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Shared decision-making: how nurses can help patients weigh up the issues

A person-centred approach will make interventions easier for patients to understand

A person-centred approach will make interventions easier for patients to understand


Picture: Daniel Mitchell

Helping patients make decisions about their treatment is a critical responsibility for healthcare professionals, yet shared decision-making can be far from straightforward.

‘There can be a mish-mash of expectations between what the patient, or their carer, thinks should happen, and what the nurse or the service provides, based on clinical reasoning,’ says Julian Barratt, head of postregistration education at Wolverhampton University’s Institute of Health.

Common examples may include requests by patients for investigations that are unnecessary, or for medication, such as antibiotics, that aren’t needed. ‘It can be challenging,’ says Dr Barratt. 

What is shared decision-making?

The National Institute for Health and Care Excellence describes shared decision making as when health professionals work with patients to make decisions about their treatment and care. It’s important that:

  • Care or treatment options are fully explored, along with their risks and benefits
  • Different choices available to the patient are discussed 
  • A decision is reached together with a health and social care professional

 

Dr Google has its drawbacks

Often people use the internet to find information about their potential medical problems. ‘Some of it may be correct, but patients are not always looking at the right sources or they misinterpret what they discover,’ he says. ‘They can convince themselves about what they think will happen, but actually it’s very different.’ 

Pressure of time can be another perceived sticking point. ‘Some nurses think that this style of consultation increases the amount of time you need to spend with a patient,’ says Dr Barratt, whose doctoral study was about collaborative communication in nurse practitioner consultations.

‘But my own research has shown that’s not true. It’s about giving the impression you have time available, even when it’s compressed. This is a key skill for nurses to develop.’

‘Showing that you’re really listening engenders trust – a big component’

Julian Barratt, head of postregistration education, Institute of Health, Wolverhampton University

For Dr Barratt, shared decision-making is characterised by an open style of communication, with practitioners working in consensus with patients, carers and sometimes their loved ones.

From the very beginning of the consultation, professionals need to be flexible about what the patient wants to discuss, helping them feel comfortable to express themselves, he advises. ‘It’s also really important to interact with the patient in an everyday style, trying to reduce formality and the use of medical terminology,’ he says. ‘Showing that you’re really listening engenders trust – a big component.’

An area where nurses excel

Potentially it’s easier for nurses to grasp this approach than it is for other healthcare professionals, such as doctors, Dr Barratt believes. ‘Interacting in a patient-centred way is very much an integrated part of the nursing role,’ he says. ‘It’s a natural perspective.’

His research demonstrates that nurses, especially those working in advanced practice, excel at combining patient-centred communication with analysis of biomedical information, such as laboratory tests, prescribing and diagnostic decisions. ‘It’s a style that’s unique to nurses working in clinical roles,’ he says.

How to encourage shared decision-making

  • Listen carefully to your patient’s opening statements, says Julian Barratt of Wolverhampton University’s Institute of Health. ‘Often they will prepare this before they come to see you,’ he says. ‘If you can listen without interrupting, you can gain lots of unfiltered information. These are critical moments’
  • Make the patient your starting point, rather than whatever is on your list, advises Lucy Watson, chair of the Patients Association. ‘Let them tell their story,’ she says. ‘And as they do, you may find they answer many of the questions you have, without your having to ask them in a clinical way’
  • Know your client. ‘Don’t rely on a diagnostic label,’ says Ian Hulatt, former RCN mental health lead and now consultant editor for RCNi’s Mental Health Practice journal.
  • Look beyond what you’re seeing, advises Lesley Carter of Age UK. ‘Make sure you’re really thinking about what makes that person tick and develop a relationship of care,’ she says. ‘This empowers them to make the best decision for them’
  • Be prepared to negotiate. ‘Establish the client’s goals while they’re in your care, working with them to achieve them,’ says Mr Hulatt
  • Ask what the patient understands is wrong with them and what they think will happen in the future. ‘We make assumptions about their knowledge and if they’ve got it wrong, we’re not dispelling those false beliefs, just adding to the confusion,’ says Ms Carter
  • Share the ideas behind your clinical reasoning, says Dr Barratt. ‘A patient may have no idea why you’re asking a certain set of questions,’ he says. ‘Give some explanation, even outlining what you’ve discovered during an examination’
  • Always check the person has understood the information you’ve given them, says Ms Carter. ‘Ask them to explain it back to you,’ she recommends. ‘It’s especially important if someone is hard of hearing or you’re in a busy ward’ 
  • Encourage questions, advises Dr Barratt. ‘Try to help your patient feel safe to disclose what they may be worrying about,’ he says

 

Communicating in an accessible way

Making sure patients fully appreciate all the implications of the choices they’re making about treatment is a key component of shared decision-making.

‘Sometimes patients may decline an intervention partly because they don’t understand what they’ve been told,’ says Dr Barratt. ‘They’re fearful, worried and don’t recognise the benefits. Thinking about strategies to enhance a patient’s understanding is really important.’

‘Patients may not fully take in everything at first… Think about how you can present the information in a more understandable way that applies to their everyday lives’

Julian Barratt

This can include repeating information at the end of a consultation, after introducing it at the beginning. ‘Patients may not fully take in everything at first.’ 

In addition, providing an overview or summary at the end can be useful. ‘You also need to make sure you discuss the risks and benefits of any proposed intervention or therapy,’ he adds. ‘This may mean using less scientific language, which lots of patients won’t be able to process. Think about how you can present the information in a more understandable way that applies to their everyday lives.’

Again, nursing staff are especially skilled at this aspect, he believes. ‘Nurses are particularly good at interpreting complex, technical, medical information, presenting it in a way that’s understandable for patients,’ says Dr Barratt.

Recognise what’s important to the individual

While the charity Age UK welcomes shared decision-making, the charity believes it doesn’t go far enough, says its clinical lead for professionals and practice, Lesley Carter.

‘Older people are not always sure what it is,’ says Ms Carter. ‘They are given choices about treatment, but then they don’t get support and the information to help them understand and balance their decision.’ For example, while it may be best for someone in their 40s to have an operation, managing the condition may be a better option for a person in their 80s, she says. ‘People need to understand the impact different decisions may have on them and their lives.’

‘Good shared decision-making begins with listening to a patient’s story’

Lucy Watson, chair, Patients Association

For those who are much older, there is still an attitude of ‘the doctor’s always right’, says Ms Carter. This, she says, can lead to an inability to express feelings. ‘Professionals need to build a relationship that gives someone the confidence to say what they really want, including choosing not to have treatments if they feel that’s better for them,’ she says.


Lesley Carter: Support and
information is sometimes lacking.

Patients Association chair Lucy Watson agrees that sometimes older people can be more deferential, expecting to be told what to do by healthcare professionals. ‘They need more preparation to be able to talk about their life,’ she says, advocating that in all these conversations, the patient must always be the starting point. ‘A patient’s experience of their condition is individual. Good shared decision-making begins with listening to their story.

Fit in with the patient’s priorities

‘When it goes wrong, it’s often because a healthcare practitioner has come to see a patient, bringing all their assessment forms, and immediately it begins with a professional agenda,’ says Ms Watson, a retired nurse. ‘You’re drawn into a medical model of decision-making. You need the clinical input, but it needs to fit with what’s important to the person.’

In practice, this might mean that rather than talking about glucose management or HbA1c with someone who has diabetes, you talk about what they would like to achieve. ‘They may want to lose weight, so they can get into the dress they’ve chosen for their daughter’s wedding,’ says Ms Watson. ‘If you start from their perspective, people are more likely to set goals for themselves and are more motivated. You begin to see outcomes that mean something to the patient that also affect their clinical outcomes.’

Strive for more equal conversations

Changing professional culture is challenging. ‘Professionals are trained in assessment processes and frameworks – it’s in their DNA,’ says Ms Watson. ‘Without them, you can’t treat, plan or deliver care. But it means it’s professionally driven. It’s a challenge to stand back and reflect on how you’ve worked with people in the past, and how you might alter your approach to make it a more equal conversation.’

‘It’s easy to slip into diagnostic tests, focusing the discussion on clinical findings. You need to find ways of explaining things using appropriate language that isn’t patronising. Even simple acronyms that are the bread and butter of healthcare, such as sending someone for an ECG, can worry patients.’

 

Demonstrate that you’ve understood

    Resolving disagreements between healthcare professionals and patients can be tricky, but listening is always the first step. ‘Acknowledging what the patient has said can be really therapeutic, because sometimes they just want the opportunity to express what they want,’ says Dr Barratt.

    By demonstrating you’ve understood, they may be more amenable to changing their course of action, he believes. Clinical guidance from organisations such as the National Institute for Health and Care Excellence can also be useful to show why some treatments aren’t recommended.

    ‘Patients feel more activated to participate in their own treatment and enabled to manage their own health’

    Julian Barratt

    The benefits of achieving good shared decision-making include better patient outcomes, alongside increased job satisfaction for healthcare professionals.

    ‘Research consistently shows patients are more satisfied with communication, and so are much more likely to adhere to interventions or a treatment plan,’ says Dr Barratt. ‘They feel more activated to participate in their own treatment and enabled to manage their own health, with a sense of well-being.’

    A collaborative approach in mental health

    In mental health, there are some specific benefits and challenges. ‘Traditionally, decision-making wasn’t shared,’ says Ian Hulatt, consultant editor of Mental Health Practice and former RCN mental health lead.

    But the growing involvement of service users has led to huge changes, underpinned by the ethos ‘nothing about us, without us’. For Mr Hulatt, making shared decisions is especially useful in some areas of mental health care, including serious and enduring mental illness, such as psychosis. ‘It’s like working in a life coach sort of way,’ he says. ‘It’s the co-production of care planning with the client to keep them on their road to recovery.’


    Ian Hulatt. Picture: Tim George

    Another example is safety or security planning, when someone is in crisis and may have already attempted self-harm or is considering it. In essence, healthcare professionals need to work with individuals to find ways they can express their feelings, without risking injury to themselves or others.

    The right to make unwise decisions

    ‘How can we safely allow you to ventilate your anger, while preventing it from escalating so neither you or we get hurt? It’s a pragmatic approach and there’s an element of dignity in it too,’ says Mr Hulatt. ‘We can be honest about our concerns, say we’re worried and find it hard to trust you at the moment, because we don’t think you trust yourself.’

    Inevitably, negotiation will lead to disagreements, Mr Hulatt points out, but under the Mental Capacity Act, individuals have the right to make unwise decisions. ‘It’s tricky when we feel we’re responsible for someone and accountable for what they may do,’ he says. ‘But if they have decision-specific capacity, they can make decisions we don’t agree with. That’s the price you pay for not taking a totally paternalistic view.’ Where there is fundamental disagreement, using advocates to mediate can be helpful, he suggests.

    Although it may be more demanding, ultimately this model is better for everyone, says Mr Hulatt. ‘Authoritarian practices are not good for anyone, brutalising the worker as well as the client,’ he says. ‘Creating this climate of cooperation makes everyone happier. It’s less of a tussle, because you’re working together on agreed goals, which are more easily achieved than those that are imposed.’

     

    Lynne Pearce is a health journalist

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