Janneke Noordman, Mariska Oosterveld-Vlug, Jany Rademakers

Shared Decision Making in Clinical Practice

Introduction

Shared decision making in clinical practice. Shared Decision Making (SDM) in clinical practice challenges patients with limited health literacy. This study identifies barriers and proposes expanded SDM models for better patient engagement.

Abstract

Shared Decision Making (SDM), currently considered a preferred model for making decisions in healthcare, requires that patients have the knowledge and skills to actively participate in the consultation and decision-making process. Patients with limited health literacy (LHL) often fail to do so. To gain insight into the experiences, needs and support for LHL-patients concerning SDM in clinical practice, five focus groups were held with 26 patients with LHL. A focus group discussion guide was developed based on 4-steps SDM models. Data was coded using thematic content analyses. LHL patients participating in this study had little experience with SDM in practice, but do prefer it. Important barriers for this are healthcare provider-related (involving patients too little in decision-making, using medical jargon), patient-related (feeling insecure to play a role in decision-making, inability to understand their diagnosis or information about treatment options), patient-provider interaction-related (relationship of trust) or system-related (too little consultation time). For SDM to take place more often, a shared responsibility between patients and healthcare providers is required. We recommend expanding the SDM models, by adding a step zero (patients understand their diagnosis) and a fifth step (reviewing the decision), to improve the process for LHL patients.

Review

This paper addresses a critical and timely subject: Shared Decision Making (SDM) in the context of patients with limited health literacy (LHL). Given the growing imperative for patient-centered care, understanding the unique challenges faced by LHL individuals in actively participating in healthcare decisions is paramount. The study effectively utilizes a qualitative approach, employing five focus groups with 26 LHL patients, to gain nuanced insights into their experiences, needs, and perceived support regarding SDM. A significant strength lies in its explicit focus on a vulnerable patient population often overlooked in SDM research, providing valuable empirical data on a topic that has substantial practical implications for improving healthcare equity. The findings highlight a comprehensive array of barriers preventing effective SDM for LHL patients, spanning healthcare provider-related issues (e.g., medical jargon, insufficient involvement), patient-related factors (e.g., insecurity, comprehension difficulties), patient-provider interaction dynamics (e.g., trust), and broader system-related constraints (e.g., consultation time). Crucially, the study reveals that despite limited prior experience with SDM, LHL patients express a strong preference for active participation, underscoring a significant unmet need. The proposed expansion of existing SDM models, by introducing a "step zero" (ensuring diagnosis comprehension) and a "fifth step" (reviewing the decision), is a particularly innovative and actionable recommendation that directly addresses identified gaps and offers a clear pathway for practical implementation. While the qualitative methodology provides rich descriptive data, it is important to consider the potential for limited generalizability, as the findings are drawn from a specific group of 26 LHL patients in an unspecified context. Future research could benefit from exploring these barriers and proposed solutions in diverse healthcare settings and with larger, more diverse LHL populations. Additionally, the abstract hints at a shared responsibility, and further investigation into healthcare providers' perspectives on the proposed SDM model expansion would offer valuable complementary insights. Nonetheless, this study makes a substantial contribution to the literature on SDM, providing a robust framework for understanding the complexities faced by LHL patients and offering clear, evidence-based recommendations to foster more inclusive and effective decision-making processes in clinical practice.

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