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Nurses' shared decision-making 'supports their own views'


Nurses are in favour of shared decision-making with patients on treatment, but tend to use it to support their own decisions, rather than how way it was intended by policy makers,say researchers.

The study interviewed 20 practice nurses on their approach to decision-making in asthma consultations.

Despite holding positive views about shared decision-making, nurses only offered opportunity for share decisions on inhalers based on their pre-selected recommendations.

The authors said: “Shared decision making was used as a tool to support the nurses’ agenda, rather than as a natural expression of equality between the nurse and patient.”

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Readers' comments (5)

  • michael stone

    This comment - Shared decision making was used as a tool to support the nurses’ agenda, rather than as a natural expression of equality between the nurse and patient - is interesting: what 'equality between nurse and patient' ?

    Clinicians are experts in clinical factors, and normally (except, it appears, for some situations when not offering treatment would be life-threatening) can decide whether or not to offer a treatment.

    But it is now accepted (this was made very clear by the GMC in its guidance to doctors last year) that the principle of 'Informed Consent/Considered Refusal' applies once a treatment is offered - the patient then considers the way an offered treatment will impact on his wider life situation, the patient considers the risks and benefits in the light of his own beliefs and desires about his life, and then the patient decides whether to accept or refuse an offered treatment. Furthermore, the patient need not explain why he is refusing a treatment - and from the clinical side, the only necessary test is 'has the patient properly understood the clinical consequences of accepting/refusing the offered treatment'.

    Everyone uses things to support their own agenda, but there is not equality between clinicians and patients: it is pretty simple, because patients can request treatment, and patients can refuse an offered treatment, while the clinicians can decide whether to offer a treatment, but they must get permission before providing that treatment.

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  • michael stone

    Re my previous comment, the following is how the GMC guidance explains the decision-making process between a mentally capable patient and a doctor, for offered treatments;

    (a) The doctor and patient make an assessment of the patient’s condition,
    taking into account the patient’s medical history, views, experience and

    (b) The doctor uses specialist knowledge and experience and clinical
    judgement, and the patient’s views and understanding of their
    condition, to identify which investigations or treatments are clinically
    appropriate and likely to result in overall benefit for the patient. The
    doctor explains the options to the patient, setting out the potential
    benefits, burdens and risks of each option. The doctor may recommend
    a particular option which they believe to be best for the patient, but
    they must not put pressure on the patient to accept their advice.

    (c) The patient weighs up the potential benefits, burdens and risks of the
    various options as well as any non-clinical issues that are relevant to
    them. The patient decides whether to accept any of the options and, if
    so, which. They also have the right to accept or refuse an option for a
    reason that may seem irrational to the doctor or for no reason at all.

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  • Good Grief, I and those I work with have always worked in partnership with our patients, who if they are conscious or mentally competent, are entirely in charge of their own decisions. We do not need 'tools' or anything or anybody else to determine this. it is basic common sense and a fundamental human right. we are not their to order our patients around. our role is merely to assist them, administer tretments to which they have agreed and offer them the care they are unable to provide for themselves.

    Where on earth do all these strange ideas and agendas and tools come from? No wonder there is so much confusion in the NHS!

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  • I find this really interesting and not a simple matter at all. Common sense is surprisingly in short supply sometimes, however I doubt very much whether it would address the subtle and complex underlying issues involved in the power dynamics of relationships. I think it has huge impact on people who are not of our profession, meeting our profession in such vulnerability. I also think that as it's as familiar for us as the air we breathe, people/patients experience is completely different and often scary, powerless and unspoken to more or less an extent. One of the things we miss, I think, is our gatekeeper role and the power invested in our expertise as gatekeepers of care or treatment options, regardless of peoples' ability to understand.
    I wonder if we simplify issues sometimes for ourselves in order to avoid the uncomfortable issues underneath that remain unaddressed?

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  • a highly complex area of psychodynamics and psychosocial factors where attitudes, interpersonal relationships and emotional states of those involved in the decision making come into play. Power struggles between nurse, doctor and patient and other staff members in an interdisciplinary team can affect the outcome of a patient's decisions.
    Shared decision making also depends upon the quality of the therapeutic relationship which includes trust, empathy and mutual respect, interdependency, psychological and physical dependence of patient on doctor or nurse and transference/countertransference, amongst some of the factors, as well as the patient's perception and understanding and level of acceptance of his/her illness and problems and how s/he envisages the benefits and outcome of the treatment and programme of care, as well as psychosocial considerations such as effects on life style, position in the family or society and financial situation.

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