Participation In Clinical Decision Research Articles

Impact of clinical decision-making participation and satisfaction on outcomes in mental health practice: results from the CEDAR European longitudinal study

The present study aimed to assess: (1) whether a more active involvement of patients is associated with an improvement of clinical symptoms, global functioning, and quality-of-life; and (2) how patients’ satisfaction with clinical decisions can lead to better outcome after 1 year. Data were collected as part of the study ‘Clinical decision-making and outcome in routine care for people with severe mental illness (CEDAR)’, a longitudinal observational study, funded by the European Commission and carried out in six European countries. Patients’ inclusion criteria were: (a) aged between 18 and 60 years; (b) diagnosis of a severe mental illness of any kind according to the Threshold Assessment Grid (TAG) ≥ 5 and duration of illness ≥ 2 years; (c) expected contact with the local mental health service during the 12-month observation period; (d) adequate skills in the language of the host countries; and (e) the ability to provide written informed consent. The clinical decision-making styles of clinicians and the patient satisfaction with decisions were assessed using the Clinical Decision Making Style and the Clinical Decision Making Involvement and Satisfaction scales, respectively. Patients were assessed at baseline and 1 year after the recruitment. The sample consisted of 588 patients with severe mental illness, mainly female, with a mean age of 41.69 (±10.74) and a mean duration of illness of 12.5 (±9.27) years. The majority of patients were diagnosed with psychotic (45.75%) or affective disorders (34.01%). At baseline, a shared CDM style was preferred by 70.6% of clinicians and about 40% of patients indicated a high level of satisfaction with the decision and 31% a medium level of satisfaction. Higher participation in clinical decisions was associated with improved social functioning and quality-of-life, and reduced interpersonal conflicts, sense of loneliness, feelings of inadequacy, and withdrawal in friendships after 1 year (p < 0.05). Moreover, a higher satisfaction with decisions was associated with a better quality-of-life (p < 0.0001), reduced symptom severity (p < 0.0001), and a significantly lower illness burden associated with symptoms of distress (p < 0.0001), interpersonal difficulties (p < 0.0001), and problems in social roles (p < 0.05). Our findings clearly show that a higher involvement in and satisfaction of patients with clinical decision-making was associated with better outcomes. More efforts have to be made to increase the involvement of patients in clinical decision-making in routine care settings.

Ethical dilemmas in nursing documentation.

Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored. To explore ethical dilemmas in nurses' conversations about nursing documentation. The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman. This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent. Ethical dilemmas were strongly present in nurses' conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients' autonomy and not causing harm, which was visible in nurses' navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses' balancing between documenting deviations and proof of nursing practice. Ethical dilemmas in nursing documentation regarding respecting patients' autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records. Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.

Achieving holistic care for the mentally ill: The need for more caregiver support groups in Africa

IntroductionCaregiver support groups provide an avenue for interactions among the caregivers of the mentally ill, where they share their fears, hopes and uncertainties about their ill relatives. They are a means to be “heard” by care providers, a platform for psychoeducation as well as an avenue for participation in clinical decision making and formulation of patients’ care plans. In most parts of Africa, such support groups do not exist and where they do, they are poorly structured and poorly funded.ObjectivesThis review was aimed at examining the concept of caregiver support groups for the mentally ill globally as revealed in the currently avaliable body of knowledge, as well as raise awareness for the need for such groups in AfricaMethodsA review of related literature was done using appropriate key words and search engines.ResultsThis review revealed the presence of well- structured support groups for the caregivers of the mentally ill in many parts of the world. The advantages of such groups and their contributions to the holistic care of these patients in those regions were also discussed, while suggesting a possible structure for their creation, sustainability and focus in Africa.ConclusionsThe support of caregivers for the mentally ill must be given keen attention by both care providers and policy makers, with prime importance given to the creation and funding of more caregiver support groups in the continent in order to achieve quality and holisitic care for the mentally ill.

Effect of Individual Counseling on the Participation Rate of Pregnant Mothers in Decision Making on the Treatment Process: Clinical Trial

Aim: Due to the high Sensitivity of pregnancy and the vulnerability of mothers during this period, their participation in clinical decisions is very important. Therefore, this study aimed to investigate the effect of individual counseling on the participation of pregnant women in decision making on the treatment process. Methods & Materials: This clinical trial study was carried out on 190 pregnant women who referred to Kosar medical-education center in Qazvin in 2018. The subjects were selected by purposeful sampling method and randomly assigned to the two groups of test and control (n=20 in each group). The intervention was conducted in one 60 minutes individual counseling session for the test group. The research tool was shared decision-making questionnaire (SDM-Q-9). Data were analyzed using SPSS 23 software, through independent t-test, paired t-test, and Chi-squared test. Findings: There was a significant difference between the mean scores of participation of the pregnant mothers before and after intervention in the test group (p<0.001) but there was no significant difference between the mean scores of the pregnant women involvement before and after intervention in the control group (p>0.05). Also, before the intervention, comparison of the mean scores of the pregnant mothers' involvement in decision making between the two groups showed no significant difference but after the intervention, a significant difference between two groups was observed (p<0.001). Conclusion: Individual counseling is an effective and appropriate intervention to increase the participation rate of pregnant mothers in decision making in the treatment process.

Decisional conflict in mental health care: a cross-sectional study.

Decisional conflict refers to the degree to which patients are engaged in and feel comfortable about important clinical decisions. Until now, the concept has received little attention in mental health care. We investigate the level of decisional conflict in mental health care and whether this is influenced by socio-demographics, treatment setting, diagnoses, and locus of control. Cross-sectional study among 186 patients in Dutch specialist mental health care using the Decisional Conflict Scale, which measures five dimensions of decisional conflict: information, support, clarification of values, certainty, and decisional quality. Descriptive statistics and forward stepwise linear regression analyses were used. Patients report relatively high levels of decisional conflict, especially those with more external locus of control. Having a personality disorder and higher education also increases decisional conflict on the dimensions support and clarification of values, respectively. Less decisional conflict was experienced by patients with psychotic disorders on the dimension certainty and by women on the information domain. Decisional conflict is common among patients in specialist mental health care and is very useful for assessing the quality of clinical decision making. Measuring decisional conflict and knowledge about influencing factors can be used to improve patients' participation in clinical decision making, adherence to treatment and clinical outcomes.

Participation rate of cancer patients in treatment decisions: a cross sectional study

Background and objective: Cancer is one of the most common diseases and the second reason of death in Iran. Giving decision making authority to patients is one of the fundamental principles of the protection of patients. Patients have rights as consumers of health care services that nurses, physician and other health professionals are responsible for maintaining and protecting it. This study aimed to determine cancer patients’ involvement in treatment decisions making. Methods:This cross-sectional study was carried out as descriptive-analytic with practical purpose in 2017 in Zahedan University of Medical Sciences. The study population included 1,000 patients who had cancer that whom 450 patients were selected by simple random sampling. To measure patient participation in treatment decisions, was used of Levente Kristona standard questionnaire. Reliability and validity of the questionnaire was confirmed (coefficient = 0.82). For data analysis used of software spss21 with descriptive statistics and chi-square tests Results: among the patients, 197 men (53%) and 177 women (47%) with a mean age of 31 years were examined. The results of this study showed that the score of mean participation in treatment decisions among the cancer patients was 30 ± 12 and it was in low level. The patients’ participation in treatment decisions had a significant relationship with education level (P = 0.027), however, it was not statistical significant with gender, age, income, occupation and type of cancer and other demographic variables (P> 0.05). Conclusion: In general, that patients' participation in clinical decision making is weak and low. Since patients’ participation in clinical decisions could affect the quality of treatment decisions, therefore, health care providers should attention more to this fact. Also, culturalizating and education according to patients’ knowledge and use of treatment techniques are recommended for clinical decision making promotion. Paper Type:Research Article.

Identification of quality care indicators in prostate cancer.

213 Background: Despite the attempts made to improve prostate cancer management with the development and implementation of clinical practice guidelines, the inefficiencies and differences that usually occur in ordinary clinical care of patients with prostate cancer significantly contribute to increase the variations in the patterns of care and patients outcomes, and costs to the health system. The goal of this project was to establish parameters for improving the care of patients with prostate cancer through the development and validation of quality indicators for the management of this disease. Methods: The ECO Foundation is a platform of experts representing the major Spanish hospitals involved in the treatment of cancer patients. A multidisciplinary group of experts supported by ECO, extracted potential indicators for prostate cancer care from the relevant medical literature. After two consecutive rounds of rating in a modified Delphi approach, followed by a consensus discussion, the expert panel prioritized the indicators selected. Results: Forty indicators were selected with a high level of agreement. They were grouped into four main groups: general, localized disease, metastasized disease, and results-related indicators. Only two indicators did not reach an agreement or disagreement. The indicators with the highest level of agreement ( &gt; 95%) were the appropriateness of diagnostic confirmation through the pathology report; patient participation in clinical decisions; complete re-staging with study of regional and bone extension; or the establishment of individual therapeutic plan with multidisciplinary participation. Conclusions: We conclude that currently available prostate cancer quality indicators represent clinical practices that are necessary for high-quality care in prostate cancer. The finalized indicator list can be directly adopted or adapted for deployment within a performance improvement program.

O papel da literacia em saúde na decisão médica partilhada

ABSTRACT: Some studies have shown the relationship between an increased and more structured involvement of patients in clinical decision making, the improvement of literacy in health and the obtainment of health gains. However, the existence of misconceptions on the part of doctors and other health professionals may contribute to their low compliance regarding shared clinical decision and discussion of treatment options, particularly with users with low levels of literacy. With this critical essay, we intend to clarify these misconceptions, by doing an in depth reflection and analysis on communication’s key elements centered on the patient – health literacy and shared decision. Relevant issues about literacy in health and shared decision were presented, on which critical content was developed. This development is the most extensive part of the essay. We transmitted the point of view of several authors and a critical analysis, and we tried to illustrate these ideas with examples and research studies, thus validating the presented arguments and answering to questions raised during the analysis. Final considerations of this critical essay stress that promoting an increased user participation in clinical decision making improves the level of health literacy, through a patient-focused communication performed by qualified professionals taking into consideration social determinants, and health gains are obtained.

Encouraging Patient-Centered Care by Including Quality-of-Life Questions on Pre-Encounter Forms.

Patient participation in clinical decision making improves outcomes, including quality of life (QOL), but the typical problem-oriented approach may impede consideration of functional goals. We wondered if patients could encourage primary care physicians to pay attention to their QOL goals by writing them on pre-encounter forms. We conducted a randomized controlled trial comparing the impact of 2 different pre-visit questionnaires on the content of patient-physician encounters in a family medicine practice at an academic medical center. Using investigator-blinded block randomization, we arranged for 8 faculty and 8 resident physicians to participate in 2 intervention and 2 control videotaped encounters each for a total of 64 encounters. The intervention questionnaire included questions about QOL goals and concerns, while the control questionnaire asked about symptoms. Videotapes were reviewed to determine whether the patients' QOL goals were mentioned and whether they were used in decision making. We also scored encounters using Modified Flanders Interaction Analysis, which assesses and codifies patient and physician communication, and the Modified Carkhuff-Truax Scale, which measures empathy, attending, congruence, and positive regard. Patients were able to record QOL goals and concerns, but QOL issues were mentioned in only 2 of the 64 encounters, once by a patient and once by a physician. In neither case was this information used in decision making. More empathy was expressed by physicians during control encounters (P = .03). Patients were able to articulate their QOL goals on paper, but that did not prime them or their physicians to alter the process or content of the clinical encounters. In fact, providing QOL information was associated with reduced physician empathy.

Family Support, Social and Demographic Correlations of Non-Adherence among Haemodialysis Patients

Non-adherence to treatment is an increasing problem for patients with end stage renal disease under haemodialysis.Aim: This study aimed to review the basic literature mentioned to the correlation between haemodialysis patient demographic characteristics and non-adherence to their treatment regimen.Method: Studies written in English published in 2002-2013 were identified through PubMed, PubMed Central, Dove press, Scopus. Clinical trials and review articles were excluded. Key- words used for search included a combination of adherence / non-adherence and haemodialysis in titles. Results: According to the literature, patient demographic characteristics are important factors for patient adherence to treatment regimen. Generally, factors associated with increased level of non-adherence to haemodialysis treatment regimen included young age, sex, race and educational level. Conclusions: Early identification of risk factors, inclusion of patients in the health care team and participation in clinical decision making, can lead to behavior adherence.

Factors Associated with Nurses' Participation in Clinical Decision Making

Factors Associated with Nurses' Participation in Clinical Decision Making

Involving patients in setting priorities for healthcare improvement: a cluster randomized trial

BackgroundPatients are increasingly seen as active partners in healthcare. While patient involvement in individual clinical decisions has been extensively studied, no trial has assessed how patients can effectively be involved in collective healthcare decisions affecting the population. The goal of this study was to test the impact of involving patients in setting healthcare improvement priorities for chronic care at the community level.MethodsDesign: Cluster randomized controlled trial. Local communities were randomized in intervention (priority setting with patient involvement) and control sites (no patient involvement). Setting: Communities in a canadian region were required to set priorities for improving chronic disease management in primary care, from a list of 37 validated quality indicators. Intervention: Patients were consulted in writing, before participating in face-to-face deliberation with professionals. Control: Professionals established priorities among themselves, without patient involvement. Participants: A total of 172 individuals from six communities participated in the study, including 83 chronic disease patients, and 89 health professionals. Outcomes: The primary outcome was the level of agreement between patients’ and professionals’ priorities. Secondary outcomes included professionals’ intention to use the selected quality indicators, and the costs of patient involvement.ResultsPriorities established with patients were more aligned with core generic components of the Medical Home and Chronic Care Model, including: access to primary care, self-care support, patient participation in clinical decisions, and partnership with community organizations (p < 0.01). Priorities established by professionals alone placed more emphasis on the technical quality of single disease management. The involvement intervention fostered mutual influence between patients and professionals, which resulted in a 41% increase in agreement on common priorities (95%CI: +12% to +58%, p < 0.01). Professionals’ intention to use the selected quality indicators was similar in intervention and control sites. Patient involvement increased the costs of the prioritization process by 17%, and required 10% more time to reach consensus on common priorities.ConclusionsPatient involvement can change priorities driving healthcare improvement at the population level. Future research should test the generalizability of these findings to other contexts, and assess its impact on patient care.Trial registrationThe Netherlands National Trial Register #NTR2496.

Medical information is not enough for patient’s participation in clinical decisions

Theoretical Framework: This research was designed to analyze whether patients rate positively doctors’ attitudes and information provided favours the patient’s participation and involvement in clinical decisions. Methods: For this, we carry out a cross-sectional analysis of data on 1070 patients discharged from 7 hospitals in Spain. Results: A total of 82% referred to be satisfied with the information, of which 3% did not have the feeling that their hospital doctor had listened carefully, 27% did not have their doubts clarified, and 76% were not informed of therapeutic alternatives. When the doctor showed a receptive attitude there was actually an increase in the number of patients that still had doubts about their diagnosis and treatment (OR= 1.9, p= 0.04). Older patients were less frequently involved in clinical decisions (χ 2 = 8.05, p=0.04) and often remained with doubts (χ 2 =9.05, p=0.03). Conclusion: The conclusion is that a substantial proportion of patients seem to assume a passive role in the interaction with the doctor. There are conditions that may restrict the patient’s autonomy which do not ever affect the patient’s rating of the information provided by the doctor.

Medical information is not enough for patient’s participation in clinical decisions

This research was designed to analyze whether patients rate positively doctors’ attitudes and information provided favours the patient’s participation and involvement in clinical decisions. For this, we carry out a cross-sectional analysis of data on 1070 patients discharged from 7 hospitals in Spain. A total of 82% referred to be satisfied with the information, of which 3% did not have the feeling that their hospital doctor had listened carefully, 27% did not have their doubts clarified, and 76% were not informed of therapeutic alternatives. When the doctor showed a receptive attitude there was actually an increase in the number of patients that still had doubts about their diagnosis and treatment (OR= 1.9, p= 0.04). Older patients were less frequently involved in clinical decisions (2= 8.05, p=0.04) and often remained with doubts (2=9.05, p=0.03). The conclusion is that a substantial proportion of patients seem to assume a passive role in the interaction with the doctor. There are conditions that may restrict the patient’s autonomy which do not ever affect the patient’s rating of the information provided by the doctor.

Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study

Communication experts have suggested that it is good practice to ask patients' directly whether they expect to receive antibiotics as part of asking about the triad of ideas, concerns, and expectations for health care. Our aim was to explore the views and experiences of family physicians about using this strategy with their patients, focusing the interview on the problem of eliciting expectations of antibiotics as a possible treatment for upper respiratory tract infections. We conducted a qualitative study using semistructured interviews with 20 family physicians in South Wales, United Kingdom, and performing thematic analysis. Family physicians assumed most patients or parents wanted antibiotics, as well as wanting to be "checked out" to make sure the illness was "nothing serious." Physicians said they did not ask direct questions about expectations, as that might lead to confrontation. They preferred to elicit expectations for antibiotics in an indirect manner, before performing a physical examination. The majority described reporting their findings of the examination as a "running commentary" so as to influence expectations and help avoid generating resistance to a soon-to-be-made-explicit plan not to prescribe antibiotics. The physicians used the running commentary to preserve and enhance the physician-patient relationship. Real-world family physicians use indirect methods to explore expectations for treatment and, on the basis of their physical examination, build an argument for reassuring the patient or parent. In contrast to proposed models in the communication literature, interventions to promote appropriate antibiotic prescribing might include a focus on training in communication skills that (1) integrates these indirect methods as part of building collaborative physician-patient relationships and (2) uses the running commentary of examination findings to facilitate participation in clinical decisions.

Communication Commentary: Psychotherapy: Separate Worlds: Bridging the Divide Between Evidence-Based and Patient-Centered Care

Communication Commentary: Psychotherapy: Separate Worlds: Bridging the Divide Between Evidence-Based and Patient-Centered Care

Barriers for an effective communication around clinical decision making: an analysis of the gaps between doctors' and patients' point of view

There are doubts on whether patients feel that they have sufficient information for actively participating in clinical decisions. To describe the type of information that patients receive. To determine whether patients consider this information sufficient, and whether it contributes or not to improve clinical safety. To identify the barriers for patient participation in clinical decision making. Cross-sectional study with 764 patients and 327 physicians. Fourteen health centres belonging to three primary care districts and three hospitals in Spain. Just 35.1% (268) (95% CI 32.2, 39.1%) of patients preferred to have the last word in clinical decisions. Age (39 vs. 62%, P < 0.001) and severity of illness (38 vs. 46%, P = 0.002) increased the tendency to take a passive role. In 85.1% (650) (95% CI 83.3, 88.3%) of the cases, patients reported having received sufficient information. Lack of consultation time (29.6%, 95% CI 25.8, 32.5%) and patients' use of Internet or other sources (19.2%, 95% CI 16.4, 22.2%) were identified as new obstacles to doctor-patient communication by the patients. Only 19.6% (64) (95% CI 15.4, 24.2%) of doctors considered that they could intervene to involve patients in the decisions. The majority of patients prefer the decisions to be made by their doctor, especially those with more severe illnesses, and older patients. Patients are not normally informed about medication interactions, precautions and foreseeable complications. The information provided by general practitioners does not seem to contribute enough to the patient involvement in clinical safety.

Relationships of power: implications for interprofessional education

Interprofessional education (IPE) is considered a key mechanism in enhancing communication and practice among health care providers, optimizing participation in clinical decision making and improving the delivery of care. An important, though under-explored, factor connected to this form of education is the unequal power relations that exist between the health and the social care professions. Drawing on data from the evaluation of a large multi-site IPE initiative, we use Witz's model of professional closure (1992) to explore the perspectives and the experiences of participants and the power relations between them. A subset of interviews with a range of different professionals (n = 25) were inductively analyzed to generate emerging themes related to perceptions of professional closure and power. Findings from this work highlight how professionals' views of interprofessional interactions, behaviours and attitudes tend to either reinforce or attempt to restructure traditional power relationships within the context of an IPE initiative.

A Study on Participation in Clinical Decision Making by Home Healthcare Nurses

This study was done to identify participation by home healthcare nurses in clinical decision making and factors influencing clinical decision making. A descriptive survey was used to collect data from 68 home healthcare nurses in 22 hospital-based home healthcare services in Korea. To investigate participation, the researcher developed 3 scenarios through interviews with 5 home healthcare nurses. A self-report questionnaire composed of tools for characteristics, factors of clinical decision making, and participation was used. Participation was relatively high, but significantly lower in the design phase (F=3.51, p=.032). Competency in clinical decision making (r=.45, p<.001), perception of the decision maker role (r=.47, p<.001), and perception of the utility of clinical practice guidelines (r=.25, p=.043) were significantly correlated with participation. Competency in clinical decision making (Odds ratio [OR]=41.79, p=.007) and perception of the decision maker role (OR=15.09, p=.007) were significant factors predicting participation in clinical decision making by home healthcare nurses. In order to encourage participation in clinical decision making, education programs should be provided to home healthcare nurses. Official clinical practice guidelines should be used to support home healthcare nurses' participation in clinical decision making in cases where they can identify and solve the patient health problems.

Clinical decision‐making: predictors of patient participation in nursing care

To investigate predictors of patients' preferences for participation in clinical decision-making in inpatient nursing care. Patient participation in decision-making in nursing care is regarded as a prerequisite for good clinical practice regarding the person's autonomy and integrity. A cross-sectional survey of 428 persons, newly discharged from inpatient care. The survey was conducted using the Control Preference Scale. Multiple logistic regression analysis was used for testing the association of patient characteristics with preferences for participation. Patients, in general, preferred adopting a passive role. However, predictors for adopting an active participatory role were the patient's gender (odds ratio = 1.8), education (odds ratio = 2.2), living condition (odds ratio = 1.8) and occupational status (odds ratio = 2.0). A probability of 53% was estimated, which female senior citizens with at least a high school degree and who lived alone would prefer an active role in clinical decision-making. At the same time, a working cohabiting male with less than a high school degree had a probability of 8% for active participation in clinical decision making in nursing care. Patient preferences for participation differed considerably and are best elicited by assessment of the individual patient. Relevance to clinical practice. The nurses have a professional responsibility to act in such a way that patients can participate and make decisions according to their own values from an informed position. Access to knowledge of patients'basic assumptions and preferences for participation is of great value for nurses in the care process. There is a need for nurses to use structured methods and tools for eliciting individual patient preferences regarding participation in clinical decision-making.