Michelle P. Salyers

Re-thinking shared decision-making: Context matters

OBJECTIVE Traditional perspectives on shared decision-making (SDM) focus attention on the point in a clinical encounter where discussion of a treatment decision begins. We argue that SDM is shaped not only by initiation of a treatment decision, but also by the entire clinical encounter, and, even more broadly, by the nature of the patient-provider relationship. METHOD The four habits approach to effective clinical communication, a validated and widely used framework for patient-provider communication, was used to understand how SDM is integrally tied to the entire clinical encounter, as well as to the broader patient-provider relationship. RESULTS The Four Habits consists of four categories of behaviors: (1) invest in the beginning; (2) elicit the patients perspective; (3) demonstrate empathy; and (4) invest in the end. We argue that the behaviors included in all four of these categories work together to create and maintain an environment conducive to SDM. CONCLUSION SDM cannot be understood in isolation, and future SDM research should reflect the influence that the broader communicative and relational contexts have on decisions. PRACTICE IMPLICATIONS SDM training might be more effective if training focused on the broader context of communication and relationships, such as those specified by the Four Habits framework.

Levels of patient activation among adults with schizophrenia: associations with hope, symptoms, medication adherence, and recovery attitudes.

Abstract Patient activation, defined as one’s attitudes and confidence toward managing illness, has been not been thoroughly studied in consumers with schizophrenia. The current study sought to understand the relationship between patient activation and symptoms, medication adherence, recovery attitudes, and hope in a sample of 119 adults with schizophrenia. The participants were enrolled in an 18-month randomized controlled study of the Illness Management and Recovery program. Data were collected at baseline; correlations and stepwise multiple regressions were used to examine the relationships and determine the unique contribution of variables. Higher patient activation was most strongly associated with positive recovery attitudes, higher levels of hope, and fewer emotional discomfort symptoms. Patient activation was significantly related to a broad measure of illness self-management, providing evidence for the construct validity of the patient activation measure. Our findings emphasize the importance of recovery-based mental health services that recognize level of patient activation as a potential factor in consumer outcomes.

A Coding System to Measure Elements of Shared Decision Making During Psychiatric Visits

OBJECTIVE Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice. METHODS A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined. RESULTS Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision. CONCLUSIONS The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts.

Job satisfaction and burnout among VA and community mental health workers.

Building on two independent studies, we compared burnout and job satisfaction of 66 VA staff and 86 community mental health center staff in the same city. VA staff reported significantly greater job satisfaction and accomplishment, less emotional exhaustion and lower likelihood of leaving their job. Sources of work satisfaction were similar (primarily working with clients, helping/witnessing change). VA staff reported fewer challenges with job-related aspects (e.g. flexibility, pay) but more challenges with administration. Community mental health administrators and policymakers may need to address job-related concerns (e.g. pay) whereas VA administrators may focus on reducing, and helping workers navigate, administrative policies.

Development and Reliability of a Measure of Clinician Competence in Providing Illness Management and Recovery

OBJECTIVE Illness management and recovery (IMR) is an evidence-based, manualized illness self-management program for people with severe mental illness. This study sought to develop a measure of IMR clinician competence and test its reliability and validity. METHODS Two groups of subject matter experts each independently created a clinician-level IMR competence scale based on the IMR Fidelity Scale and on two unpublished instruments used to evaluate provider competence. The two versions were merged, and investigators used the initial version to independently rate recordings of IMR sessions. Ratings were compared and discussed, discrepancies were resolved, and the scale was revised through 14 iterations. The resulting IMR Treatment Integrity Scale (IT-IS) includes 13 required items and three optional items rated only when the particular skill is attempted. Four independent raters then used the IT-IS to score tapes of 60 IMR sessions and 20 control group sessions. RESULTS The IT-IS showed excellent interrater reliability (.92). A factor analysis supported a one-factor model that showed good internal consistency. The scale successfully differentiated between IMR and control groups. Reliability and validity of individual items varied widely. CONCLUSIONS The IT-IS is a promising measure of clinician competence in providing IMR. The scale could be used for research and quality assurance and as a supervisory feedback tool. Future research is needed to examine item-level changes, predictive validity of the IT-IS, discriminant validity compared with other more structured interventions, and the reliability and validity of the scale for nongroup IMR.

An exploratory analysis of racial factors in staff burnout among assertive community treatment workers.

We examined racial differences in burnout among case managers working with people with severe mental illness, using the Maslach Burnout Inventory. Compared to Caucasians, African Americans reported significantly less Emotional Exhaustion and Depersonalization, but did not differ on levels of Personal Accomplishment. These differences could not be explained by geographic location or perceptions of the work environment; however, age accounted for group differences in Depersonalization. Racial incongruence with caseload appeared to be one factor in burnout, particularly for Emotional Exhaustion. Race of both staff and clients may be important to consider in understanding staff burnout.

Agenda Setting in Psychiatric Consultations: An Exploratory Study

OBJECTIVE Patient- or consumer-centeredness has been recognized as a critical component of quality in primary health care, but is only beginning to be recognized and studied in mental health. Among the first opportunities to be consumer-centered is collaboratively producing an agenda of topics to be covered during a clinic visit. Early agenda setting sets the stage for what is to come and can affect the course, direction, and quality of care. The purpose of this work is to study agenda setting practices among 8 prescribers (5 psychiatrists and 3 nurse practitioners) at the beginning of their encounters with 124 consumers diagnosed with schizophrenia spectrum disorders (56%), bipolar disorder (23%), major depression (15%), and other disorders (6%). METHOD We modified an extant agenda-setting rubric by adding behaviors identified by a multidisciplinary team who iteratively reviewed transcripts of the visit openings. Once overall consensus was achieved, two research assistants coded all of the transcripts. Twenty-five transcripts were scored by both raters to establish interrater reliability. RESULTS We identified 10 essential elements of agenda setting. Almost 10% of visits had no agenda set, and only 1 of 3 encounters had partial or complete elicitation of a single concern. Few additional concerns (4%) were solicited, and no encounter contained more than 6 essential elements. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Collaborative agenda setting represents a unique opportunity to translate the concept of consumer-centeredness into mental health care. Initial results suggest the rating system is reliable, but the essential elements are not being used in practice.

Patient Activation in Schizophrenia: Insights from Stories of Illness and Recovery

Using a mixed-methods approach, we sought a deeper understanding of patient activation in 46 participants with schizophrenia. We qualitatively examined narratives for themes related to patient activation and divided the sample based on the mental health version of the patient activation measure. Participants high in patient activation described acceptance, control over illness, a wide range of activities that help them, and highlighted collaborative treatment experiences. The groups did not differ in understanding the cause of illness, what makes symptoms worse, or things they were proud of. Active management of schizophrenia mirrors physical health activation in several ways.

Parents served by assertive community treatment: parenting needs, services, and attitudes.

OBJECTIVE Assertive Community Treatment (ACT) is an evidence-based practice for individuals with severe mental illness. Although at least half of all people with severe mental illness are parents, little is known about their experiences as parents and as recipients of mental health interventions like ACT. The purpose of the current study was to examine the experiences of parent consumers served by ACT. METHOD Seventeen parents being served by ACT teams were interviewed about parenting, parenting needs, severe mental illness, satisfaction with ACT services, and suggestions for improved parent-focused treatment services. RESULTS All parents identified at least one positive aspect of parenting and most parents (77%) also identified negative aspects of parenting. Loss of custody emerged as a significant parenting problem, with most parents (88%) experiencing custody loss at least once. Parents expressed interest in numerous parent-focused services, including family therapy, parenting skills, communication skills training, resources for children, and peer support groups. Most participants with adult children (88%) reported having no unmet parent-related needs and high satisfaction (4.63 of 5) with ACT services, whereas parents with young children (78%) reported having several unmet parenting needs and relatively lower satisfaction (3.78 out of 5) with ACT services. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The ACT treatment model may not be adequately serving parents of young, dependent children. Findings suggest the need for more attention and focus on parent consumers, including identification of parental status and improved parent-related treatment services and support.

Using simulation to assess the influence of race and insurer on shared decision making in periviable counseling.

Introduction Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling. Methods We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semistructured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance. Results Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P < 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = <0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients. Conclusions This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients’ sociodemographic characteristics and deserves further study.