Healthcare providers' intentions to engage in an interprofessional approach to shared decision-making in home care programs: A mixed methods study

Abstract

In an interprofessional approach to shared decision-making (IP-SDM), an interprofessional team collaborates in identifying best options and helps patients determine their preferences, enabling them to take more control over the treatment plan. However, little is known about fostering IP-SDM in Canada's healthcare system. Therefore, we sought to evaluate health professionals' intentions to engage in IP-SDM in home care and explore the factors associated with this intention. A total of 272 eligible home care providers completed a questionnaire based on the theory of planned behavior. Eight managers and one healthcare team caring for the frail elderly were interviewed about possible barriers and facilitators. Analysis involved descriptive statistics and multivariate analysis of quantitative data and content analysis of qualitative data. On a scale of − 3 (strongly disagree) to +3 (strongly agree), the mean intention to engage in IP-SDM was positive (1.42 ± 1.39). The intention was influenced by the following theory-based determinants (R2 = 57%; p ≤ 0.002), i.e. cognitive attitude (p < 0.001) subjective norm (p < 0.0001) and perceived behavioral control (p < 0.0001), with variations depending on the type of provider. Barriers included lack of time, poor team cohesion and high staff turnover. Facilitators included team cohesion and shared tools. Future programs implementing IP-SDM could address these barriers and facilitators.

Inter-professional shared decision making – increasing the “shared” in shared decision making

“…[12,18] IP-SDM presents additional barriers to implementation including lack organizational resources and processes to implement IP-SDM as this model may require greater collaboration among professionals. [9,10,18,28] In addition, because of the team nature of IP-SDM, there are challenges specific to working in teams including turnover and difficulty establishing cohesion. [10,30] IP-SDM teams must trust their team members to deliver consistent and coordinated messages to the patient.…”

“…[17] Studies suggest that health professionals are less confident in communicating with other members of the team than with patients. [9,10,18,19] Historically, physicians have been viewed as ultimately responsible for decision and certainly the physician carries the most legal risk. These factors can create an imbalance in roles that may undermine IP-SDM efforts.…”

“…IP team members with different training must incorporate diverse work methods or terminology and may fear loss of professional identity with change, issues of power and responsibilities, and challenges of conflict discussion and joint decision making. [9,10,12,18,31] …”

“…Effective engagement in the SDM process requires more time than a typical patient visit and patients may vary in their level of health literacy. [9,12,18,28,29] SDM must afford time for the patient to process decision-related information and reach a conclusion, both of which may add time to the encounter. Providers are not typically compensated for SDM despite the greater time commitment, [10] perhaps fostering negative attitudes toward the process.…”

“…[9][10][11][12][13][14] Makoul and Clayman [15] identify 8 steps in an SDM protocol: identifying and explaining the decision to be made, discussing the risks and benefits of each option, eliciting patient values and preferences, discussing patient's ability and self-efficacy, presenting recommendations, checking and clarifying patient understanding, making or explicitly deferring decision, arranging follow up. In a traditional SDM context, these steps are preformed by the physician, typically within a single visit but can be distributed across visits.…”