The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital

Acceptability and usability of the Planning Advance Care Together (PACT) website for improving patients' engagement in advance care planning

Objectives

Most prior advance care planning (ACP) interventions lack integration of the social context of patients' ACP process, which patients indicate is critically important. The current study developed the Planning Advance Care Together (PACT) website to foster inclusion of loved ones in the ACP process.

Methods

To provide feedback about the PACT website, patients with advanced cancer (N = 11), their caregivers (N = 11), and experts (N = 10) participated in semi-structured interviews. Patients and caregivers also completed standardized ratings of acceptability and usability.

Results

Overall, patient (n = 11) and caregiver (n = 11) ratings of acceptability and usability of the website exceeded benchmark cut-offs (≥24 on the Acceptability E-Scale and ≥ 68 on the System Usability Scale). Patients, caregivers, and experts liked the topic of ACP but felt that it could be emotionally challenging. They recommended focusing more on planning and less on end of life. They appreciated being able to include loved ones and recommended adding resources for caregivers.

Conclusions

Study findings support the preliminary usability and acceptability of the PACT website. Findings will be used to inform a modified prototype of the PACT website that is interactive and ready for field testing with patients with advanced cancer and their loved ones.

Innovation

We utilized a novel application of the shared mind framework to support patients with advanced cancer in engaging their loved ones in the ACP process.

What value structure underlies shared decision making? A qualitative synthesis of models of shared decision making

OBJECTIVE

To construct the underlying value structure of shared decision making (SDM) models.

METHOD

We included previously identified SDM models (n = 40) and 15 additional ones. Using a thematic analysis, we coded the data using Schwartz's value theory to define values in SDM and to investigate value relations.

RESULTS

We identified and defined eight values and developed three themes based on their relations: shared control, a safe and supportive environment, and decisions tailored to patients. We constructed a value structure based on the value relations and themes: the interplay of healthcare professionals' (HCPs) and patients' skills [Achievement], support for a patient [Benevolence], and a good relationship between HCP and patient [Security] all facilitate patients' autonomy [Self-Direction]. These values enable a more balanced relationship between HCP and patient and tailored decision making [Universalism].

CONCLUSION

SDM can be realized by an interplay of values. The values Benevolence and Security deserve more explicit attention, and may especially increase vulnerable patients' Self-Direction.

PRACTICE IMPLICATIONS

This value structure enables a comparison of values underlying SDM with those of specific populations, facilitating the incorporation of patients' values into treatment decision making. It may also inform the development of SDM measures, interventions, education programs, and HCPs when practicing.

A qualitative study on the perioperative experiences and demands of haemophilic arthropathy patients undergoing total joint replacement

INTRODUCTION

Total joint replacement is the optimal treatment option for patients with severe haemophilic arthritis. Current research emphasizes patient-reported outcomes as a vital measure for evaluating surgical outcomes and patient satisfaction. Nevertheless, very limited information about the subjective experience of perioperative haemophiliacs in the literature, highlighting the need for exploration in this area.

AIM

To investigate the psychological experiences and health demands of haemophilic arthropathy patients during the perioperative period of total joint replacement.

DESIGN

Qualitative descriptive research with semistructured individual interviews.

METHODS

From June to September 2023, nine patients with severe haemophilic arthropathy who underwent total joint replacement at a Haemophilia Diagnosis and Treatment Centre in China were interviewed for average 37 min per person. Data were analysed using the traditional content analysis method and reported following the consolidated criteria for reporting qualitative research. The study is reported according to the COREQ checklist.

RESULTS

Interviews described two main themes: (1) emotional decline which involves preoperative overoptimism, early postoperative anxiety and disease uncertainty during the early independent rehabilitation. (2) wellness aspiration which includes rehabilitation support and spiritual healing.

CONCLUSION

This study reveals the patients' significant psychological changes and their well-being aspiration, particularly out-of-hospital rehabilitation needs. Strengthening communication between multidisciplinary teams and patients, enhancing the involvement of nurses, broadening the scope of functions at primary Haemophilia Treatment Centres, and developing telerehabilitation, these concerted efforts may improve the overall treatment experience for patients.

For which decisions is Shared Decision Making considered appropriate? - A systematic review

OBJECTIVE

To identify decision characteristics for which SDM authors deem SDM appropriate or not, and what arguments are used.

METHODS

We applied two search strategies: we included SDM models from an earlier review (strategy 1) and conducted a new search in eight databases to include papers other than describing an SDM model, such as original research, opinion papers and reviews (strategy 2).

RESULTS

From the 92 included papers, we identified 18 decision characteristics for which authors deemed SDM appropriate, including preference-sensitive, equipoise and decisions where patient commitment is needed in implementing the decision. SDM authors indicated limits to SDM, especially when there are immediate life-saving measures needed. We identified four decision characteristics on which authors of different papers disagreed on whether or not SDM is appropriate.

CONCLUSION

The findings of this review show the broad range of decision characteristics for which authors deem SDM appropriate, the ambiguity of some, and potential limits of SDM.

PRACTICE IMPLICATIONS

The findings can stimulate clinicians to (re)consider pursuing SDM in situations in which they did not before. Additionally, it can inform SDM campaigns and educational programs as it shows for which decision situations SDM might be more or less challenging to practice.

Confucian Familism and Shared Decision Making in End-of-Life Care for Patients with Advanced Cancers

Shared decision-making (SDM) has been institutionally recognized as clinically effective by many Western healthcare systems. Nevertheless, it appears culturally unattractive in China, a country that adheres to Confucian familism which strongly prefers collective family decisions. This study examined this conflict and assessed the influence of Confucian familism on SDM in end-of-life (EOL) care for advanced cancer patients. Between August and November 2018, 188 EOL advanced-cancer patients were randomly recruited from 640 cancer hospital medical records at a Tertiary A-level hospital in Shandong province. Eventually, 164 (87.23%) sample patients were included in the statistical analysis after the non-responsive cases (4.79%) and missing value (7.98%) were removed. SDM was measured through SDM-Q-9, and the patient's siblings were used as indicators of Confucian Familism. Of the 164 patients, the mean SDM score was 38/100; 47.6% were thoroughly unfamiliar with their treatment plans and fell outside the decision-making procedure. Each patient had four siblings on average. Ceteris paribus, more siblings led to lower SDM. Moreover, being 56-65 years old and open-minded were associated with higher SDM, while higher satisfaction of the quality of EOL care yielded lower SDM. In conclusion, Confucian familism weakened patient-clinician SDM in EOL care for advanced cancer patients.

Theoretical model and measurement of shared decision making in web-based pharmaceutical care consultation

Objectives

We aimed to construct a theoretical model and an observer-based measurement of shared decision making (SDM) in web-based pharmaceutical care consultation.

Methods

We first constructed a theoretical model through analysis of SDM models and interviews with 24 key informants. Then, the initial measurement was formulated, and the content was evaluated by 16 key informants alone. A cross-sectional study was executed, where 300 provider-patient encounters were collected at the online platform ‘Good Doctor Website’, for reliability and validity assessment. Content validity was evaluated by appropriateness score, that is the median of 7–9 and without disagreement. Interrater reliability was evaluated by Spearman correlation coefficient using 30 out of 300 samples. Single indicator validity was tested by Pearson correlation analysis, and convergent validity was evaluated by the Multiple Indicators Multiple Causes (MIMIC) model using 300 samples.

Results

Theoretical model constructed included four elements: ‘comprehensive understanding of the patient's condition’, ‘exchanging ideas on medication options’, ‘achieving a medication plan’, and ‘providing decision support’. Measurement constructed included four dimensions and 19 items, and four dimensions were in accordance with four elements of the theoretical model. We found median scores of these dimensions and items were 7–9 and without disagreement, indicating good content validity. Spearman correlation coefficients of 19 items were greater than 0.750, suggesting good interrater reliability. Pearson coefficients between 19 items and their external variables were significant (p < 0.001), and MIMIC model results showed that the R² values of dimensions 1–4 were over 0.5, indicating good single indicator validity and convergent validity.

Conclusions

Characteristics of web-based pharmaceutical care consultation, highlighting the importance of medication history, medication regimen, and detailed medication plan, were observed in the theoretical model. Measurement constructed had good reliability and validity and may be used by health policymakers to improve the quality of pharmaceutical care consultation online.

Barriers to shared decision-making with women of reproductive age affected by a chronic inflammatory disease: a mixed-methods needs assessment of dermatologists and rheumatologists

OBJECTIVES

The main study objective was to identify challenges and barriers experienced by dermatologists and rheumatologists when engaging women of reproductive age in shared decision-making (SDM) related to treatment and management of chronic inflammatory disease (CID) before, during and after pregnancy.

DESIGN

A mixed-methods study was conducted, employing (1) semistructured interviews, (2) an online survey and (3) triangulation of findings.

PARTICIPANTS

524 dermatologists and rheumatologists entered the study; 495 completed it; 388 met inclusion criteria for analysis. Participants were included if actively practising in Germany (GER), the UK or the USA; had a minimum 5% caseload of female patients of reproductive age with either axial spondyloarthritis, psoriasis, psoriatic arthritis or rheumatoid arthritis; and had experience prescribing biologics.

RESULTS

48 interviews and 340 surveys were analysed. Interviews underscored dermatologists and rheumatologists' suboptimal integration of SDM in clinical practice. In the survey, 90% (n=305) did not know about SDM models. A perceived lack of competency counselling patients on pregnancy and family planning was also identified during interviews. Among the survey sample, 44% (n=150) of specialists agreed they preferred leaving pregnancy-related discussions to obstetricians and/or gynaecologists and 57% (n=189) reported having suboptimal skills discussing contraceptive methods with patients. Another finding that emerged from interviews was the perception that all biologics are strictly contraindicated during pregnancy. Suboptimal knowledge was noted among 57% (n=95) of dermatologists and 48% (n=83) of rheumatologists surveyed in that regard, with a statistically significant difference by country among dermatologists (GER: 42% vs UK: 71% vs USA: 57%, p=0.015).

CONCLUSIONS

This study identified low levels of knowledge, skill and confidence, as well as attitudinal issues, that explain why SDM is not fully integrated in dermatology and rheumatology clinical practice. Blended-learning interventions are recommended to assist CID specialists in developing effective communication and patient engagement competencies.

Perceptions and experiences of older patients and healthcare professionals regarding shared decision-making in pulmonary rehabilitation: A qualitative study

OBJECTIVE

To understand the perceptions and experiences of older patients with chronic obstructive pulmonary disease (COPD) and healthcare professionals (HCPs) regarding shared decision-making in pulmonary rehabilitation (PR).

DESIGN

A qualitative study using single, semi-structured interviews, and thematic analysis.

SETTING

Face-to-face interviews were conducted in the Jiangnan University, in hospital and in patients' homes.

PARTICIPANTS

Twenty-two older patients with COPD and 29 HCPs.

METHODS

An initial codebook and semi-structured interview guide were developed based on the shared decision-making 3-circle conceptual model. Thematic analysis was used to analyze data.

RESULTS

The study identified 10 themes that describe the perceptions and experiences of patients and HCPs involved in PR decision-making: (1) patients' confidence, (2) patients' perceptions of the cost-benefit of decisions, (3) patients' perceived stress about the consequences of decision-making, (4) HCPs' perceived stress on shared decision-making, (5) cognitive biases of patients toward illness and rehabilitation, (6) shared decision-making as a knowledge gap, (7) the knowledge gap between patients and HCPs, (8) authority effect, (9) family support, (10) human resources. These themes were then divided into three groups according to their characteristics: (1) the feelings of the participants, (2) knowledge barriers, and (3) support from the social system.

CONCLUSION

Patients and HCPs described their negative perceptions and experiences of participating in decision-making in PR. The implementation of shared decision-making in PR is currently limited; therefore, health education for patients and families should be strengthened and a training system for HCPs in shared decision-making should be established.

Using DEMATEL Technique to Identify the Key Success Factors of Shared Decision-Making Based on Influential Network Relationship Perspective

In the field of medicine, shared decision-making (SDM) is an important issue primarily aimed at resolving the problem of information asymmetry between clinicians and patients in the selection of treatment options and follow-up nursing plans. Most previous studies on this topic have focused on key elements and the development and implementation of SDM scales. This study used the decision-making trial and evaluation laboratory (DEMATEL) method to establish a network of influence relationships among factors that are keys to the success of the SDM process. Survey data were obtained from a well-known brain hospital in China. The key factors of success included tailor information, flexibility approach, check understanding patient, document (discussion about) decision, present evidence, make or explicitly defer decision, and patient values and preferences. We determined that clinicians should provide a series of treatment options and follow-up care plans based on a patientʼs conditions and preferences. Clinicians should also actively communicate with patients and their families to ensure a thorough understanding of the entire treatment and nursing process. This study also highlights the academic value of the cross-disciplinary integration of medical decision issues and multiple attribute decision-making methodologies.

Addressing Goals of Parents of Hospitalized Children: A Qualitative Analysis of Parents' and Physicians' Perspectives

OBJECTIVE

Goals of care discussions are crucial in helping parents navigate complex medical decisions and shown to improve quality of care. Little is known about whether physicians elicit or address parents' goals during a child's hospitalization. The purpose of this study was to understand the current practice of goal setting at the beginning of hospitalization by exploring the perspectives of parents of hospitalized children and their hospital physicians.

METHODS

A qualitative study with semi-structured interviews was conducted from 2018 to 2019 at a 361-bed quaternary suburban freestanding children's hospital. Twenty-seven parents of hospitalized children and 16 pediatric hospital medicine faculty were matched to participate. Data were analyzed using modified grounded theory, with themes identified through constant comparative approach.

RESULTS

Five themes were identified: 1) Majority of hospitalized children's parents want to share their goals with physicians. 2) Parents and physicians share the same underlying goal of getting the child better to go home. 3) Parents of children with chronic diseases identified nonhospital goals that were not addressed. 4) Physicians do not explicitly elicit but rather assume what parents' goals of care are. 5) Factors related to patient, parent, and physician were identified as barriers to goal setting.

CONCLUSIONS

Physicians may not consistently elicit parents' goals of care for their hospitalized children at the start of hospitalization. Parents desire their physicians to explicitly ask about their goals and involve them in goal setting during hospitalization. Strategies were identified by parents and physicians to improve goal setting with parents of hospitalized children.

Evaluation of the Use of Shared Decision Making in Breast Cancer: International Survey

OBJECTIVES

To assess shared decision-making (SDM) knowledge, attitude and application among health professionals involved in breast cancer (BC) treatment.

MATERIALS AND METHODS

A cross-sectional study based on an online questionnaire, sent by several professional societies to health professionals involved in BC management. There were 26 questions which combined demographic and professional data with some items measured on a Likert-type scale.

RESULTS

The participation (459/541; 84.84%) and completion (443/459; 96.51%) rates were high. Participants strongly agreed or agreed in 69.57% (16/23) of their responses. The majority stated that they knew of SDM (mean 4.43 (4.36-4.55)) and were in favour of its implementation (mean 4.58 (4.51-4.64)). They highlighted that SDM practice was not adequate due to lack of resources (3.46 (3.37-3.55)) and agreed on policies that improved its implementation (3.96 (3.88-4.04)). The main advantage of SDM for participants was patient satisfaction (38%), and the main disadvantage was the patients' paucity of knowledge to understand their disease (24%). The main obstacle indicated was the lack of time and resources (40%).

CONCLUSIONS

New policies must be designed for adequate training of professionals in integrating SDM in clinical practice, preparing them to use SDM with adequate resources and time provided.

Observer Ratings of Shared Decision Making Do Not Match Patient Reports: An Observational Study in 5 Family Medicine Practices

BACKGROUND

Measuring shared decision making (SDM) in clinical practice is important to improve the quality of health care. Measurement can be done by trained observers and by people participating in the clinical encounter, namely, patients. This study aimed to describe the correlations between patients' and observers' ratings of SDM using 2 validated and 2 nonvalidated SDM measures in clinical consultations.

METHODS

In this cross-sectional study, we recruited 238 complete dyads of health professionals and patients in 5 university-affiliated family medicine clinics in Canada. Participants completed self-administered questionnaires before and after audio-recorded medical consultations. Observers rated the occurrence of SDM during medical consultations using both the validated OPTION-5 (the 5-item "observing patient involvement" score) and binary questions on risk communication and values clarification (RCVC-observer). Patients rated SDM using both the 9-item Shared Decision-Making Questionnaire (SDM-Q9) and binary questions on risk communication and values clarification (RCVC-patient).

RESULTS

Agreement was low between observers' and patients' ratings of SDM using validated OPTION-5 and SDM-Q9, respectively (ρ = 0.07; P = 0.38). Observers' ratings using RCVC-observer were correlated to patients' ratings using either SDM-Q9 (r_pb = -0.16; P = 0.01) or RCVC-patients (r_pb = 0.24; P = 0.03). Observers' OPTION-5 scores and patients' ratings using RCVC-questions were moderately correlated (r_φ = 0.33; P = 0.04).

CONCLUSION

There was moderate to no alignment between observers' and patients' ratings of SDM using both validated and nonvalidated measures. This lack of strong correlation emphasizes that observer and patient perspectives are not interchangeable. When assessing the presence, absence, or extent of SDM, it is important to clearly state whose perspectives are reflected.

Shared Decision-making With Parents of Hospitalized Children: A Qualitative Analysis of Parents' and Providers' Perspectives

OBJECTIVES

Shared decision-making (SDM) is the pinnacle of patient-centered care and has been shown to improve health outcomes, especially for children with chronic medical conditions. However, parents perceive suboptimal involvement during hospitalization. The objective was to explore the perspectives of parents of hospitalized children and their hospital providers on facilitators and barriers to SDM in the hospital and identify strategies to increase SDM.

METHODS

A qualitative study was conducted by using semistructured interviews with parents of hospitalized children with and without complex chronic conditions and their pediatric hospital medicine faculty. Parents and faculty were matched and individually interviewed on the same day. Two investigators iteratively coded transcripts and identified themes using modified grounded theory, with an additional author reviewing themes.

RESULTS

Twenty-seven parents and 16 faculty participated in the interviews. Four themes emerged: (1) parents and providers value different components of SDM; (2) providers assume SDM is easier with parents of children with medical complexity; (3) factors related to providers, parents, patients, and family-centered rounds were identified as barriers to SDM; and (4) parents and providers identified strategies to facilitate SDM in the hospital.

CONCLUSIONS

There is a discrepancy between parents' and providers' understanding of SDM, with parents most valuing their providers' ability to actively listen and explain the medical issue and options with them. There are many barriers that exist that make it difficult for both parties to participate. Several strategies related to family-centered rounds have been identified that can be implemented into clinical practice to mitigate these barriers.

The effect of interprofessional education on healthcare providers' intentions to engage in interprofessional shared decision-making: Perspectives from the theory of planned behaviour

AIMS AND OBJECTIVES

The present study aimed to investigate the effects of interprofessional education on healthcare providers' intentions to engage in an interprofessional shared decision-making (IP-SDM) process at emergency department and exploring the affecting factors on their intentions.

METHODS

We conducted the study through a sequential explanatory mixed method (quantitative-qualitative) design. All ED residents and nurses from two university hospitals were invited and assigned to the intervention and control groups. The intervention group was exposed to case-based learning sessions conducted by applying interprofessional strategies. The intentions of the participants engaged in IP-SDM were assessed before and 2 weeks after the intervention by a questionnaire designed based on the theory of planned behaviour. The questionnaire scores were compared between the intervention and control groups using analysis of covariance (ANCOVA). Partial eta-squared (η² ) was used for effect size calculations in ANCOVA. Subsequently, to explore the affecting factors in engagement in IP-SDM, qualitative data were collected through semi-structured individual interviews. The inductive content analysis approach by Elo and Kyngas was employed to analyze the qualitative data.

RESULTS

Out of 117 potentially eligible healthcare professionals, 113 completed the study in the intervention (n = 55) and control (n = 58) groups. The results showed that the difference between the mean scores of the learners in the intervention (1.41 ± 0.27) and control (0.80 ± 0.52) groups was statistically significant (P-value = .00001). The main effect of the intervention and a large educational effect size for the intervention were found to be statistically significant F (1, 11) = 180.54, P-value = .00001, η² = 0.62. The qualitative data analysis showed two main categories of "team-based facilitators" and "contextual challenges" as the main affecting factors in the engagement of participant in IP-SDM.

CONCLUSION

Our findings suggested that applying interprofessional education strategies could improve the learners' intention to engage in IP-SDM. Moreover, the results showed that the interprofessional collaboration among team members, adherence to the team-based care principles, and administrative support at different levels could be the influential factors the intentions of the participants to engage in IP-SDM.

Key components of shared decision making models: a systematic review

OBJECTIVES

To (1) provide an up-to-date overview of shared decision making (SDM)-models, (2) give insight in the prominence of components present in SDM-models, (3) describe who is identified as responsible within the components (patient, healthcare professional, both, none), (4) show the occurrence of SDM-components over time, and (5) present an SDM-map to identify SDM-components seen as key, per healthcare setting.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Peer-reviewed articles in English presenting a new or adapted model of SDM.

INFORMATION SOURCES

Academic Search Premier, Cochrane, Embase, Emcare, PsycINFO, PubMed, and Web of Science were systematically searched for articles published up to and including September 2, 2019.

RESULTS

Forty articles were included, each describing a unique SDM-model. Twelve models were generic, the others were specific to a healthcare setting. Fourteen were based on empirical data, 26 primarily on analytical thinking. Fifty-three different elements were identified and clustered into 24 components. Overall, Describe treatment options was the most prominent component across models. Components present in >50% of models were: Make the decision (75%), Patient preferences (65%), Tailor information (65%), Deliberate (58%), Create choice awareness (55%), and Learn about the patient (53%). In the majority of the models (27/40), both healthcare professional and patient were identified as actors. Over time, Describe treatment options and Make the decision are the two components which are present in most models in any time period. Create choice awareness stood out for being present in a markedly larger proportion of models over time.

CONCLUSIONS

This review provides an up-to-date overview of SDM-models, showing that SDM-models quite consistently share some components but that a unified view on what SDM is, is still lacking. Clarity about what SDM constitutes is essential though for implementation, assessment, and research purposes. A map is offered to identify SDM-components seen as key.

TRIAL REGISTRATION

PROSPERO registration CRD42015019740.

Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention

PURPOSE

To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco.

METHOD

The 8-week Patient Engagement Project Study intervention, delivered at four services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the nine-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams' SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least one trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on nine SDM behaviors per patient encounter.

RESULTS

In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all nine SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33-2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team.

CONCLUSIONS

The intervention increased behaviors supporting SDM during ward rounds on four independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.