The principles in practice series: part 2
Shared decision making – what it is and how to practise it to deliver outcomes that matter to patients
Making the most appropriate decision is becoming increasingly complex for both patients and professionals. It is known that healthcare providers can have differing perceptions of their patients’ need for information1 and their preferences for involvement in decisions about their own health2.
Shared decision making (SDM) allows the dental team and patients to navigate these decisions together in a collaborative way. SDM moves communication away from a “Dentist knows best” philosophy towards
a more personalised approach to care.
What is shared decision making?
SDM is a process by which patients and healthcare professionals work together to choose investigations and treatments based on a combination of clinical evidence, clinical judgement and the patient’s informed preferences. It is a vital component of person-centred care. SDM itself is not new, and many will believe they practice it already; however, it is important to highlight that SDM goes beyond the provision of opinion (paternalistic) and information (informative) to the patient3. True shared decision making is a two-way exchange of these between clinicians and patients (Figure 1).
Figure 1: the spectrum of shared decision making. Adapted from Dignity in Action4
While most practitioners aim to arrive at the best clinical decision, they can miss the opportunity for bidirectional sharing of knowledge and information. The only way to achieve true shared decision making is through meaningful conversations with patients. This involves a two-way exchange of clinical knowledge and expertise and patients contributing knowledge of their own preferences, values, risk tolerance and their concerns.
How to practice shared decision making
There is a range of tools that patients and healthcare professionals can use in partnership, to facilitate meaningful conversations. They focus on discussing risks and benefits in ways patients can understand.
One such example is the BRAN tool. BRAN – an acronym for: Benefits, Risks, Alternatives or do Nothing – is a tool comprising questions to support patients make informed choices about their care and treatment options. The BRAN tool is promoted as part of the NHS24 ‘It’s OK to Ask’ national campaign5, the aim of which is to raise awareness of the ‘BRAN’ questions amongst patients and the public, encouraging them to ask questions and become involved in their own care.
The questions are:
- What are the Benefits?
- What are the Risks?
- What are the Alternatives?
- What if we do Nothing?
Patient interviews and focus groups conducted by Dr Heather Cassie and funded by The Healthcare Improvement Studies (THIS) Institute6, with patients from across the UK, explored the use of SDM in the context of reducing unnecessary tests and treatments in primary care dentistry.
Findings identified a need for information to help them understand the decision-making processes around their treatment options and a desire to be more involved in conversations about their care.
“I think for me the most important thing is communicating that [risk assessment process] to the patient and how that decision’s been come to and arrived at and communicated in a clear and accessible way.”
– Patient 1
“If your dentist is offering you these treatments, ask them why, ask them why that treatment works, what are the benefits of that treatment? What would happen if you don’t get it? Get the facts straight first before you agreed to get it.”
– Patient 14
When asked about using the BRAN tool to structure conversations, one focus group participant commented:
“It is stimulating and reassuring to see dentistry doing this. It’s just brilliant. It’s very, very responsible. The message you’re giving out to people like me is that you are compassionate about your patients.”
Another tool to support structuring conversations is the DECIDE model7,8,9, shown in Figure 2. BRAN and the DECIDE are included in the NHS Education for Scotland ‘Having Realistic Conversations’ training resource10. DECIDE is also recommended across Scotland for structuring conversations with patients to involve them in decisions about their care.
Conclusion
Having meaningful, open conversations about a patient’s care allows you to really hear your patient, leading to decisions that are right for them, and outcomes that matter to them. Shifting the paradigm to this default takes time and concerted effort from clinicians and patients alike. However, granting patients the ability to involve themselves more actively in their care allows a sharing not only in decision making, but in responsibility for their own oral health.
References
- Willems S, De MS, Deveugele M, Derese A, De MJ. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns. 2005;56:139–146. doi: 10.1016/j.pec.2004.02.011. [DOI] [PubMed] [Google Scholar]
- Strull WM, Lo B, Charles G. Do patients want to participate in medical decision making? JAMA. 1984;252:2990–2994. [PubMed] [Google Scholar]
- The Health Foundation, Helping people share decision making. London: The Health Foundation (2012).
- Dignity In Action | Patients’ Shared Decision Making Styles: Accommodating Various Approaches.
- It’s OK to Ask | NHS inform.
- Welcome to The Healthcare Improvement Studies Institute – THIS Institute
- DECIDE: structuring a shared decision making conversation | Right Decisions
- Guo, Kristina L. PhD, MPH. DECIDE: A Decision-Making Model for More Effective Decision Making by Health Care Managers. The Health Care Manager 39(3):p 133-141, 7/9 2020. Available at: DOI:10.1097/HCM.0000000000000299.
- Shared Decision Making (DECIDE) | Turas | Learn.
- Having Realistic Conversations | Turas | Learn