Shared decision making (SDM) is regarded as an ideal in chronic illness care but is difficult to implement in practice. Communication and reflection play an important role and need further investigation. Using grounded theory, we studied patient-provider interaction in a difficult and advanced area: managing poorly controlled diabetes. A person-centered communication and reflection model was developed, identifying SDM in chronic care to be a question of professionals gaining insight into patients' decisions, rather than the opposite. The model reveals important choices in communication and reflection, which were decisive for whether SDM was achieved or not. SDM involved co-creating person-centered knowledge: concrete evidence which empowered patients and professionals in problem solving. Although further testing is required, the general tenets of the model are expected to be applicable across chronic conditions. Findings indicate that SDM in chronic illness care requires innovation in current approaches to decision making and problem solving.
Conflicts in problem solving are known from diabetes research on patients with good glycemic control but have rarely been studied in the care of patients with poor glycemic control. Equally, the different perspectives of health care providers and patients have not been a focus in previous studies. The authors studied the interactions between health care providers and 11 diabetes patients with poor glycemic control in a grounded theory study at a Danish university hospital. Keeping Life and Disease Apart was identified as a core category. It involved a pattern of conflicts both between and within patients and health professionals, which disempowered them in problem solving. Three approaches to problem solving were identified: A compliance-expecting approach kept the pattern unchanged, a failure-expecting approach deadlocked the pattern, and a mutuality-expecting approach appeared to neutralize the conflict.
Few researchers have explored how relationships between patients and providers might change problem solving in clinical practice. The authors used grounded theory to study dyads of 11 people with diabetes and poor glycemic control, and 8 nurses interacting in diabetes teams. Relational Potential for Change was identified as a core category that involved three types of relationships. Professionals mostly shifted between less effective relationships characterized by I-you-distant provider dominance and I-you-blurred sympathy. Although rarely seen, a third relationship, I-you-sorted mutuality proved more effective than the others in exploiting the Relational Potential for Change. The three types of relationship differed in (a) scope of problem solving, (b) the roles assigned to the patient and the professionals, (c) use of difficult feelings and different points of view, and (d) quality of knowledge achieved as the basis for problem solving and decision making. The authors discuss implications for practice and further research.
The flexible GSD intervention benefitted younger adult women by significantly improving glycaemic control and decreasing diabetes related distress. No effect was seen among men.
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