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How nurses can encourage shared decision making

George, Tracy P. MSN, APRN-BC

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doi: 10.1097/01.NURSE.0000431767.44118.c3
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In Brief

NURSES OFTEN COUNSEL and educate patients about healthcare decisions. Whether these decisions are simple or complex, the nurse's approach can make a difference in the patient's choice and, ultimately, the quality and safety of patient care.

In the past, many healthcare professionals used a paternalistic approach to guide patients toward a specific healthcare decision. But today, healthcare professionals are more likely to use a shared decision-making approach when discussing treatment options with patients.

For example, the healthcare provider in a family practice setting may discuss initiating insulin versus adding a novel oral medication to treat type 2 diabetes and provide literature discussing the pros and cons of each. When the patient returns for a follow-up appointment in 1 week, the nurse can use a shared decision-making approach to help the patient make a sound decision that suits the patient's lifestyle and personal preferences. Besides describing this approach and patient decision-making tools, this article outlines the advantages.

Move to shared decision making

The hallmark of shared decision making is involving the patient in making healthcare decisions with the healthcare provider.1 Shared decision making acknowledges the patient's preferences, lets the patient make informed choices, and shows respect for the patient's choices.2

According to the 2001 Institute of Medicine recommendations, “Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them.”3 Patient care should be individualized based on the patient's preferences, taking into account the patient's values and culture.3

Giving patients a more active role in their healthcare decisions has helped lower medical costs and improve health outcomes, health literacy, and disease control.3,4 It's also been associated with improved patient satisfaction with healthcare decisions and the informed consent process.2,5

Patients are more likely to adhere to treatment if they participate in the decision-making process.2 Younger and better educated patients often prefer shared decision making when making healthcare decisions.4

Older patients, immigrants, and patients with dementia may be less interested in shared decision making, but vulnerable groups of patients may benefit greatly when they're involved with their healthcare decisions.1 Nurses need to adapt the shared decision-making process for vulnerable populations by listening, observing nonverbal communication, and showing respect for patients' values.6

With the emphasis on interdisciplinary collaboration and medical homes with the Patient Protection and Affordable Care Act (ACA), more nurses will be employed in primary care practices in the future where shared decision making is being used more commonly. Section 3506 of the ACA mandates that the Secretary of the Department of Health and Human Services establish an entity to create, test, and distribute decision aids.5 Also, patient involvement, including shared decision making, is required in order to be involved with the Medicare Shared Savings program.7

Using a decision aid

Patient decision aids provide information about treatment options in an easily understood format. Decision aids may include DVDs, brochures, or Internet activities.7 In addition, electronic health records may link providers to appropriate decision aids, and decision aids can be added as modules to current computer systems.1

Used in addition to the nurse's counseling, patient decision aids can help patients to sort out their choices and possible outcomes, and participate more fully in healthcare decision making.8 Stacey et al. found that decision aids were associated with improved communication, knowledge, and patient involvement.9 For more information about specific aids and websites, see Choosing a decision-making aid.

Some of the decision aids are printable handouts, and some direct the patient to visit a website. The patient decision aids provide information about the risks and benefits of each treatment option, while encouraging patients to decide whether they need additional information or consultation with a healthcare provider.

Patient decision aids may be translated into other languages and are written at the eighth grade reading level or lower based on readability scoring.10 The International Patient Decision Aids Standards Collaboration provides a checklist for the content, development process, and effectiveness of the decision aid.10

Now, how can a nurse use shared decision making in a real-life scenario?

Putting theory into practice

As an example, let's consider Ms. K, 22, who needs a new form of birth control because of many issues with other forms of contraception. She can't always remember to take oral contraceptive pills, and when she tried depot-medroxyprogesterone acetate injections, she gained 20 lb (9 kg). The vaginal ring wasn't comfortable for her, and the contraceptive patch caused a skin rash. She and her husband want to use a more effective birth control method than condoms because she's starting law school in the fall and can't afford to become pregnant now.

Her friends have suggested the contraceptive implant or intrauterine device, but she's undecided. How should the nurse in the health clinic counsel Ms. K?

To use shared decision making during the patient's visit, the nurse first needs to listen to the patient's concerns about her birth control options. It's easy to be directive in counseling when a patient is unsure about a treatment option, but as long as Ms. K chooses a safe and effective option, the nurse must be careful not to share her opinion about treatments. Instead, the nurse should provide Ms. K with objective information about all the options and encourage her to make her own decision.

In the end, Ms. K chooses the contraceptive implant. Later she says she's very satisfied with her choice of birth control and reports that making her contraceptive treatment decision was a positive experience.

Nurses everywhere can help their patients make good decisions and feel satisfied with their healthcare experience by using shared decision making.

Choosing a decision-making aid

Here's a handy guide to decision-making tools as well as resources to help find the best one for each situation.

The Ottawa Personal Decision Guide:

This guide, which provides a general example of a decision aid, meets criteria of the International Patient Decision Aids Standards.11 The nurse and patient can work together to complete this decision aid, with the nurse facilitating the patient's decision with an open approach to counseling. It can be used for many different types of patient healthcare decisions.

The Ottawa Hospital Research Institute:

This organization has developed many specific patient decision aids for conditions such as diabetes, acne, and breast cancer.12

The Mayo Clinic's Shared Decision Making National Resource Center:

This lists major organizations dedicated to patient-centered care and shared decision making as well as upcoming and past conferences on these topics.

World Health Organization Decision-Making Tool for Family Planning Clients and Providers:

According to Johnson, Kim, and Church, this tool enhanced patients' participation in their contraceptive decision making, resulting in a shift away from physician-directed decision making about methods.13

The MAGIC Programme in the United Kingdom:

Here, MAGIC means “making good decisions in collaboration.” Read about this approach taken in the United Kingdom.


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3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
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9. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;(10):CD001431.
10. International Patient Decision Aid Standards Collaboration. IPDAS 2005: Criteria for Judging the Quality of Patient Decision Aids. 2012.
11. Ottawa Hospital Research Institute and University of Ottawa. Ottawa Personal Decision Guide. 2012.
12. Ottawa Hospital Research Institute. Decision aid library inventory. 2012.
13. Johnson SL, Kim YM, Church K. Towards client-centered counseling: development and testing of the WHO Decision-Making Tool. Patient Educ Couns. 2010;81(3):355–361.


Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368(1):6–8.
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