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School of Medicine

Embedding a new model of shared decision making in healthcare policy and practice

GP and patient

Our research identifies key barriers to shared decision making.

Shared decision making (SDM) empowers individuals to make decisions about their treatment options with the support of their clinician. It is a collaborative process which utilises the clinician's expertise, but acknowledges the preferences, values and circumstances of the patient. It is widely accepted and evidenced as the gold standard approach to making healthcare decisions. However, routine implementation in practice has been slow.

GP and Patient hands

Our researchers have led a major research programme to identify the barriers to routine SDM implementation. As a result of their findings, various tools were developed to help embed this approach in routine healthcare settings.

These tools included a new ‘three-talk’ SDM model, healthcare professional skills training, and improved patient decision aids for use in clinical consultations, all of which are key to helping people make informed and value-based choices about healthcare that take their personal preferences into consideration.

Making Good Decisions in Collaboration (MAGIC)

The research project, a joint research programme between Cardiff University and Newcastle universities, was titled the Making Good Decisions in Collaboration (MAGIC) Programme. Key barriers to SDM implementation in various routine clinical settings were identified, and different forms of training and patient decision aids developed.

Our own research focused on developing a new SDM model for clinical practice. Concurrently, Newcastle University explored alternative ways to support SDM engagement and measurement within organisations.

MAGIC
Shared decision making model for clinical practice used in training programmes.

The MAGIC programme research found that clinicians:

  • believed that they already involved patients in decisions about their care
  • often reported that patients did not want SDM
  • lacked the right tools to implement SDM
  • did not have time to focus on SDM due to other demands on time

The team also found that:

  • patients often felt unable to participate in SDM due to lack of knowledge, or due to the perceived power imbalance in the clinician-patient relationship
  • providing patients with decision aids during the consultation led to greater engagement than tools provided after consultations (such as information leaflets and website links)
  • it was challenging to capture the difference that SDM made to patients

The identification of these areas kick-started the Cardiff University team to focus on how SDM implementation could be more successful.

Addressing the barriers to shared decision making

The 'three-talk' model

Our research team developed a new teaching model designed to guide clinicians on how they could integrate SDM in patient consultations. The ‘three-talk' model was based on three stages of patient engagement:

  1. Choice talk ensured that the patient knew that options were available, that they had choice in their decisions, and that their personal preferences were important.
  2. Option talk described the options available, including the risks and benefits of each.
  3. Decision talk focused on patient preferences, or what matters most to the patient, and sought to arrive at a shared treatment decision.

The SDM Train the Trainer programme

Our research team found that the most important factor in enabling SDM was the attitude and communication skills of the clinician during a consultation. In response, a 'Train the Trainer' programme was established.

This combines skills-training workshops, role play scenarios, and implementation planning. The aim of the programme is for clinicians to develop the necessary attitudes, skills and competencies to routinely embed SDM in clinical practice, with adaptations across different clinical settings.

The role play scenarios help clinicians explore what matters to patients, significantly improving communication of treatment risks and addressing attitudinal barriers. Many clinicians who undertook the training acknowledged that rather than 'doing this already' they could implement SDM much better.

Use of patient decision aids

Our research team also identified the most effective ways to share information about treatment options and risks using patient decision aids.

Patient decision aids aim to provide evidence-based information to help patients understand treatment risks and benefits, allowing them to engage in informed and shared decision making.

Although multiple types of patient decision aids have been developed previously, our team found that the most effective approach was a simple within-consultation format based on frequently asked questions from previously tested tools.

Essentially, this approach lays out the pros and cons of treatment options against the frequently asked questions of patients. When used within a consultation, patients become more involved with the process.

Clinicians described this as a ‘handover’ effect, with patients becoming more confident and engaging in collaborative dialogue when they were passed the decision aid.

A minimum certification standard – the first internationally recognised quality criteria framework for patient decision aids – was developed as a result of the research and was divided into three categories:

  1. qualifying criteria – required in order for an intervention to be considered a decision aid
  2. certification criteria – without which a decision aid is judged to have a high risk of harmful bias
  3. quality criteria – these strengthen a decision aid but do not present a high risk of harmful bias if not met
GP yellow top

Publishing our research is important, but what matters most is collaborating with our NHS colleagues to make sure that our research makes a difference and improves patient care. Working directly with the healthcare teams to make real changes and improve person-centred care has been extremely rewarding.
Dr Natalie Joseph-Williams Senior Lecturer in Improving Patient Care, Joint Academic Lead for Public Involvement and Engagement

Impact

  • SDM was applied to support more effective clinical decision-making and had a positive impact on interactions with patients and explanation of treatment options.
  • Training of NHS and Public Health Wales healthcare professionals throughout Wales, using the Cardiff ‘three-talk' model to support improved SDM in their organisations.
  • The creation of training packages that could be easily adapted for different settings for example, the embedding of SDM into clinical practice in the Musculoskeletal Physiotherapy service in Aneurin Bevan Health Board.
  • Our research influenced new UK policies and international standards for the creation of patient decision aids in the US, Canada and Norway.

Publications

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