Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis

Abstract

ObjectivesShared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED.MethodsWe conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory.ResultsFifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives.ConclusionsEPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.

Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review

“…Of the included articles, the majority focused on emergency department settings [ 45 , 47 , 48 , 55 , 56 ] and acute mental health settings [ 50 , 51 , 54 ], with other settings including cardiology [ 52 , 57 ], oncology [ 53 ], stroke rehabilitation [ 44 ], and acute monitoring [ 49 ]. There were 11 authors for 14 articles, with four separate articles by Schoenfeld included [ 47 , 48 , 55 , 56 ]. These articles also represented the majority of articles included regarding SDM in the emergency department.…”

“…which drugs they had been treated with previously) [ 54 ] - Use posters/reminders to create awareness of SDM implementation programme [ 44 , 49 ] - Tailored information services for patients [ 46 ] - Support cross-site learning through regular meetings [ 44 , 46 ] - Pool information from separate SDM initiatives to speed knowledge translation [ 46 ] - Promote awareness of the benefits of SDM through research [ 55 ] - Promote patient awareness of SDM through national campaign [ 46 ] 2. Skills (An ability or proficiency acquired through practice) Barriers - Lack of training in SDM [ 44 , 48 – 51 , 55 , 56 ] - Lack of communication skills [ 51 , 55 ] - Lack of skills to train junior doctors in SDM [ 48 , 56 ] - Overreliance on clinical algorithms for determining treatment decisions [ 48 , 56 ] - Decision is left to the patient [ 53 ] - Informational capacity to make informed decisions (barrier and facilitator) [ 45 , 47 , 50 , 52 , 54 , 56 ] - Senior clinicians are expected to teach junior doctors how to do SDM without having training themselves [ 48 , 56 ] - Lack of training to do SDM [ 46 , 48 , 50 , 51 , 56 ] Facilitators - Communication skills, i.e. ability to explain risks and benefits of treatment option [ 45 – 48 , …”

“…Skills (An ability or proficiency acquired through practice) Barriers - Lack of training in SDM [ 44 , 48 – 51 , 55 , 56 ] - Lack of communication skills [ 51 , 55 ] - Lack of skills to train junior doctors in SDM [ 48 , 56 ] - Overreliance on clinical algorithms for determining treatment decisions [ 48 , 56 ] - Decision is left to the patient [ 53 ] - Informational capacity to make informed decisions (barrier and facilitator) [ 45 , 47 , 50 , 52 , 54 , 56 ] - Senior clinicians are expected to teach junior doctors how to do SDM without having training themselves [ 48 , 56 ] - Lack of training to do SDM [ 46 , 48 , 50 , 51 , 56 ] Facilitators - Communication skills, i.e. ability to explain risks and benefits of treatment option [ 45 – 48 , 50 – 53 , 56 , 57 ] - Formal training in SDM [ 44 , 48 – 51 , 55 , 56 ] - Trust in one’s own clinical skills and ability [ 47 , 55 – 57 ] - Awareness of one’s own limitations as a clinician [ 55 , 57 ] - Has been given education in communication with patients [ 48 , ...…”

“…as nurse or long-term patient) [ 45 , 47 , 54 ] - Require full team interdisciplinary training to ensure language is the same across disciplines when implementing SDM [ 44 , 50 ] - Provide training on use of Patient Decision Aids [ 44 , 46 , 57 ] - Opportunity to practice SDM with senior clinicians [ 48 ] - SDM is part of medical student’s education [ 46 , 48 ] - Including patients in SDM education [ 46 ] - Support cross-site learning through regular meetings [ 46 ] 3. Social/professional role and identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting) Barriers - Clinicians belief that their role is to make decisions and convince patients [ 50 , 52 , 56 ] - Not wanting to seem indecisive [ 48 , 56 ] - Belief that colleagues do not want to do SDM [ 55 , 57 ] - Patient has no or limited ongoing primary care [ 50 , 56 ] - Belief that clinician’s role is to make decisions [ 47 , 57 ] - Belief that nurses should not be involved in SDM [ 49 ] - Not wanting to be labelled “difficult” [ 45 , 46 , 53 ] - Perceived unacceptability of asking clinician questions [ 45 ] - Social stigma of having and seeking treatment for mental illness [ 50 ] Facilitators - Clinician sees role as educator of patients [ 46 , 49 , 50 , 52 , 53 ...…”

Different Perceptions Exist Between Health Care Providers and the General Population Regarding the Importance of Findings on Additional Imaging for Trauma Consults

“…While intuitive, practice of these concepts is challenging, particularly in emergency and critical-care services. 18,19 There are times when there is a single standard of care and time is of the essence; in these situations, patient involvement has little immediate significance in treatment, but these are the exception rather than the rule. 17 In the remainder of medicine, the patient should actively participate in decision-making.…”