Building ground for didactics in a patient decision aid for hip osteoarthritis. Exploring patient-related barriers and facilitators towards shared decision-making

ObjectiveThe aim of the present study was to explore patient-related barriers and facilitators towards shared decision-making (SDM) during routine orthopedic outpatient consultations as part of the process of developing a patient decision aid (PDA) for patients with hip osteoarthritis (OA).MethodsConsultations comprising nineteen hip OA patients referred to an orthopedic surgeon for treatment decision-making were observed, audio recorded and transcribed. Iterative thematic analysis proceeded, based on a taxonomy of generic patient-related barriers towards SDM grounded in the Theory of Planned Behavior (TPB).ResultsA targeted taxonomy provided a structured overview of 26 factors influencing hip OA patients’ intention to engage in SDM. Patients’ perceived ability to change the agenda of the visit emerged as seminal factor and was added to the generic taxonomy.ConclusionUsing a TPB-based taxonomy, we were able to identify and structure generic and context specific SDM barriers. Addressing patients’ communication self-efficacy should be included as didactic feature in PDAs.Practice implicationsPDAs for hip OA should be designed for the broad spectrum of decision-making support needs occurring throughout the continuum of the disease. The provided taxonomy may contribute as guidance within implementation strategies that aim to support patients’ intentions to engage in SDM.     

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.     

Barriers and facilitators to discussing HPV with head and neck cancer patients: A qualitative study using the theoretical domains framework

ObjectiveThe incidence of human papillomavirus-associated head and neck cancers (HPV-HNC) is increasing worldwide. Research in other clinical contexts has shown that healthcare professionals (HCPs) can find discussing HPV with patients challenging. However, limited research has been conducted in HNC. This study aimed to investigate barriers and facilitators to, discussing HPV among HCPs caring for patients with HNC in Ireland.MethodsSemi-structured telephone/face-to-face interviews were conducted with HCPs. Barriers and facilitators to discussing HPV with patients were identified using the Theoretical Domains Framework (TDF).Results20 HCPs (8 clinicians, 3 nurses, 9 allied healthcare professionals) were interviewed. Barriers to discussing HPV included professionals' lack of HPV knowledge, difficulties in talking about sexual issues with patients and lack of privacy to discuss HPV in busy clinic settings. Facilitators included increasing public and patient awareness of the link between HPV and HNC and professional education and skills development.ConclusionsThis is the first theoretically informed study to identify barriers and facilitators to discussing HPV with HNC patients. HCPs consider HPV discussions to be an essential part of HNC patient care.Practice implicationsUnderstanding the issues associated with patient-provider HPV communication will help develop effective interventions to support HCPs in their HPV discussions.     

What Influences the Implementation of Shared Decision Making: An Umbrella Review

ObjectiveTo provide a cogent summation of the evidence base of the key barriers and facilitators to implementing shared decision making (SDM).MethodsAn umbrella review of existing reviews on SDM was adopted. Databases were searched from 1997 to December 2018. Studies were included if they performed a review of barriers and facilitators to SDM. Results: 7 eligible reviews were identified. The five themes identified were: patient factors, professional factors, environmental factors, relationship factors, and factors related to information provision. Lack of time was the main factor hindering the implementation of SDM. Encouragement and motivation of providers to use SDM was a significant enabler of SDM implementation.ConclusionsThe provision of time and resources are insufficient if not accompanied by efforts to support and motivate providers to use SDM.Practice implicationsHealthcare providers need to be educated on the importance of building a relationship with their patients. To enhance this relationship, physicians may need to improve their interaction skills. They need to be curious and explore their patients' preferences, listen to them and respect their opinions, explain options and outcomes, and encourage them to participate in the decision making.     

Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions

ObjectiveTo update a systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.MethodsFrom March to December 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched. Studies were included if they reported on health professionals’ perceived barriers and facilitators to implementing shared decision-making in practice. Quality of the included studies was assessed. Content analysis was performed with a pre-established taxonomy.ResultsOut of 1130 titles, 10 new eligible studies were identified for a total of 38 included studies compared to 28 in the previous version. The vast majority of participants (n = 3231) were physicians (89%). The three most often reported barriers were: time constraints (22/38) and lack of applicability due to patient characteristics (18/38) and the clinical situation (16/38). The three most often reported facilitators were: provider motivation (23/38) and positive impact on the clinical process (16/38) and patient outcomes (16/38).ConclusionThis systematic review update confirms the results of the original review.Practice implicationsInterventions to foster implementation of shared decision-making in clinical practice will need to address a range of factors.     

Barriers and facilitators to exchanging health information: a systematic review

ObjectivesWe conducted a systematic review of studies assessing facilitators and barriers to use of health information exchange (HIE).MethodsWe searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Library databases between January 1990 and February 2015 using terms related to HIE. English-language studies that identified barriers and facilitators of actual HIE were included. Data on study design, risk of bias, setting, geographic location, characteristics of the HIE, perceived barriers and facilitators to use were extracted and confirmed.ResultsTen cross-sectional, seven multiple-site case studies, and two before-after studies that included data from several sources (surveys, interviews, focus groups, and observations of users) evaluated perceived barriers and facilitators to HIE use. The most commonly cited barriers to HIE use were incomplete information, inefficient workflow, and reports that the exchanged information that did not meet the needs of users. The review identified several facilitators to use.DiscussionIncomplete patient information was consistently mentioned in the studies conducted in the US but not mentioned in the few studies conducted outside of the US that take a collective approach toward healthcare. Individual patients and practices in the US may exercise the right to participate (or not) in HIE which effects the completeness of patient information available to be exchanged. Workflow structure and user roles are key but understudied.ConclusionsWe identified several facilitators in the studies that showed promise in promoting electronic health data exchange: obtaining more complete patient information; thoughtful workflow that folds in HIE; and inclusion of users early in implementation.     

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.     

Healthcare professionals’ behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review

ObjectiveTo explore the barriers to and facilitators of healthcare professionals’ implementation of SDM regarding screening programmes.MethodA systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves.ResultsEight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes.ConclusionThe results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts.Practical implicationsThe authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals’ behaviour within the context of the uncertainty of screening programmes.     

Communicating with older adults with long-term conditions about self-management goals: A systematic review and thematic synthesis

ObjectiveTo synthesise a body of fine-grained observational research on communication between healthcare professionals (HCPs), older adults, and carers regarding self-management goals and actions.MethodsWe conducted a systematic review, searching nine electronic databases and the grey literature. Two reviewers independently selected for inclusion following a two-stage process and studies and discrepancies were resolved through consultation with the review team.Results898 records were retrieved, and eight studies were included in the review. Aggregative thematic analysis resulted in 13 categories of communication practices across three decision-making domains: (1) initiating: actions occurring prior to the commitment point; (2) proposing: putting forward a course of action; and (3) committing and closing: committing (or not) to the course of action.ConclusionsDespite an increasing emphasis on the importance of personalised care planning and shared decision-making (SDM) to support older people’s health and wellbeing, HCPs did not consistently practice this approach and, in some cases, worked in opposition to it.Practice implicationsWe encourage HCPs to prepare older adults to engage actively with SDM and the goal setting process by employing patient-centred communication resources. These could assist with identifying different types of goals that are realistic and relevant to patients in daily life.     

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.     

Healthcare professionals’ assertions and women’s responses during labour: A conversation analytic study of data from One born every minute

ObjectiveCommunication during labour is consequential for women’s experience yet analyses of situated labour-ward interaction are rare. This study demonstrates the value of explicating the interactional practices used to initiate ‘decisions’ during labour.MethodsInteractions between 26 labouring women, their birth partners and HCPs were transcribed from the British television programme, One Born Every Minute. Conversation analysis was used to examine how decisions were initiated and accomplished in interaction.FindingsHCPs initiate decision-making using interactional practices that vary the ‘optionality’ afforded labouring women in the responsive turn. Our focus here is on the minimisation of optionality through ‘assertions’. An ‘assertive’ turn-design (e.g. ‘we need to…’) conveys strong expectation of agreement. HCPs assert decisions in contexts of risk but also in contexts of routine activities. Labouring women tend to acquiesce to assertions.ConclusionThe expectation of agreement set up by an assertive initiating turn can reduce women’s opportunities to participate in shared decision-making (SDM).Practice implicationsWhen decisions are asserted by HCPs there is a possible dissonance between the tenets of SDM in British health policy and what occurs in situ. This highlights an educational need for HCPs in how best to afford labouring women more optionality, particularly in low-risk contexts.     

What adolescents living with long-term conditions say about being involved in decision-making about their healthcare: A systematic review and narrative synthesis of preferences and experiences

Objective

To understand the preferences and experiences of adolescents (age 10–19) with long-term conditions (LTCs) towards involvement in discussions and decisions regarding management of their condition.

Impact of specialized pediatric palliative care programs on communication and decision-making

ObjectiveTo summarize and analyze the impact of specialized pediatric palliative care (SPPC) programs on communication and decision-making for children with life-threatening conditions.MethodsOur search strategy covered MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL, Scopus, and Embase through September 2018.ResultsWe reviewed 13 studies analyzing the impact of SPPC programs on communication and decision-making using a wide range of outcome indicators. Study quality was poor in 58% of included papers. SPPC programs improved communication and decision-making between families and healthcare professionals (HCPs), within and between families, and among HCPs.ConclusionSPPC programs generally support and improve communication and decision-making for children with life-threatening conditions, their families and associated HCPs. Families referred to an SPPC program had more discussions with HCPs on a broad variety of topics. However, data on communication with children, siblings, and other family members was scarce and of poor quality.Practice implicationsMore research on SPPC program efficacy is needed from the perspective of the ill child, as well as about barriers to end-of-life discussions and the specific aspects of SPPC programs responsible for improving outcomes.     

A scoping review of interventions to promote the adoption of shared decision-making (SDM) among health care professionals in clinical practice

ObjectivesTo identify and summarize evidence on interventions to promote the adoption of shared decision-making (SDM) among health care professionals (HCPs) in clinical practice.MethodsElectronic databases including: MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane library were searched to determine eligible peer-reviewed articles. Grey literature was searched for additional interventions. Eligibility screening and data extraction were independently completed. Results are presented as written evidence summaries and tables.ResultsOur search yielded 238 articles that met our inclusion criteria. Interventions mostly targeted physicians (46%), had multiple educational modalities (46%), and were administered in group settings (44%) before the clinical encounter (71%). Very few were developed based on the learning needs of targeted HCPs (24%). Many of the SDM outcome tools used for evaluation were developed for the respective study and lacked evidence of validity and reliability (30%).ConclusionWe identified a sizable number of interventions to promote the adoption of SDM, however, these interventions were heterogeneous in their assessments for effectiveness and implementation. Therefore, it is a challenge to infer which strategies and practices are best to promote SDM adoption.Practice implicationsThe need for evidence-based standards for developing SDM interventions targeting HCPs and assessing acceptability, effectiveness and implementation is suggested.     

Improving remote lifestyle intervention studies in children: Participant and caregiver feedback of the smart heart study

ObjectivesWe sought to describe and analyze the quantitative and qualitative feedback obtained from participants and their caregivers of the Smart Heart study, a successful 12-month lifestyle intervention for children with overweight or obesity and congenital heart disease that provided remote lifestyle counseling, to improve future lifestyle interventions in children.MethodsThirty-six participants and caregivers were polled using a standard program evaluation questionnaire at the end of the intervention. Feedback was compiled into themes, and facilitators and barriers to program success were identified.ResultsThere was a high level of satisfaction with the intervention and staff interactions as well as a low perceived burden of participation. There were also specific concerns, including mixed impressions regarding technology usage and a less impressive indication of actual impactful behavior change.ConclusionsThe study identified five themes, and corresponding facilitators and barriers to participant compliance, from the Smart Heart intervention feedback and offered suggestions for improving future lifestyle behavioral intervention study designs in children.Practice implicationsRemote smartphone counseling is effective and efficient. It is recommended that the counseling messages are specific, the counseling schedule is patient-centric, patient burden is limited, methods with immediate patient feedback are used and family is included when feasible.     

Persuasive communication in medical decision-making during consultations with patients with limited health literacy in hospital-based palliative care

ObjectiveBoth patients in the palliative phase of their disease and patients with limited health literacy (LHL) have an increased risk of being influenced by healthcare providers (HCPs) when making decisions. This study aims to explore to what extent persuasive communication occurs during shared decision-making (SDM) by (1) providing an overview of persuasive communication behaviours relevant for medical decision-making and (2) exemplifying these using real-life outpatient consultations.MethodsAn exploratory qualitative design was applied: (1) brief literature review; (2) analysis of verbatim extracts from outpatient consultations and stimulated recall sessions with HCPs; and (3) stakeholder meetings.Results24 different persuasive communication behaviours were identified, which can be divided in seven categories: biased presentation of information, authoritative framing, probability framing, illusion of decisional control, normative framing, making assumptions and using emotions or feelings.ConclusionsPersuasive communication is multi-faceted in outpatient consultations. Although undesirable, it may prove useful in specific situations making it necessary to study the phenomenon more in depth and deepen our understanding of its mechanisms and impact.Practice implicationsAwareness among HCPs about the use of persuasive communication needs to be created through training and education. Also, HCPs need help in providing balanced information.     

“I think that everybody should be involved”: What informs experiences of shared decision-making in supporting people living with schizophrenia spectrum disorders?

ObjectiveTo identify facilitators and barriers associated with shared decision-making (SDM) in Australians affected by schizophrenia spectrum disorders.MethodsWe surveyed 78 participants with lived experience and held 12 in-depth interviews, including seven carers.ResultsA multiple linear regression model identified two independent variables significantly associated with degree of SDM: Personal Wellbeing Index scores (ß = .32, t = 3.3, p = .001) and treatment satisfaction rating (ß =.46, t = 4.7, p < .001), indicating that higher personal wellbeing and higher treatment satisfaction were significantly related to higher degree of SDM. Two key themes were identified through interview data: a complex pathway to SDM and impacts on wellbeing. Sub-themes included: self and carer characteristics, holistic care, education and knowledge, and power balance. Generally, participants reported a desire for SDM, noting that healthcare professionals inconsistently involve them in treatment decisions.ConclusionSDM is associated with treatment satisfaction and personal wellbeing among people living with schizophrenia spectrum disorders, but can be difficult to implement due to a range of challenges.Practice implicationsThere is a need to improve SDM in this population by decreasing stigma and discrimination, balancing power in consultations, increasing access to holistic treatment, and improving education and knowledge.     

Communicating about HPV in the context of head and neck cancer: A systematic review of quantitative studies

ObjectiveRising incidence of HPV-positive head and neck cancers (HPV-HNC) means HPVinfection is increasingly relevant to patient-provider consultations. We performed a systematic review to examine, in the context of patient-provider HNC consultations: discussions about HPV, attitudes towards discussing HPV and information needs.MethodsWe searched Embase, PsychINFO, and CINAHL + for studies to August 2018. Eligible studies included: HNC healthcare professionals (HCPs) and/or HNC patients investigated HNC patient-provider communication about HPV.ResultsTen studies were identified: six including HCPs and four including HNC patients. HCPs varied in confidence in HPV discussions, which was related to their HPV knowledge. Both HCPs and patients acknowledged the need for reliable HPV information. Factors which facilitated HPV discussions included accessible HPV information for patients and HCPs and good HPV knowledge among HCPs. Barriers included the perception, among HCPs, that HPV was a challenging topic to discuss with patients.ConclusionsInformation deficits, communication challenges and barriers to discussing HPV were identified in HNC patient-provider consultations.Practice implicationsAppropriate HPV information is needed for HCPs and patients. Professional development initiatives which increase HCPs’ HPV knowledge and build their communication skills would be valuable.     

The challenges of facilitating primary healthcare discussions on traditional,complementary and alternative medicine for childhood eczema: Piloting a computerized template

ObjectiveHealthcare practitioners (HCPs) experience barriers to changing routine consultation practice. Communication and recording of traditional, complementary and alternative medicines (TCAM) is inadequate. This pilot study explored the challenges of implementing a computerized template in primary care to facilitate communication on TCAM for paediatric eczema.MethodsA computerized template to record TCAM use, with links to evidence-based TCAM databases, was designed, based on qualitative research with patients and HCPs. Four London general practices implemented the template integrated with usual practice. Twelve focus groups during the 6 month study period explored HCPs’ knowledge, communication and information sources regarding TCAM and perceived barriers to template implementation.ResultsHCPs were initially enthusiastic about discussing TCAM, for improving communication and understanding patient's choices, but the template was used in under a third of consultations. HCPs were surprised at low TCAM use (10%) and lack of correlation with eczema or ethnicity. Reported barriers were time and remembering, due to busy, target-driven practice.ConclusionHCPs recognize the importance of discussing TCAM use for childhood eczema, and potential benefits for HCP–patient communication.Practice implicationsFuture tools to facilitate TCAM discussion should prioritise use of existing IT systems and address barriers to use, especially lack of time.