Shared decision making (SDM) often focuses narrowly on the physician-patient dyad. But nurses, especially in oncology, play a crucial role in SDM as they support the basic needs of patients and help them navigate key decision points during cancer care. In frequent interactions with patients, nurses directly influence SDM, although they may not see their work specifically in those terms. The role of nurses in SDM, as in other aspects of nursing practice, is largely invisible.1 As one oncology nurse said, “Shared decision-making is [just] not something nurses do.”
Oncology nurses not only have broad knowledge of the medical side of difficult decisions about chemotherapy, surgery, radiation therapy, and other treatments that may affect life expectancy and quality of life, they also routinely learn patients’ preferences and values. Given that SDM reconciles those elements,2,3 nurses are well positioned to be partners in SDM.
Research on nurses’ roles in SDM4–8 and our own experiences in cancer care reveal specific ways that oncology nurses contribute to SDM even when they do not recognize it. If nurses and other care-team members became more aware of—and sought to increase—nurses’ role in SDM, care would become more patient-centered. Our commentary focuses on 4, often invisible, roles that oncology nurses play in SDM—and on the barriers to, and benefits from, nurses’ involvement in SDM. The quotations and examples we cite come from clinical practice in Denmark and Canada.
Oncology nurses are part of the interprofessional (IP) team.4,5 Team members work with patients and families to provide integrated, cohesive answers to specific questions at key junctures and to develop strategies that implement and support decision-making with the patient. Nurses, specifically, can help resolve IP conflicts and support the SDM process while remaining nondirective about the best option. As a young doctor noted, “If I don’t know something, I turn to the nurses. I know what the textbooks say; they know it through experience, too.” Nurses can directly participate in SDM with patients. For example, nurses at Denmark’s Vejle Hospital developed a patient decision aid to discuss options and identify patients’ nutrition preferences.
Decision coaching is nondirective support, delivered by a trained healthcare provider, to help patients actively make decisions with their doctors.9 Nurses make for excellent decision coaches, given their frequent contact with patients. Specifically, they assess patients’ decisional needs, tailor decision supports to match them and then monitor and facilitate progress in how decisions are implemented. For example, nurses in Saskatoon, Canada, coach men with early-stage prostate cancer to better understand the pros and cons of their options and help them clarify their values for outcomes/features of their options.10 Their options often include active-surveillance or treatment as recommended by urologists, radiation oncologists, or both.
Nurses’ training in nurse-patient relationships emphasizes the importance of patients’ perspectives, values, and preferences.8 Nurses receive formal education about diseases, pharmacology, psychology, and anatomy, and whole-person care. This unique combination enables oncology nurses to help patients integrate complex cancer-care information with personal preferences11—and then to advocate for the patient’s preferences with other IP team members.
For instance, a nurse in Ottawa, Canada, asked to act as a hospitalized patient’s advocate at a meeting between the doctor and the patient’s family when the patient was too ill to participate. Another nurse, in Vejle, Denmark, knew that a patient was terrified of losing her hair during treatment and the doctor had not fully appreciated this fear. The nurse conferred with the doctor who identified an alternative, appropriate chemotherapy, which the patient ultimately chose after considering the pros and cons.
As care-related decisions are made, the oncology nurse translates the patient’s perspective to other IP team members and vice versa, bridging the personal and clinical viewpoints. “Some doctors don’t communicate so that patients feel safe, or maybe don’t understand what’s been said,” one oncology nurse noted. “You need to be good at reading what to do now, to make the patient feel seen and heard.”
Often intensive communication on healthcare decisions requires frequent check-ins, as well as follow-through to assess patients for decisional conflict or, in some cases, anticipated decision regret. Some nurses follow a patient for the duration of treatment or hospitalization to enhance continuity. One oncology nurse who had a trust-based relationship with an 81-year-old patient helped her tell the doctor she was reluctant to follow the recommendation for adjuvant chemotherapy, because she feared its side effects more than the increased risk of disease recurrence.
Overcoming Barriers to Nurses’ Roles in SDM
Nurses provide supportive care, including meeting patients’ informational and other needs,12 which are closely connected to patients’ quality of life (QoL). Patients with cancer report that QoL preferences should be considered in treatment decision making.13 Oncology nurses—who simultaneously act as care-team member, decision coach, patient advocate, and ongoing liaison—have an opportunity to recognize their roles in SDM and to address related barriers.
Research has identified patients’ perceived barriers to SDM.14 The Table focuses on factors influencing nurses’ participation in SDM; most of these barriers are rooted in misconception, myth, and traditional medical hierarchy. Overcoming these barriers is essential to providing patient-centered care. Our direct observations have shown us that when oncology nurses play a direct and explicit role in SDM, concrete benefits ensue. These benefits, listed in the Table, offer great value to nurses, doctors, other healthcare professionals, and healthcare organizations alike—and, most important, to patients and their families.
Oncology Nurses’ Involvement in SDM
|✓ Belief that SDM is “a doctor’s thing” and that the physician-patient relationship merits “no interference”
✓ Nurses’ lack of confidence in their skills to engage in SDM
✓ Nurses’ lack of reflection on their own role in supporting SDM
✓ Other healthcare professionals’ unwillingness to acknowledge nurses’ roles in SDM
✓ The misconception that not all patients want SDM
✓ The myth that SDM takes too much time
✓ The misperception that SDM does not fit into existing workflows
✓ Nurses’ concern that they have too many other competing tasks
✓ Belief that patients merely need more informational materials or decision aids
✓ Lack of individual and organizational motivation to pursue SDM
|✓ More patients will experience SDM on a routine basis
✓ Patients will be better prepared to take part in SDM
✓ Nurses will find even greater meaning in their work
✓ Patient-specific preferences will influence better clinical decision-making
✓ Patients will receive well-informed, broad-based support for expressing their feelings and concerns
✓ Patients will experience less decisional conflict and decision regret
✓ Nurses will strengthen relationships with their patients
✓ Doctors will be better supported in their own SDM roles
✓ Interprofessional teams will become more egalitarian
✓ Patient-centered culture will be strengthened in the organization
Abbreviation: SDM, shared decision making.
To fully realize those benefits, nursing schools should offer more SDM-related theory and training, so that nurses reflect on and develop their SDM skills. And cancer hospitals should view SDM as a development goal for all healthcare professionals, including physicians and nurses, making best practices in SDM part of lifelong learning.15 With such a strong foundation in education, clinical practice, and organizational priorities, oncology nurses’ involvement in SDM can become a more conscious goal for everyone involved in cancer care.
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