Manipulation and free will in shared decision making

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

Patient‐centred care through a broader lens: Supporting patient autonomy alongside moral deliberation

Patient‐centred care (PCC) is an essential component of high‐quality healthcare and shared decision‐making is its cornerstone. Yet, integrating the principles of PCC into healthcare practice is not always straightforward and shared decision‐making can be complicated and ethically demanding. While ethicists and academics routinely debate moral aspects of clinical care, such discussion among clinicians is less overt. In this paper, we use Emmanuel et al.’s deliberative model to provide a practical framework for considering ethical aspects of PCC and shared decision‐making. The model encourages us to appreciate PCC through a broader lens and consider patient autonomy alongside other moral obligations such as justice and the equitable distribution of finite resources. The model can be used by healthcare providers, patients and caregivers to facilitate dialogue and moral deliberation regarding the merit of their preferences and values; in this way, individualised care can be delivered without compromising other important ethical obligations.     

Effects of an educational programme on shared decision‐making among Korean nurses

This study was conducted to examine the effects of an educational programme on shared decision‐making on end‐of‐life care performance, moral sensitivity and attitude towards shared decision‐making among Korean nurses. A quasi‐experimental study with a non‐equivalent control group pretest–posttest design was used. Forty‐one clinical nurses were recruited as participants from two different university hospitals located in Daegu, Korea. Twenty nurses in the control group received no intervention, and 21 nurses in the experimental group received the educational programme on shared decision‐making. Data were collected with a questionnaire covering end‐of‐life care performance, moral sensitivity and attitude towards shared decision‐making. Analysis of the data was done with the chi‐square test, t‐test and Fisher's exact test using SPSS/Win 17.0 (SPSS, Inc., Chicago, IL, USA). The experimental group showed significantly higher scores in moral sensitivity and attitude towards shared decision‐making after the intervention compared with the control group. This study suggests that the educational programme on shared decision‐making was effective in increasing the moral sensitivity and attitude towards shared decision‐making among Korean nurses.     

Shared decision‐making in mental and behavioural health interventions

Elements of shared decision‐making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision‐making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision‐making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision‐making when working with patients.     

Who is the patient? Tensions between advance care planning and shared decision‐making

Shared decision‐making takes many forms, involving different kinds of agents who share the requirement that they must have sufficient decision‐making capacity for the decision in question. Advance care planning (ACP) is commonly viewed as a form of shared decision‐making between carers and patients who anticipate losing decision‐making capacity. What is unclear in this situation is the identity status of an individual who has become mentally incapacitated and how to evaluate their rights and interests. This is known as the identity problem of ACP. This paper suggests that the identity problem can be most convincingly addressed by understanding ACP based on narrative views of identity. These views, however, create a tension in our current medico‐legal framework for attributing decision‐making capacity. Current laws and guidelines favour maximum inclusiveness and hence mandate supported decision‐making of those with reduced or only focally preserved decision‐making capacity. Yet, an ACP framework based on narrative identity and the relevant capacities to construct such narratives results in more demanding capacity requirements than current medico‐legal practice requires. The law thus espouses conflicting views as to who can be an appropriate decision‐making authority for patient care. I therefore conclude that the law governing medical care needs to be clearer about how to resolve the identity problem and revisit its position on ACP or supported decision‐making for those who have only focally preserved decision‐making capacity.     

Emancipation in decision-making in women's health care

Background. Emancipation as a nursing concept is derived from a long‐standing history of social oppression and is easily addressed by both critical social theory and feminist theory. It is the apparent concept to describe a phenomenon witnessed in nursing when caring for women in the decision‐making process about health care issues. Emancipation has been recognized by expert clinical observation. Aim. The aim of this paper is to define the concept of emancipation for possible future application to nursing practice for the promotion of humanistic nursing care in women's health, specifically applied to the decision‐making process. Method. A literature search was carried out using the CINAHL database and the keywords nursing and emancipation, and covering the period 1985–2003. The Rodgers and Knafl (2000) method of concept analysis was then used to derive a conceptual meaning of emancipation that benefits patient care as well as professional nursing development. Emancipation is broken down into antecedents, attributes and consequences. Related concepts are also explored, compared and discussed to synthesize relevant characteristics. Findings. This concept analysis identifies emancipation in decision‐making as a nursing phenomenon by discussing the antecedent of oppression and exploring the identified attributes: (a) empowerment, (b) personal knowledge, (c) social norms, (d) reflection and (e) flexible environment. The consequence of emancipation is free choice. It is a futuristic concept with strong historical ties in need of exploration and development within the context of women's health care in relation to decision‐making. Conclusions. The concept model illustrates emancipated decision‐making, with its five attributes in relation to oppression as a non‐linear phenomenon. Areas for further study include the exploration of the contribution of each critical attribute and its relationship to emancipated decision‐making, and the decision‐making process in relation to patient satisfaction and how long the person continues to adhere to the decision. Also the professional nursing role in promotion of emancipated decision‐making is virtually unexplored, but is an important concept in the paradigm of shared decision‐making about health care alternatives.     

Shared decision making and physical therapy: What,when, how,and why?

BackgroundShared decision making is a means of translating evidence into practice and facilitating patient-centred care by helping patients to become more active in the decision-making process. Shared decision making is a collaborative process that involves patients and clinicians making health-related decisions after discussing the available options; the benefits and harms of each option; and considering the patient's values, preferences, and personal circumstances.MethodsThis paper describes what shared decision making is, why it is important, when it is appropriate, and key elements. We report on physical therapists’ current use of and attitudes to shared decision making and explore factors that influence its uptake. Lastly, we examine what is needed to promote greater use of this approach.ResultsKey elements in the shared decision making process are: identifying the problem that requires a decision; providing an explanation of the health problem, including, where appropriate, the natural history of the condition; discussing the available options and the potential benefits and harms of each option; eliciting the patient's values, preferences, and expectations; and assisting the patient to weigh up the options to reach an informed decision. When applied in practice, shared decision making has been found to improve patient-clinician communication; improve patients’ accuracy of their expectations of intervention benefits and harms, involvement in decision-making, and feeling of being informed; and increase both patients’ and clinicians’ satisfaction with care.ConclusionDespite physical therapists’ enthusiasm for shared decision making, uptake of this approach has been slow. Multi-level strategies and behaviour change are required to encourage and support the sustainable incorporation of shared decision making in practice.     

An Integrated System's Nursing Shared Governance Model: A System Chief Nursing Officer's Synergistic Vehicle for Leading a Complex Health Care System

Seton Nursing reengineered previous models of care and leadership to accommodate rapid growth of its health care system from individual acute care sites to a health care system with consistent quality and standardization of like units across the system. Shared governance promotes collaboration with shared decision making and accountability; however, the role and methods of a system chief nursing officer to connect shared governance across a new system has not been previously described. A system chief nursing officer can significantly influence and guide the nursing strategic direction at all the health care system-related facilities by utilizing a single, systemwide nursing shared governance structure. Using this structure provides a venue to maximize the influence of a transformational leader and creates efficiencies in workforce development, resource management, best practice identification, and spread of initiatives and improvements to adapt to an ever-changing health care landscape. This is the story of one such system chief nursing officer.     

Don't just do something,stand there! The value and art of deliberate clinical inertia

It can be difficult to avoid unnecessary investigations and treatments, which are a form of low‐value care. Yet every intervention in medicine has potential harms, which may outweigh the potential benefits. Deliberate clinical inertia is the art of doing nothing as a positive response. This paper provides suggestions on how to incorporate deliberate clinical inertia into our daily clinical practice, and gives an overview of current initiatives such as ‘Choosing Wisely’ and the ‘Right Care Alliance’. The decision to ‘do nothing’ can be complex due to competing factors, and barriers to implementation are highlighted. Several strategies to promote deliberate clinical inertia are outlined, with an emphasis on shared decision‐making. Preventing medical harm must become one of the pillars of modern health care and the art of not intervening, that is, deliberate clinical inertia, can be a novel patient‐centred quality indicator to promote harm reduction.     

Reaching a shared understanding of shared decision making in health care: NICE's experience of scoping the shared decision making guideline

NICE's guideline on shared decision making, currently under development, endeavours to support shared decision making as part of routine health care practice. In this article, we summarize our learning to date, gained through the scoping of the guideline, on the key challenges that need to be addressed in the guideline. The production of a scope is the first stage in the development of a NICE guideline, setting the parameters for what will be considered in the guideline. The process for scoping the shared decision making guideline involved discussion with early recruited committee members and engagement with registered stakeholders, through both a workshop and formal consultation. Important, and sometimes divergent, viewpoints about shared decision making were revealed through this process. The key challenges centred on the issues of a need for a common definition of shared decision making, measurability, opportunities, barriers to implementation, and feasibility. Recognizing these challenges aided the refinement of the scope in terms of what the guideline will cover, draft questions and main outcomes for consideration.     

Family-Centered Rounds in the Neonatal Intensive Care Unit

Promotion of family‐centered care is common in neonatal intensive care units (NICUs) across the nation. Yet, true collaboration and shared decision‐making with families in the care of their baby is not the standard of care. Family‐centered rounds can provide the opportunity for this level of collaboration, but care must be taken to overcome barriers to family‐centered rounds.     

Decision‐making preference and opportunity in VA ambulatory care patients: Association with patient satisfaction

Using data from the Veterans Health Study, associations were examined for decision‐making preference, decision‐making opportunity, and satisfaction with medical care among a sample of 266 men who use Department of Veterans Affairs (VA) ambulatory health care services. Results indicated that veterans with a high preference for involvement in decision‐making and low provider‐offered decision‐making opportunities had significantly lower satisfaction with medical care compared to veterans with either low preference for decision‐making involvement with high or low opportunity, or those with a high decision‐making preference and high decision‐making opportunity. The findings suggest that health care providers may increase patient satisfaction with medical care by providing opportunities for decision‐making to patients who prefer involvement in their health care decision‐making. Provider strategies for increasing patient decision‐making involvement are discussed. © 1999 John Wiley & Sons, Inc. Res Nurs Health 22: 39–48, 1999.     

Perceptions of crisis care in populations who self‐referred to a telephone‐based mental health triage service

Although psychiatric crises are very common in people with mental illness, little is known about consumer perceptions of mental health crisis care. Given the current emphasis on recovery‐oriented approaches, shared decision‐making, and partnering with consumers in planning and delivering care, this knowledge gap is significant. Since the late 1990s, access to Australian mental health services has been facilitated by 24/7 telephone‐based mental health triage systems, which provide initial psychiatric assessment, referral, support, and advice. A significant proportion of consumers access telephone‐based mental health triage services in a state of crisis, but to date, there has been no published studies that specifically report on consumer perceptions on the quality and effectiveness of the care provided by these services. This article reports on a study that investigated consumer perceptions of accessing telephone‐based mental health triage services. Seventy‐five mental health consumers participated in a telephone interview about their triage service use experience. An eight‐item survey designed to measure the responsiveness of mental health services was used for data collection. The findings reported here focus on the qualitative data produced in the study. Consumer participants shared a range of perspectives on telephone‐based mental health triage that provide invaluable insights into the needs, expectations, and service use experiences of consumers seeking assistance with a mental health problem. Consumer perceptions of crisis care have important implications for practice. Approaches and interventions identified as important to quality care can be used to inform educational and practice initiatives that promote person‐centred, collaborative crisis care.     

Shared governance--nurses making a difference

AIM: This paper aims to describe how shared governance can be successfully integrated into existing management structures in a large medical directorate. It will show how the shared governance philosophy can lead to the creation of a culture where nurses feel important and valued and also consider its use as a foundation for the implementation of the nursing strategy. BACKGROUND: The hospital adopted shared governance in 1995 with the setting up of councils led by staff nurses. Shared governance advocates claim it broadens involvement of clinically-based nurses in the process of change through devolved decision-making thereby enhancing clinical practice and increasing staff moral and self-esteem. Key issues Shared governance is a cultural change that will develop the leadership and management skills of all grades of staff. Shared governance is not a quick fix for the profession; involvement of all staff needs time, persistence, determination and a strong commitment to training and development. CONCLUSION: The national nursing strategy puts nurses in a position to positively influence health care for the advantage of patients, however, for nurses to grasp this opportunity cultural change is required. This practical example of shared governance demonstrates how it can be used to create a proactive culture, focused on improving patient care. The nurturing and developing of clinically-based nurses provides them with the knowledge and skills to challenge the status quo and lead change. Thus, shared governance is an excellent foundation from which to develop the nursing strategy.     

患者偏好与医患共同决策

循证医学提倡医务人员应用证据并考虑患者价值和偏好作出决策。医患共同决策基于医患双方均为"专家"的理念, 即医生作为医学专家提供医学专业意见, 而患者作为了解自身偏好的专家, 双方在充分讨论后共同作出医学决策。在此过程中, 医务人员应同时具备获取最佳证据以及应用决策辅助系统实现医患共同决策的能力。本文通过比较不同医学决策模式, 讨论医患共同决策的理论与实践, 并列举与中国医疗环境相关的、医患共同决策可能面临的挑战与障碍因素, 以期为临床作出合理决策以及提高医疗服务质量提供借鉴。     

Does shared decision making respect a patient's relational autonomy?

According to many of its proponents, shared decision making (“SDM”) is the right way to interpret the clinician‐patient relationship because it respects patient autonomy in decision‐making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this paper argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy.