Marie Truglio-Londrigan

A qualitative systematic review of internal and external influences on shared decision-making in all health care settings

Review question/objective The objective of this review is to identify and synthesize the best available evidence related to the meaningfulness of internal and external influences on shared‐decision making for adult patients and health care providers in all health care settings. The specific questions to be answered are: What are the internal and external influences on shared decision making from the perspective of adult patients in all health care settings? What are the internal and external influences on shared decision making from the perspective of health care providers caring for adult patients in all health care settings? Background Patient‐centered care is emphasized in todays healthcare arena. This emphasis is seen in the works of the International Alliance of Patients’ Organizations (IAOP) who describe patient‐centered healthcare as care that is aimed at addressing the needs and preferences of patients.1 The IAOP presents five principles which are foundational to the achievement of patient‐centered healthcare: respect, choice, policy, access and support, as well as information.1 These five principles are further described as: respect for the patients needs, preferences, values, autonomy, and independence; the right of the patient to have a choice to participate as a partner in making healthcare decisions based on their individual abilities and preferences; meaningful and active involvement in healthcare policy‐making through sharing in decision‐making to ensure that patients are at the center of the policy design; support of a patients access to safe, quality and appropriate services; and the development and offering of age appropriate, linguistically, educationally, and culturally designed information that will enable the individual patient to make decisions about their healthcare needs. Within the description of these five principles the idea of shared decision‐making is clearly evident. The concept of shared decision‐making began to appear in the literature in the 1990s.2 It is defined as a “process jointly shared by patients and their health care provider. It aims at helping patients play an active role in decisions concerning their health, which is the ultimate goal of patient‐centered care.”3(p.23) The details of the shared decision‐making process are complex and consist of a series of steps including: the recognition that a decision can or must be made; identifying the possible courses of action; listing the pros, cons, and other characteristics of each possibility; comparing the options and identifying one as probably better than the rest; accepting or rejecting options resulting in the final choice; authorization of the final choice; and implementation of that choice.4 Three overall representative decision‐making models are noted in contemporary literature. These three models include: paternalistic, informed decision‐making, and shared decision‐making.5 The paternalistic model is an autocratic style of decision‐making where the healthcare provider carries out the care from the perspective of knowing what is best for the patient and therefore makes all decisions. The informed decision‐making model takes place as the information needed to make decisions is conveyed to the patient and the patient makes the decisions without the healthcare provider involvement.5 Finally, the shared decision‐making model is representative of a sharing and a negotiation towards treatment decisions. 5 Thus, these models represent a range with patient non‐participation at one end of the continuum to informed decision making or a high level of patient power at the other end.5 Several shared decision‐making models focus on the process of shared decision‐making previously noted. A discussion of several process models follows below. Charles et al.5 depicts a process model of shared decision‐making that identifies key characteristics that must be in evidence. The patient shares in the responsibility with the healthcare provider in this model. The key characteristics included: the participation of at least two parties, both parties take steps to participate in the process of treatment decision‐making, information sharing occurs as a prerequisite to share in decision‐making, an ultimate decision is made, and both parties agree to the decision. This model illustrates that there must be at least two individuals participating, however, family and friends may be involved in a variety of roles such as the collector of information, the interpreter of this information, coach, advisor, negotiator, and caretaker.5,6 This model also depicts the need to take steps to participate in the shared decision‐making process. To take steps means that there is an agreement between and among all involved that shared decision‐making is necessary and preferred. Research about patient preferences, however, offers divergent views. The link between patient preferences for shared decision‐making and the actuality of shared decision‐making in practice is not strong.5 Research concerning patients and patient preferences on shared decision‐making points to variations depending on age, education, socio‐economic status, culture, and diagnosis. 7‐12 Healthcare providers may also hold preferences for shared decision‐making; however, research in this area is not as comprehensive as is patient focused research.13 Elwyn et al.14 explored the views of general practice providers on involving patients in decisions. Both positive and negative views were identified ranging from receptive, noting potential benefits, to concern for the unrealistic nature of participation and sharing in the decision‐making process.14 An example of this potential difficulty, from a healthcare provider perspective, is identifying the potential conflict that may develop when a patients preference is different from clinical practice guidelines.15 This is further exemplified in healthcare encounters when a situation may not yield itself to a clear answer but rather lies in a grey area. These situations are challenging for healthcare providers.12 The notion of information sharing as a prerequisite to shared decision‐making offers insight into another process. The healthcare provider must provide the patient the information that they need to know and understand in order to even consider and participate in the shared decision‐making process. This information may include the disease, potential treatments, consequences of those treatments, and any alternatives, which may include the decision to do nothing. Without knowing this information the patient will not be able to participate in the shared decision‐making process. The complexity of this step is realized if one considers what the healthcare provider needs to know in order to first assess what the patient knows and does not know, the readiness of the patient to participate in this educational process and learn the information, as well as, the individual learning styles of the patient taking into consideration the patients ideas, values, beliefs, education, culture, literacy, and age. Depending on the results of this assessment the health care provider then must communicate the information to the patient. This is also a complex process that must take into consideration the relationship, comfort level, and trust between the healthcare provider and the patient.16 Finally, the treatment decision is reached between both the healthcare provider and the patient. Charles et al.5 portrays shared decision‐making as a process with the end product, the shared decision, as the outcome. This outcome may be a decision as to the agreement of a treatment decision, no agreement reached as to a treatment decision, and disagreement as to a treatment decision. Negotiation is a part of the process as the “test of a shared decision (as distinct from the decision‐making process) is if both parties agree on the treatment option.”5(p.688) Towle and Godolphin17 developed a process model that further exemplifies the role of the healthcare provider and the patient in the shared decision‐making process as mutual partners with mutual responsibilities. The capacity to engage in this shared decision‐making rests, therefore, on competencies including knowledge, skills, and abilities for both the healthcare provider and the patient. This mutual partnership and the corresponding competencies are presented for both the healthcare provider and the patient in this model. The competencies noted for the healthcare provider for shared decision making include: Develop a partnership with the patient. Establish or review the patients preferences for information. Establish or review the patients preferred role in decision‐making. Ascertain and respond to the patients ideas, concerns, and expectations. Identify choices and evaluate the research evidence. Present evidence, taking into account competencies 2 and 3, in a way that helps the patient to reflect on and assess the impact of alternative decisions with regard to his or her values and lifestyle. Negotiate a decision in partnership with the patient and resolve conflict. Agree on an action plan and complete arrangements for follow‐up.17 Patient competencies include: Define the preferred health care provider‐patient relationship. Find a healthcare provider and establish, develop, and adapt a partnership. Articulate health problems, feelings, beliefs, and expectations in an objective and systematic manner. Communicate in order to understand and share relevant information. Access information. Evaluate information. Negotiate decisions, give feedback, resolve conflict, and agree on an action plan.17 This model illustrates the shared decision‐making process with emphasis on the role of the healthcare provider and the patient very similar to the prior model.5 This model, however, gives greater emphasis to the process of the co‐participation of the healthcare provider and the patient. The co‐participation depicts a mutual partnership

Effectiveness of sleep education programs to improve sleep hygiene and/or sleep quality in college students: a systematic review.

Background Sleep health is essential for overall health, quality of life and safety. Researchers have found a reduction in the average hours of sleep among college students. Poor sleep has been associated with deficits in attention, reduction in academic performance, impaired driving, risk-taking behaviors, depression, impaired social relationships and poorer health. College students may have limited knowledge about sleep hygiene and the behaviors that supports sleep health, which may lead to poor sleep hygiene behavior. Objectives To identify, appraise and synthesize the best available evidence on the effectiveness of sleep education programs in improving sleep hygiene knowledge, sleep hygiene behavior and/or sleep quality versus traditional strategies. Inclusion criteria Types of participants All undergraduate or graduate college students, male or female, 18 years and older and of any culture or ethnicity. Types of interventions Formal sleep education programs that included a curriculum on sleep hygiene behavior. Educational delivery methods that took place throughout the participants’ college experience and included a variety of delivery methods. Types of studies Randomized controlled trials (RCTs) and quasi-experimental studies. Outcomes Sleep hygiene knowledge, sleep hygiene behavior and/or sleep quality. Search strategy Literature including published and unpublished studies in the English language from January 1, 1980 through August 17, 2015. A search of CINAHL, CENTRAL, EMBASE, Academic Search Complete, PsychINFO, Healthsource: Nursing/Academic edition, ProQuest Central, PubMed and ERIC were conducted using identified keywords and indexed terms. A gray literature search was also performed. Methodological quality Quantitative papers were assessed by two reviewers using critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data extraction Data were extracted using the JBI-MAStARI data extraction tool. Data extracted included interventions, populations, study methods and outcomes of significance to the review question and objectives. Data synthesis Meta-analysis was not possible due to limited studies and variability of design and interventions; therefore, results are presented in narrative form. Results This systematic review yielded three RCTs and one quasi-experimental study for inclusion. Two studies reported outcomes on sleep hygiene knowledge; one showing a statistically significant improvement (Pu200a=u200a0.025) and the other reported no difference (test of significance not provided). Two studies reported on sleep hygiene behavior; one showing no difference (Pu200a>u200a0.05) and the other reporting a statistically significant improvement (Pu200a=u200a0.0001). Four studies reported on sleep quality; three reporting no difference (Pu200a>u200a0.05) and the other reporting a statistically significant improvement (Pu200a=u200a0.017). Conclusion This reviewed article identified insufficient evidence to determine the effectiveness of sleep education on sleep hygiene knowledge, sleep hygiene behavior or sleep quality in this population.

Learning the faculty role: using the evolving case story of professor able in an online master of nursing education program.

This article presents the use of a case story about a fictitious character, Professor Able, as a strategy to learn about the role of the nurse educator and to assist in the transition from clinical practice into that role. The story evolves over a 13-week semester in an engaging, asynchronous online environment where students explore what it means to be a nurse educator. The story of Professor Able provides insights into faculty issues such as academic freedom, integrity, governance, and diversity. Students online discussions highlight the interactive learning experience and outcomes generated by the use of the case story. This teaching strategy offers support for nurses transitioning into the much-needed role of nurse educator.

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.

The Patient Experience With Shared Decision Making: A Qualitative Descriptive Study.

Shared decision making is a process characterized by a partnership between a nurse and a patient. The existence of a relationship does not ensure shared decision making. Little is known about what nurses need to know and do for this experience to take place. A qualitative descriptive study was implemented using Coalizzis method. Semistructured interviews were held with patients, and 3 themes were uncovered. The findings suggest that a nurses conduct aimed at drawing patients in and inviting them to participate in a conversation leads toward shared decisions. Infusion nurses may find this information useful as they engage their patients in shared decisions.

A systematic review of medication reconciliation strategies to reduce medication errors in community dwelling older adults

Review Question/Objective nThe review objective is to identify and synthesise the best available evidence on effects of medication reconciliation strategies on medication errors among community dwelling older adults. The review question is: What is the effectiveness of medication reconciliation strategies on medication errors among community dwelling older adults? n nTypes of Participants nThis review will consider studies that include older adults (65 years of age and older), regardless of gender, race, or ethnicity, living in the community. n nTypes of Interventions nThis review will consider studies that evaluate medication reconciliation strategies compared to usual care. n nType of Outcome nThis review will consider studies that include outcome measures of medication errors including but not limited to errors related to prescribing, labelling, dispensing, medication administration, and medication reconsolidation.

Appreciative Inquiry: An Innovative Initiative for Continuous Improvement in Doctoral Education

In 1998 the Lienhard School of Nursing (LSN), College of Health Professions, Pace University implemented formal quality improvement (QI) initiatives geared toward collecting data that would be used to improve and enhance the student experience as well as a method of meeting United States accreditation standards for universities, and for health care programs. The LSN is accredited by the Commission on Collegiate Nursing Education (CCNE), and Pace University holds national collegiate accreditation through the Middle States Commission on Higher Education.