• DOI:10.11124/jbisrir-2012-432
• Corpus ID: 37476003

A qualitative systematic review of internal and external influences on shared decision‐making in all health care settings

@article{TruglioLondrigan2012AQS,
  title={A qualitative systematic review of internal and external influences on shared decision‐making in all health care settings},
  author={Marie Truglio‐Londrigan and Jason T. Slyer and Joanne K. Singleton and Priscilla Sandford Worral},
  journal={JBI Database of Systematic Reviews and Implementation Reports},
  year={2012},
  volume={10},
  pages={4633–4646}
}

• M. Truglio‐Londrigan, J. Slyer, +1 author P. Worral
• Published 12 December 2012
• Medicine, Political Science
• JBI Database of Systematic Reviews and Implementation Reports

Review question/objective The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared‐decision making for adult patients and health care providers in all health care settings. The specific questions to be answered are: What are the internal and external influences on shared decision making from the perspective of adult patients in all health care settings? What are the internal and external influences on shared decision making from the perspective of health care providers caring for adult patients in all health care settings? Background Patient‐centered care is emphasized in today's healthcare arena. This emphasis is seen in the works of the International Alliance of Patients’ Organizations (IAOP) who describe patient‐centered healthcare as care that is aimed at addressing the needs and preferences of patients.1 The IAOP presents five principles which are foundational to the achievement of patient‐centered healthcare: respect, choice, policy, access and support, as well as information.1 These five principles are further described as: respect for the patient's needs, preferences, values, autonomy, and independence; the right of the patient to have a choice to participate as a partner in making healthcare decisions based on their individual abilities and preferences; meaningful and active involvement in healthcare policy‐making through sharing in decision‐making to ensure that patients are at the center of the policy design; support of a patient's access to safe, quality and appropriate services; and the development and offering of age appropriate, linguistically, educationally, and culturally designed information that will enable the individual patient to make decisions about their healthcare needs. Within the description of these five principles the idea of shared decision‐making is clearly evident. The concept of shared decision‐making began to appear in the literature in the 1990s.2 It is defined as a “process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient‐centered care.”3(p.23) The details of the shared decision‐making process are complex and consist of a series of steps including: the recognition that a decision can or must be made; identifying the possible courses of action; listing the pros, cons, and other characteristics of each possibility; comparing the options and identifying one as probably better than the rest; accepting or rejecting options resulting in the final choice; authorization of the final choice; and implementation of that choice.4 Three overall representative decision‐making models are noted in contemporary literature. These three models include: paternalistic, informed decision‐making, and shared decision‐making.5 The paternalistic model is an autocratic style of decision‐making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision‐making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement.5 Finally, the shared decision‐making model is representative of a sharing and a negotiation towards treatment decisions. 5 Thus, these models represent a range with patient non‐participation at one end of the continuum to informed decision making or a high level of patient power at the other end.5 Several shared decision‐making models focus on the process of shared decision‐making previously noted. A discussion of several process models follows below. Charles et al.5 depicts a process model of shared decision‐making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included: the participation of at least two parties, both parties take steps to participate in the process of treatment decision‐making, information sharing occurs as a prerequisite to share in decision‐making, an ultimate decision is made, and both parties agree to the decision. This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker.5,6 This model also depicts the need to take steps to participate in the shared decision‐making process. To take steps means that there is an agreement between and among all involved that shared decision‐making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision‐making and the actuality of shared decision‐making in practice is not strong.5 Research concerning patients and patient preferences on shared decision‐making points to variations depending on age, education, socio‐economic status, culture, and diagnosis. 7‐12 Healthcare providers may also hold preferences for shared decision‐making; however, research in this area is not as comprehensive as is patient focused research.13 Elwyn et al.14 explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision‐making process.14 An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patient's preference is different from clinical practice guidelines.15 This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.12 The notion of information sharing as a prerequisite to shared decision‐making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision‐making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision‐making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patient's ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.16 Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al.5 portrays shared decision‐making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the “test of a shared decision (as distinct from the decision‐making process) is if both parties agree on the treatment option.”5(p.688) Towle and Godolphin17 developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision‐making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision‐making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include: Develop a partnership with the patient. Establish or review the patient's preferences for information. Establish or review the patient's preferred role in decision‐making. Ascertain and respond to the patient's ideas, concerns, and expectations. Identify choices and evaluate the research evidence. Present evidence, taking into account competencies 2 and 3, in a way that helps the patient to reflect on and assess the impact of alternative decisions with regard to his or her values and lifestyle. Negotiate a decision in partnership with the patient and resolve conflict. Agree on an action plan and complete arrangements for follow‐up.17 Patient competencies include: Define the preferred health care provider‐patient relationship. Find a healthcare provider and establish, develop, and adapt a partnership. Articulate health problems, feelings, beliefs, and expectations in an objective and systematic manner. Communicate in order to understand and share relevant information. Access information. Evaluate information. Negotiate decisions, give feedback, resolve conflict, and agree on an action plan.17 This model illustrates the shared decision‐making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model.5 This model, however, gives greater emphasis to the process of the co‐participation of the healthcare provider and the patient. The co‐participation depicts a mutual partnership