A descriptive model of shared decision making derived from routine implementation in clinical practice ('Implement-SDM'): Qualitative study
A descriptive model of shared decision making derived from routine implementation in clinical practice ('Implement-SDM'): Qualitative study
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DOI：
10.1016/j.pec.2019.07.016
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发表时间：
2019-10-01
影响因子：
3.5
通讯作者：
Edwards, Adrian
中科院分区：
文献类型：
--
作者：
Joseph-Williams, Natalie;Williams, Denitza;Edwards, Adrian
目的：需要研究了解共同决策（SDM）是如何在常规临床环境中实施的。我们的目的是1)描述临床医生和患者之间的SDM过程；2)研究SDM过程与SDM的规定性模型相比有多好；3)提出一个基于日常实践中观察到的SDM的描述性模型。方法：通过卡迪夫和瓦尔大学健康委员会（英国）团队连续招募慢性肾脏疾病和早期乳腺癌患者。对协商进行了录音、抄写和专题分析。结果：观察了76次咨询：26次透析前咨询和25例乳腺癌患者各2次咨询。观察了“三谈模式”的关键阶段。然而，我们也观察到更多的元素和更大的复杂性：一个独特的准备阶段；量身定制和不断发展的综合选项对话；患者和临床医生形成“知情偏好”；分布式和多阶段决策；以及更开放的规划讨论。决策辅助工具的使用是有限的。结论：与现有理论模型中先前的描述相比，观察到的情况更为复杂。实践意义：该模型可以为未来的培训和倡议提供基础，以促进SDM的发展，并解决政策中提倡的，但在实践中很少实现的差距。(C) 2019 Elsevier B.V.版权所有
Objective: Research is needed to understand how Shared Decision-Making (SDM) is enacted in routine clinical settings. We aimed to 1) describe the process of SDM between clinicians and patients; 2) examine how well the SDM process compares to a prescriptive model of SDM, and 3) propose a descriptive model based on observed SDM in routine practice.Methods: Patients with chronic kidney disease and early stage breast cancer were recruited consecutively via Cardiff and Vale University Health Board (UK) teams. Consultations were audio-recorded, transcribed and thematically analysed.Results: Seventy-six consultations were observed: 26 pre-dialysis consultations and two consultations each for 25 breast cancer patients. Key stages of the Three Talk Model' were observed. However, we also observed more elements and greater complexity: a distinct preparation phase; tailored and evolving integrative option conversation; patients and clinicians developing 'informed preferences'; distributed and multi-stage decisions; and a more open-ended planning discussion. Use of decision aids was limited.Conclusion: A more complex picture was observed compared with previous portrayals in current theoretical models.Practice ilmplications: The model can provide a basis for future training and initiatives to promote SDM, and tackle the gap between what is advocated in policy, but rarely achieved in practice. (C) 2019 Elsevier B.V. All rights reserved.