ESSENTIALS

Shared decision making (SDM) is

a healthcare delivery model that Shared Decision
Making
mandates patient-centered care
for clinical practice. Practicing SDM
ensures that patients and family
caregivers are engaged in making
decisions about their care and treat- Improving patient outcomes by understanding
ment with healthcare providers. This the benefits of and barriers to effective communication
article reviews the evidence on how
nurses can influence the outcomes Beth Faiman, PhD, MSN, APRN-BC, AOCN®, and Joseph D. Tariman, PhD, RN, ANP-BC, FAAN
of cancer treatment decisions by

S
using the SDM model.

AT A GLANCE hared decision making (SDM) and clinical nursing staff members, all of
ɔɔ SDM is a treatment decision- is an important component whom have the opportunity to engage and
making model that requires of patient engagement in assist patients and caregivers with criti-
collaboration between healthcare which the healthcare pro- cal treatment decisions. Previous studies
providers and the patient or family vider invites the patient or have frequently cited nurses as trusted
caregiver. his or her caregiver to collaborate on treat- members of the healthcare team, and
ɔɔ Practicing SDM can improve ment decisions (Kane, Halpern, Squiers, patients often share their thoughts, con-
patient-reported outcomes Treiman, & McCormack, 2014; Tariman et cerns, and desired treatment options with
following treatment decisions. al., 2016; Tariman & Szubski, 2015). With their nurses and advanced practice provid-
ɔɔ Competency with SDM en- the number and complexities of treat- ers; therefore, they are well positioned to
courages patient engagement ment options continuing to increase, the engage patients in SDM (Singh et al., 2010;
and participation in treatment SDM model encourages patients, family Tariman et al., 2016; Tariman & Szubski,
decisions and can improve the caregivers, and healthcare providers to 2015). The four essential elements of SDM
patient–provider relationship. evaluate clinical information (e.g., data focus on integrating patient desires and
from research, the patient’s overall health wishes so that patients can determine
status) and compare the risks and benefits their best treatment option. Effective
to select the most appropriate treatment SDM requires at least two participants
option. This article provides an overview (e.g., a healthcare provider and a patient or
of the benefits of and barriers to effective family caregiver). Both parties share infor-
SDM and recommends interventions to mation regarding the decision to be made
enhance the use of the SDM model among and take the necessary steps to reach a
nurses and healthcare providers. consensus about the preferred treatment
decision. SDM is considered successful
Shared Decision Making when mutual agreement is reached be-
SDM is a treatment decision-making tween the patient or caregiver and the
model that can be implemented during healthcare provider(s) on the treatment
patient encounters with healthcare teams decision (Charles, Gafni, & Whelan, 1997).
or providers. Although many healthcare
providers may prefer to implement SDM Benefits
KEYWORDS into routine patient encounters, many Previous studies have evaluated the
shared decision making; variables, such as high levels of uncertain- financial and emotional benefits of pos-
patient-centered care; cancer ty, the complexity of medical decisions, itive patient-provided communication
treatment; competence multiple treatment options, and time encounters (Montori, Kunneman, &
constraints, can limit or prevent the use Brito, 2017; Müller et al., 2019). According
DIGITAL OBJECT of SDM during communication encoun- to Steffensen et al. (2018), patient de-
IDENTIFIER ters (Kane et al., 2014). In most cancer cision aids are associated with overall
10.1188/[Link].540-542 centers, the healthcare team consists of improved decision quality and decision-
physicians, advanced practice providers, making processes that lead to improved

540 CLINICAL JOURNAL OF ONCOLOGY NURSING OCTOBER 2019, VOL. 23, NO. 5 [Link]
 ASSOCIATE EDITOR JEAN E. BOUCHER, PhD, RN, ANP-BC, AOCNP®

patient or health system outcomes. In a physicians report that they are often re- The SHARE (Seek, Help, Assess, Reach,
study by Hughes et al. (2018), poor SDM luctant to offer recommendations to avoid Evaluate) approach was established with
techniques were associated with poorer biasing the patient (Tamirisa et al., 2017). patient-centered outcomes in mind and
patient-reported health outcomes, de- outlines the following five essential steps
creased established quality indicators, and Interventions for effective SDM practice during patient
higher healthcare use. Additional stud- In a 2018 Cochrane review, Légaré et al. encounters (AHRQ, 2014):
ies have reported significant and positive evaluated the efficacy of interventions ɐɐ Step 1: Seek your patient’s participation.
affective-cognitive outcomes when SDM meant to increase the use of SDM among ɐɐ Step 2: Help your patient explore and
was used to enhance patient-centered healthcare professionals. The review in- compare treatment options.
communication (Shay & Lafata, 2015; cluded 87 studies (45,641 patients and ɐɐ Step 3: Assess your patient’s values and
Street, Mazor, & Arora, 2016). Positive 3,113 healthcare professionals) that were preferences.
affective-cognitive outcomes increase pa- primarily performed in the United States, ɐɐ Step 4: Reach a decision with your
tient autonomy and decrease decisional Germany, Canada, and the Netherlands. patient.
regret, which further supports the use of The studies evaluated how using decision ɐɐ Step 5: Evaluate your patient’s decision.
the SDM model (Charles et al., 1997). aids, patient activation, question prompt In collaboration with the Oncology
lists, training for patients, and other Nursing Society’s Chicago chapter re-
Barriers
Despite the strategies recommended by
government agencies, such as the Agency "Patients often share their thoughts,
for Healthcare Research and Quality
(AHRQ) and the Institute of Medicine concerns, and desired treatment
Committee on Quality of Health Care in
America, and numerous studies support-
options with their nurses and
ing the use of SDM in patients with cancer, advanced practice providers."
a lack of time, and a disconnect between
the information provided to patients and
their verbalized understanding of the risks
of therapy are commonly cited barriers to variables encourages the use of SDM. search committee, Tariman et al. (2018)
patient engagement (Kane et al., 2014). In a Studies reviewed by Légaré et al. (2018) developed and psychometrically tested
qualitative study by McCarter et al. (2016) also included interventions that were ad- the properties of the Competency Scale
on the promoters and barriers to nurs- ministered alone (single intervention) or for SDM-Nurses (SDM-N) in a sample of
ing, practice, patient, institutional policy, in combination (multifaceted interven- 242 oncology nurses in the hematology-
professional, scope of practice, insurance tion) to determine the best practices of oncology setting. To enhance and im-
coverage, and administrative barriers were SDM. Légaré et al. (2018) concluded that prove the implementation of SDM using
identified as reasons for limited partici- the evidence was not robust enough to
pation in SDM. Another study explored recommend one particular intervention
patient and physician perceptions of using over another. Similarly, a study by Müller TEST YOUR KNOWLEDGE
an SDM model in clinical encounters for et al. (2019) evaluated a variety of strate-
cancer care (Tamirisa et al., 2017). In the gies for training healthcare providers in What is the first step of the SHARE (Seek, Help,
Tamirisa et al. (2017) study, physicians SDM. Based on the evidence, Müller et al. Assess, Reach, Evaluate) decision-making
reported that they incorporate patient au- (2019) recommend establishing interna- approach for patient engagement?
tonomy during decision making, relaying tional guidelines that include a core set of ɔɔ Speak to the physician.

information to support decisions without expected outcomes to measure the best ɔɔ Select the best treatment.

making specific treatment recommenda- practice for training providers on SDM. ɔɔ Set a specific short-term goal.

tions—an approach that was perceived to In addition, tools have been estab- ɔɔ Seek the patient’s participation.

be preferred by most patients. The study lished to assist healthcare providers

findings suggest that, although patients with implementing the SDM model Answer: The SHARE approach encourages
want to be involved in the decision-making into their practice. The AHRQ devel- healthcare providers to begin by inviting the
process, they prefer physicians to provide oped a comprehensive tool that can help patient to participate in the decision-making
evidence-based recommendations based healthcare providers incorporate SDM process.
on their individual preferences. However, strategies into routine patient encounters.

[Link] OCTOBER 2019, VOL. 23, NO. 5 CLINICAL JOURNAL OF ONCOLOGY NURSING 541
ESSENTIALS

the SHARE approach, the SDM-N can making: Expanded reference guide with sample conversa- outcomes. Medical Decision Making, 35, 114–131. https://
be used to assess competency with SDM tion starters. Retrieved from [Link] [Link]/10.1177/0272989x14551638
during education and training. In addi- professionals/education/curriculum-tools/ Singh, J.A., Sloan, J.A., Atherton, P.J., Smith, T., Hack, T.F.,
tion, the SDM-N can be used to evaluate shareddecisionmaking/tools/tool-2/[Link] Huschka, M.M., . . . Degner, L.F. (2010). Preferred roles
the use of SDM among nurses and other Charles, C., Gafni, A., & Whelan, T. (1997). Shared in treatment decision making among patients with
healthcare providers. Based on responses decision-making in the medical encounter: What does it cancer: A pooled analysis of studies using the Control
from participants, the SDM-N scale was mean? (Or it takes at least two to tango). Social Science Preferences Scale. American Journal of Managed Care,
shown to be reliable and valid (Cronbach and Medicine, 44, 681–692. [Link] 16, 688–696.
alpha = 0.91) (Tariman et al., 2018). A s0277-9536(96)00221-3 Steffensen, K.D., Vinter, M., Crüger, D., Dankl, K., Coulter,
quality improvement project involving 60 Hughes, T.M., Merath, K., Chen, Q., Sun, S., Palmer, E., A., Stuart, B., & Berry, L.L. (2018). Lessons in integrating
practicing oncology nurses in Chicago and Idrees, J.J., . . . Pawlik, T.M. (2018). Association of shared shared decision-making into cancer care. Journal of
its surrounding areas corroborated the decision-making on patient-reported health outcomes Oncology Practice, 14, 229–235. [Link]
reliability of the instrument in measuring and healthcare utilization. American Journal of Surgery, jop.18.00019
the competence of oncology nurses with 216, 7–12. [Link] Street, R.L., Jr., Mazor, K.M., & Arora, N.K. (2016). Assessing
SDM (Warzyniec, Tariman, & Simonovich, .01.011 patient-centered communication in cancer care:
in press). Kane, H.L., Halpern, M.T., Squiers, L.B., Treiman, K.A., & Measures for surveillance of communication outcomes.
McCormack, L.A. (2014). Implementing and evaluating Journal of Oncology Practice, 12, 1198–1202. [Link]
Conclusion shared decision making in oncology practice. CA: A Can- .org/10.1200/JOP.2016.013334
Although some barriers to effective cer Journal for Clinicians, 64, 377–388. [Link] Tamirisa, N.P., Goodwin, J.S., Kandalam, A., Linder, S.K.,
SDM exist, the benefits of positive 10.3322/caac.21245 Weller, S., Turrubiate, S., . . . Riall, T.S. (2017). Patient and
patient–provider encounters are widely Légaré, F., Adekpedjou, R., Stacey, D., Turcotte, S., Kryworuc- physician views of shared decision making in cancer.
supported in the literature. Ensuring that hko, J., Graham, I.D., . . . Donner-Banzhoff, N. (2018). Health Expectations, 20, 1248–1253. [Link]
nurses understand their unique position in Interventions for increasing the use of shared decision 10.1111/hex.12564
engaging patients with SDM can encourage making by healthcare professionals. Cochrane Database Tariman, J.D., Katz, P., Bishop-Royse, J., Hartle, L., Szubski,
patients or their caregivers to have a more of Systematic Reviews, 7, CD006732. [Link] K.L., Enecio, T., . . . Masterton, K.J. (2018). Role competen-
active role in decisions about treatment 10.1002/14651858.CD006732.pub4 cy scale on shared decision-making nurses: Development
and care and lead to improved outcomes. McCarter, S.P., Tariman, J.D., Spawn, N., Mehmeti, E., and psychometric testing. SAGE Open Medicine, 6, 1–10.
Additional research can measure the Bishop-Royse, J., Garcia, I., . . . Szubski, K. (2016). Barriers [Link]
direct or indirect effects of the competen- and promoters to participation in the era of shared treat- Tariman, J.D., Mehmeti, E., Spawn, N., McCarter, S.P.,
cy and involvement of nurses during SDM ment decision-making. Western Journal of Nursing Re- Bishop-Royse, J., Garcia, I., . . . Szubski, K. (2016). On-
encounters on patient-reported outcomes search, 38, 1282–1297. [Link] cology nursing and shared decision making for cancer
following cancer treatment decisions. 6650648 treatment. Clinical Journal of Oncology Nursing, 20,
Montori, V.M., Kunneman, M., & Brito, J.P. (2017). Shared 560–563. [Link]
Beth Faiman, PhD, MSN, APRN-BC, AOCN®, is a decision making and improving health care: The answer .560-563
nurse practitioner in the Department of Hematology is not in. JAMA, 318, 617–618. [Link] Tariman, J.D., & Szubski, K.L. (2015). The evolving role of
and Medical Oncology at the Taussig Cancer Institute jama.2017.10168 the nurse during the cancer treatment decision-making
in Cleveland, OH; and Joseph D. Tariman, PhD, RN, Müller, E., Strukava, A., Scholl, I., Härter, M., Diouf, N.T., process: A literature review. Clinical Journal of Oncology
ANP-BC, FAAN, is codirector of the Doctor of Nursing Légaré, F., & Buchholz, A. (2019). Strategies to evaluate Nursing, 19, 548–556. [Link]
Practice program in the School of Nursing in the healthcare provider trainings in shared decision-making .548-556
College of Science and Health at DePaul University in (SDM): A systematic review of evaluation studies. BMJ Warzyniec, A., Tariman, JD., & Simonovich, S.D. (In press).
Chicago, IL. Faiman can be reached at faimanb@ccf Open, 9(6), e026488. [Link] Effects of a web-based shared decision-making education
.org, with copy to CJONEditor@[Link]. -2018-026488 on knowledge, attitudes, adaptability and communication
Shay, L.A., & Lafata, J.E. (2015). Where is the evidence? A skills among oncology nurses: A pilot study. Clinical
The authors take full responsibility for this content. systematic review of shared decision making and patient Journal of Oncology Nursing.
Faiman has previously consulted for and received
support from Amgen, Bristol-Myers Squibb, Celgene,
Janssen Biotech, and Takeda Oncology. DO YOU HAVE AN INTERESTING TOPIC TO SHARE?
Essentials updates readers about the foundation of clinical oncology practice. If you are interested in
REFERENCES writing for this department, contact Associate Editor Jean E. Boucher, PhD, RN, ANP-BC, AOCNP®, at
Agency for Healthcare Research and Quality. (2014). The [Link]@[Link].
SHARE approach—Essential steps of shared decision

542 CLINICAL JOURNAL OF ONCOLOGY NURSING OCTOBER 2019, VOL. 23, NO. 5 [Link]
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