments yield large variations in SDM measures.ConclusionEliciting patient preferences is a complex phenomenon that can be difficult to reduce into an accurate number. Detailed analysis can shed light on how patient preferences are elicited, and its consequences for patient involvement. Comparing CA and SDM measurements can contribute to specifying communicative actions that SDM scores are based on.Practice implicationsOur findings have implications for SDM communication skills training and further development of SDM measurements.     

‘That’s the doctor’s job’: Overcoming patient reluctance to be involved in medical decision making

ObjectiveTo review the barriers to patient engagement and techniques to increase patients’ engagement in their medical decision-making and care.DiscussionBarriers exist to patient involvement in their decision-making and care. Individual barriers include education, language, and culture/attitudes (e.g., deference to physicians). Contextual barriers include time (lack of) and timing (e.g., lag between test results being available and patient encounter). Clinicians should gauge patients’ interest in being involved and their level of current knowledge about their condition and options. Framing information in multiple ways and modalities can enhance understanding, which can empower patients to become more engaged. Tools such as decision aids or audio recording of conversations can help patients remember important information, a requirement for meaningful engagement. Clinicians and researchers should work to create social norms and prompts around patients asking questions and expressing their values. Telehealth and electronic platforms are promising modalities for allowing patients to ask questions on in a non-intimidating atmosphere.ConclusionResearchers and clinicians should be motivated to find ways to engage patients on the ethical imperative that many patients prefer to be more engaged in some way, shape, or form; patients have better experiences when they are engaged, and engagement improves health outcomes.     

Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trial

ObjectiveTo evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict.MethodsA total of 130 outpatients with LDDs recruited from orthopedic or rehabilitation clinics were randomly assigned to the SDM intervention (n = 67) or comparison (n = 63) groups. Patients in the intervention group received decision aids (DAs) with decision coaching and those in controlled group received standard educational materials from a health educator. The primary outcome was decision self-efficacy, and secondary outcomes were control preference, SDM process, conflict, and satisfaction.ResultsThe SDM intervention significantly improved decision self-efficacy (mean difference [MD] = 7.1, 95% confidence interval [CI]: 1.7–12.5, partial η² = 0.05) and reduced conflict (MD = −7.0, 95% CI: −12.2 to −1.9, partial η² = 0.06), especially in patients without family involvement, compared with the health education group. However, no significant between-group differences were observed in other outcomes.ConclusionSDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs.Practice ImplicationsClinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.     

Patients’ preferred and perceived decision-making roles,and observed patient involvement in videotaped encounters with medical specialists

ObjectiveTo assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients’ perceived role.MethodsWe asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument.ResultsMost patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001).ConclusionsMost patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows.Practice implicationsA clearer understanding of patients’ medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns.     

Engaging patients in population-based chronic disease management: A qualitative study of barriers and intervention opportunities

ObjectiveCardiovascular disease (CVD) continues to be a leading cause of morbidity in the U.S. Managing CVD risk factors, such as diabetes or hypertension, can be challenging for many individuals. We investigated the barriers experienced by patients who persistently struggled to reach their CVD risk factor control goals.MethodsThis qualitative study examined patient, clinician, and researcher observations of individuals’ experiences in a chronic disease management program. All participants (n = 332) were enrolled in a clinical trial testing a skills-based group intervention seeking to improve healthcare engagement. Data were analyzed through a general inductive approach and resulting themes were structured along the Capability-Opportunity-Motivation-Behavior framework.ResultsAnalyses identified care engagement barriers related to participants’ communication skills and activation, care team relationship processes, and emotional factors. Although most participants reported benefitting from skills training, persistent barriers included distrust of their providers, shame about health challenges, and dissatisfaction with care team interactions that were described as impersonal or unresponsive.Conclusions and practice implicationsEfforts to support engagement in CVD risk factor management programs should address whether patients and their care team have the necessary skills, opportunities and confidence to proactively communicate health needs and engage in non-judgmental interactions for goal-setting, rapport-building, and shared decision-making.     

Shared decision making within goal setting in rehabilitation settings: A systematic review

ObjectiveTo map out and synthesise literature that considers the extent of shared decision-making (SDM) within goal-setting in rehabilitation settings and explore participants’ views of this approach within goal-setting.MethodsFour databases were systematically searched between January 2005–September 2015. All articles addressing SDM within goal-setting involving adult rehabilitation patients were included. The literature was critically appraised followed by a thematic synthesis.ResultsThe search output identified 3129 studies and 15 articles met the inclusion criteria. Themes that emerged related to methods of SDM within goal-setting, participants’ views on SDM, perceived benefits of SDM, barriers and facilitators to using SDM and suggestions to improve involvement of patients resulting in a better process of goal-setting.ConclusionsThe literature showed various levels of patient involvement existing within goal-setting however few teams adopted an entirely patient-centred approach. However, since the review has identified clear value to consider SDM within goal-setting for rehabilitation, further research is required and practice should consider educating both clinicians and patients about this approach.Practice implicationsTo enhance the use of SDM within goal-setting in rehabilitation it is likely clinicians and patients will require further education on this approach. For clinicians this could commence during their training at undergraduate level.     

Shared decision-making for delivery mode: An OPTION scale observer-based evaluation

ObjectiveShared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION¹² scale to obstetric consultations.MethodsFifty-eight outpatient consultations were rated; statistical associations between OPTION¹² scores and sociodemographic data of both patient and physicians were determined.ResultsThe OPTION¹² total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION¹² items never reached the minimum skill level.ConclusionA low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested.Practice implicationsThe OPTION¹² scale may prove useful for testing the extent of pregnant women’s involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.     

A shared decision-making communications workshop improves internal medicine resident skill,risk-benefit education,and counseling attitude

ObjectiveWe assessed the impact of a workshop on first-year medicine residents (PGY1) shared decision-making (SDM) communication skill, risk-benefit education, and attitude.MethodsA SDM skills-focused workshop was integrated into an academic medical center PGY1 ambulatory rotation in 2016–2017. Pre/post recordings of virtual Objective Structured Clinical Examinations (OSCEs) with standardized patients sharing decisions were scored using OPTION5. Risk-benefit education, including decision aid use, was measured. Pre/post surveys assessed SDM practice attitudes and perceived barriers.Results31 of 48 (65%) PGY1 workshop attendees completed pre/post OSCEs yielding 62 videos. OPTION5 scores improved from 27/100 pre to 56/100 post (p < 0.001). Pre/post increases in integration of qualitative (15/31 vs 31/31, p < 0.001) and quantitative (3/31 vs 31/31, p < 0.001) risk measures, and decision aids (1/3 vs 31/31, p < 0.001) were observed. Pro-SDM attitude of decisional neutrality increased 16.6% pre to 71.9% post-survey (P < 0.001). Barriers to SDM remain.ConclusionThis PGY1 workshop with virtual OSCEs improved SDM communication skills, the ability to find and provide risk-benefit education, and SDM-facilitating attitude.Practice implicationsResidency programs can improve SDM skills, risk-benefit education, and attitudes with a workshop intervention. Perceived time constraints and cognitive biases regarding risk-benefit estimates should be addressed to ensure quality SDM in practice.     

Patient involvement and language barriers: Problems of agreement or understanding?

ObjectiveThis study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation.MethodsFrom a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM.ResultsThough the physician did extensive interactional work to secure the patient’s understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient’s participation. In ratings of PCC and SDM, this case scored well above average.ConclusionDespite the fact that this encounter displays some of the ‘best actual practice’ of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement.Practice implicationsWhen facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges.     

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

ObjectivesThe importance of shared decision-making (SDM) in relation to induction of labour (IOL) is recognised, little is known about women’s experiences of and satisfaction with decision-making and how this can be improved. The aim of this study was to 1) gain insight into women’s experiences of SDM in relation to IOL, 2) understand the factors associated with satisfaction versus dissatisfaction during SDM, and 3) identify recommendations for service improvement.MethodsQualitative semi-structured telephone interviews were conducted with 32 women who had a recent IOL at one of eight public hospitals in Sydney, Australia. An inductive approach to coding and categorisation of themes was used.ResultsWhile women reported varied experiences with SDM, many reported not feeling that they had a choice about IOL, not being presented with the risks and benefits of different birth options, and receiving insufficient information about the IOL process and methods. Satisfaction versus dissatisfaction with SDM appeared more closely related to a woman’s willingness to have an IOL and their willingness to defer decision-making, rather than the process of SDM. Recommendations for improvement included improved SDM practices, access to guidelines and continuity of care.ConclusionThere is a need to improve SDM processes around IOL.Practice implicationsParticular areas for improvement include more comprehensive discussions surrounding the pros and cons of different birth methods and the IOL process. Decision aids and clinician training may assist with SDM.     

Factors associated with level of shared decision making in Malaysian primary care consultations

ObjectiveTo measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country.MethodsA cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels.Results199 patients and 31 doctors participated. Mean consultation time was 14.3 min (+ SD 5.75). Patients’ age ranged from 18 to 87 years (median age of 57.5 years). 52.8 % of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p < 0.05) and increased consultation time (β = 0.407, p < 0.01) were associated with higher OPTION scores.ConclusionsPatients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity.Practice implicationsMalaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities.     

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons

ObjectiveTo evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care.MethodsUsing a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians’ attitude and knowledge, and uptake of the ptDA.Results317 patients were included. The intervention improved physicians’ knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p = 0.004), patients who saw surgeons instead of residents (mean difference 5.46, p = 0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p = 0.036).ConclusionOur multifaceted intervention did not improve SDM and ptDA uptake was low.Practice ImplicationsIn orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.     

Does training general practitioners result in more shared decision making during consultations?

ObjectiveWe conducted a clustered randomised controlled trial to study the effects of shared decision making (SDM) on patient recovery. This study aims to determine whether GPs trained in SDM and reinforcing patients’ treatment expectations showed more trained behaviour during their consultations than untrained GPs.MethodsWe compared 86 consultations conducted by 23 trained GPs with 89 consultations completed by 19 untrained GPs. The primary outcomes were SDM, as measured by the OPTION scale, and positive reinforcement, as measured by global observation. Secondary outcomes were the level of autonomy in decision making and the duration of the consultation.ResultsIntervention consultations scored significantly higher on most elements of the OPTION scale, and on the autonomy scale; however, they were three minutes longer in duration, and the mean OPTION score of the intervention group remained below average.ConclusionTraining GPs resulted in more SDM behaviour and more autonomy for the patient; however, this increase is not attributable to the adoption of a patient perspective. Furthermore, while we aimed to demonstrate that SDM facilitates the reinforcement of patients’ positive expectations, the measurement of this behaviour was not reliable.Practice implicationsIn supporting SDM, professionals should give greater attention to patients’ treatment expectations.