Patients, please: Improving the healthcare decision-making process

It’s a patient’s right to be involved in decisions about their healthcare – so why aren’t we doing it enough?

From childbirth through to emergency care, our hospital system can do better to include patients in decision-making.

Patients who are included in the decision-making process have better health outcomes, and show increased quality of life.

In Australia, it’s a patient’s right to be involved in decisions about their care, but they’re not always included, especially in hospitals.

Shared decision-making (SDM) is the process by which patients and clinicians come to a decision regarding the next steps in the patient’s care. It involves an active two-way discussion.

The clinician brings their knowledge about risks and benefits of different treatment options and their clinical expertise, while the patient is also considered an expert in their own life, their values, preferences and goals.

Why don’t patients get enough say?

We conducted a systematic review to investigate what gets in the way of SDM in hospital settings. So far, research has focused on primary and secondary care. SDM implementation in hospitals appears to be a relatively young field with little research. This makes it difficult for hospitals to use evidence to implement the process.

There’s a wide range of barriers across primary, secondary and hospital care. Clinicians tell us there isn’t enough time, or they don’t have communication skills necessary.

Some clinicians believe patients don’t want to be involved in decisions; that they should “sell” patients on a certain option, or make the decision for them.

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Patients tell us they don’t have enough information, they don’t feel supported, and believe they shouldn’t disagree with their clinician.

We also found specific barriers to the hospital setting, including noisy and busy ward environments, and a lack of private spaces in which to have conversations.

Our review also aimed to include additional stakeholder insights beyond the usual patient-clinician relationship, including hospital leaders, hospital administrators, and government policymakers, making us the first review to examine other stakeholders.

Why is it difficult for hospitals to implement shared decision-making?

Hospitals have been asked to implement shared decision-making through policies at both the state and federal level, – for example, the National Accreditation Standards – but without a solid evidence base to guide them, hospitals are left to create implementation strategies based on shared decision-making research from primary and secondary care contexts.

Further research is needed to understand the barriers and facilitators to shared decision-making – by ensuring we research in the hospital context, and include hospital leaders, administrators, and government policymakers.

Implementation involved multiple stakeholders in the healthcare system. These stakeholders may have insights not yet explored by research focusing on patients and clinicians.

How do we help hospitals involve patients in shared decision-making?

Include stakeholders in research, in addition to clinicians and patients

Shared decisions happen between patients and clinicians, but are influenced by the system in which they occur. Patients and clinicians may not have insight into the factors influencing their decision-making, such as hospital policies and strategic planning, government policy and strategic planning, and funding allocation.

We need to include hospital leaders and administrators, and government policymakers to understand these factors, and how to address them.

Ensure everyone knows what shared decision-making is, and have the skills to practise it

In order to fulfil the rights of patients to be involved in decisions about their care, we must ensure every staff member working in the health service understands what SDM is, and why it’s important.

Clinicians also need practice communicating risks and benefits. Educators, governing bodies, government agencies and health services should ensure their staff are given practical training in how to have SDM conversations.

Promote shared decision-making through physical space – make sure there are private, quiet spaces, and enough time

Clinicians tell us it’s difficult to have SDM conversations in noisy and busy ward environments, and when they’re pressed for time. Health services should ensure there’s adequate space and privacy in which to conduct SDM conversations.

Encourage patients to be included in decisions about their care, and use suitable language and tools available (patient decision aids, if available)

Clinicians must ensure their patient has suitable information for their needs. This may include using an interpreter, providing information in a preferred language, providing information in plain language, and/or ensuring jargon is not used.

Patient decision aids can be used as a tool to help patients take part in decision-making. They allow patients to explore, clarify and communicate their own preferences in relation to the decision options available.

It’s important to note these aren’t stand-alone tools, but should be used in consultation with clinicians.

Enable clinicians to provide options

Many clinicians believe they must provide one option or “sell” a certain option. Health policymakers in government and health services must ensure clinicians feel supported to engage patients in SDM. This can be done through guideline and policy development to support the use of SDM.

Build trusting and supportive relationships with patients

Patients and clinicians believe it’s easier to share decision-making when there’s trust between them. Trust is facilitated by continuity of care – patients being able to see the same clinician regarding their care.

Many patients find decision-making easier when they have a support person to help them make sense of the information provided, and have someone to advocate for them. This can be a carer, family member or friend.

Context is everything when making healthcare decisions

Changing practice to include patients in decisions about their care can seem like a daunting task. It’s not as simple as telling clinicians they need to change their practice, giving clinicians training, or giving patients an informational pamphlet.

True change involves all levels of the healthcare system, and there’s no one-size-fits-all approach. The factors affecting decisions in maternity care will differ from those in emergency, and what works in one health service may not work in another.

Health services must ensure they understand their own context and their own people in order to drive change.

True change involves all levels of the healthcare system, and there’s no one-size-fits-all approach.

A behavioural approach can be useful, as it allows health services to deep-dive into what helps and gets in the way from multiple perspectives. Then, using theory-informed behaviour change to address the specific factors discovered while considering what is and isn’t feasible for the decision context and the service.

Understanding what helps and hinders SDM from multiple stakeholder perspectives, while taking into account contextual factors, is key to upholding a patient's right to be included in decisions about their care.