Shared Decision-Making for Nursing Practice: An Integrative Review

Background: Shared decision-making has received national and international interest by providers, educators, researchers, and policy makers. The literature on shared decision-making is extensive, dealing with the individual components of shared decision-making rather than a comprehensive process. This view of shared decision-making leaves healthcare providers to wonder how to integrate shared decision-making into practice. Objective: To understand shared decision-making as a comprehensive process from the perspective of the patient and provider in all healthcare settings. Methods: An integrative review was conducted applying a systematic approach involving a literature search, data evaluation, and data analysis. The search included articles from PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and PsycINFO from 1970 through 2016. Articles included quantitative experimental and non-experimental designs, qualitative, and theoretical articles about shared decision-making between all healthcare providers and patients in all healthcare settings. Results: Fifty-two papers were included in this integrative review. Three categories emerged from the synthesis: (a) communication/ relationship building; (b) working towards a shared decision; and (c) action for shared decision-making. Each major theme contained sub-themes represented in the proposed visual representation for shared decision-making. Conclusion: A comprehensive understanding of shared decision-making between the nurse and the patient was identified. A visual representation offers a guide that depicts shared decision-making as a process taking place during a healthcare encounter with implications for the continuation of shared decisions over time offering patients an opportunity to return to the nurse for reconsiderations of past shared decisions.


Appropriate statistical analysis
Bernhard et al.

Conceptual papers (n = 16)
Charles et al.  -SDM is associated with satisfaction with decisions primarily noted in: understanding information, treatment preferences elicitation, and weighing options. Isaacs et al. (2013) United States -Cross-sectional survey To assess the relationship between older adults' perceptions of SDM in the selection of analgesic to take at home for acute musculoskeletal pain, patient satisfaction with analgesic, and changes in pain scores.
111 individuals age 65 and older who visited an emergency department.
-Patients who participated in the decisions were more likely to report satisfaction with the analgesic and a decrease in pain.

LeBlanc, Kenny, O'Connor,
and Légaré (2009) Canada -Before and after study To explore the effect of feeling uninformed, unclear values, inadequate support, and the perception that an ineffective decision has been made on one's own outcome and on the other person's outcome.
Secondary analysis of data from 112 dyads of physicians and patients.
-Patient and physician uncertainty o is influenced by personal deficits and by the deficits of the other member of the dyad.

Légaré et al. (2011) Canada -Cross-sectional survey
To assess the willingness of women and their family physicians to engage in SDM in regards to prenatal Down-syndrome screening.
109 pregnant women and 41 family physicians.
-A woman's attitude, significant others, self-efficacy, perceived moral correctness, and their family physician attitude influence willingness to engage in SDM.

iv Shared Decision-Making for Nursing Practice
The Open Nursing Journal, 2018, Volume 12

Author/Country/ Method Aims/Objectives Participants Findings
Mandelblatt, Kreling, Figeuriedo, and Feng (2006) United States -Prospective cohort study To describe patient and physician determinants of SDM in older women with breast cancer and evaluate whether SDM is associated with treatment patterns or short-term outcomes of care.
718 women 67 years of age and older treated for early stage breast cancer in 29 different sites from five geographic regions.
-Younger women reported higher SDM than women 75 years of age and older. -Women accompanied to consultations reported higher SDM than women who went to appointments alone. -Women who reported having a treatment choice reported higher SDM than those who felt they did not have a choice. -SDM was associated with satisfaction.
Ommen, Thuem, Pfaff, and Janssen (2011) Germany -Retrospective cross-sectional study To investigate the relationship between social support (emotional and informational), SDM, and inpatients' trust in physicians.
2,197 patients who received inpatient treatment.
-A relationship between SDM behaviors, social support age, socioeconomic status, gender, and patient's trust in physicians were noted.

Shabason, Mao, Frankel, and Vapiwala (2014) United States -Cross-sectional survey
To assess the prevalence of SDM and the perception of control in treatment decisions among patients receiving radiation therapy, and to explore the relationship between a patient's desire for and perception of control during radiation therapy on satisfaction, anxiety, depression, and fatigue.
305 patients undergoing radiation therapy for a diagnosis of cancer.
-Approximately 1/3 of the patients experienced SDM, 1/3 perceived control in treatment decisions, 3/4 reported being satisfied and 1/3 reported feeling very satisfied with their plan of care. -Patient satisfaction was associated with perceived SDM and patientperceived control. -Increase in anxiety, depression, and fatigue was reported from patients who desired but did not perceive control. To investigate the practice, experiences, and views of family physicians as they attempt to implement informed and shared decisionmaking in practice.
6 family physicians received training on SDM and the information on the competencies for SDM. 198 data sets including: physician logs, patient satisfaction questionnaire, audiotapes, and group interview.
-Physicians viewed the training sessions as positive. -Physicians noted a need for additional competences for SDM.

Truglio-Londrigan (2013) United States -Qualitative descriptive
To describe the experience of SDM in homecare from the nurse's perspective. 10 home-care nurses.
Themes uncovered: -Begin where the patient is.
-Education for SDM.
-The village and SDM.
-Whose decision is it? To provide greater conceptual clarity about SDM and identify key characteristics of this model.
Characteristics of SDM noted: -SDM involves at least two participants: the physician and patient. -Both parties participate in the process of treatment decision-making. -Information sharing is a prerequisite to SDM. -A treatment decision is made and both parties agree to the decision.

Charles, Gafni, and Whelan (1999) Canada
To revisit and add elements to an earlier conceptual framework on SDM Charles et al. (1997).
The revised framework: -Identifies different analytic stages (information exchange, deliberation, deciding on treatment).
-Recognizes that the decision-making approach may change during the healthcare encounter.
-Identifies decision approaches that lie between the paternalistic, shared, and advocating models.

Charles, Gafni, Whelan, and O'Brien (2006) Canada
To discuss the influence of culture on the process of treatment decision-making and SDM in the physician-patient encounter.
- To discuss the relevance of SDM in chronic care and to suggest how it can be integrated with evidence-based practice in nursing.
Chronic care warrants SDM and inviting the patient to participate in the decision-making process. -SDM takes place within the context of evidencebased practice. -Attributes to be aware of include: levels of research and corresponding evidence, intervention options available, burden of side effects with each intervention option, impact on the patient, patient's values and beliefs, and availability of resources.

Hain and Sandy (2013) United States
To discuss a patient-provider partnership model of care that supports SDM.
-The patient-provider partnership facilitates and supports SDM. -Collaboration and engagement are essential in experiences when power is shared and where there is trust and mutual respect. -The patient-provider partnership leads towards autonomy and empowerment. -Informed patients are more likely to be autonomous and engaged in their care, leading to better health outcomes. -Decision aids may be valuable tools to assist in this process.
Landmark, Gulbrandsen, and Svennevig (2015) Norway To describe how sharing in decisions are negotiated through epistemic and deontic resources.
There is a complex interplay that takes place via communication as patients and providers engage in the negotiation process leading to decisions.

Légaré and Witteman (2013) Canada
To describe three elements of SDM: recognizing that a decision is required, understanding the best available evidence, and incorporating the patient's values and preferences into the decision.
Essential elements of SDM: -Provider and patient must recognize that a decision is needed. -Both parties understand the best available evidence. -The decision considers the patient's values and preferences. Barriers: -Time -Patient characteristics. Implementing SDM requires: -Provider education in the SDM approach.
-Practice needs to be reorganized around the principles of patient engagement. -Patient-mediated interventions that facilitate the patient's interactions with the provider and the healthcare system.

Montori, Gafni, and Charles (2006) Canada, United States
To discuss SDM with patients with chronic conditions.
-Treatment decisions in the chronic care setting are likely to require an active patient role; patients have a longer window of opportunity to make decisions and to revisit and reverse these decisions. -Barriers to SDM in this context: inadequate appointment durations (time) and long periods between visits (time).
Muthalagappan, Johansson, Kong, and Brown (2013) United Kingdom To explore the ethical basis and empirical evidence around SDM in dialysis decisions among frail older adults with end stage renal disease.
-SDM is a continuum that depends on a patient's situation, preferences, and degree of understanding.
Ethical principles dictate supporting a patient's decision.

Sacchi et al. (2015) Italy
To promote the shift from a traditional, physician-centered, clinical decision process to a more personalized, patient-oriented SDM environment.
Personalized decision models can be used as a means to facilitate SDM by taking into account individual patient preferences.

Shalowitz and Wolf (2004) United States
To discuss the conceptual framework of SDM and how obstacles to SDM for lower literacy patients may contribute to healthrelated harms.
SDM noted as three stages: -Information flows are bi-directional.
-Deliberation concerning which course of action best "fits" the patient's life, ideas, values, and beliefs. -Decisions that signify both parties agree on the treatment option. -Limited literacy is a barrier.

Siminoff and
Step (2005) United States To propose a model that identifies the communication process as a vehicle for decision making that is embedded within the physician-patient relationship and acknowledges it as a social process.