Shared decision making: what do clinicians need to know and why should they bother?

Shared decision making enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances. It is not a single step to be added into a consultation, but a process that can be used to guide decisions about screening, investigations and treatments. The benefits of shared decision making include enabling evidence and patients' preferences to be incorporated into a consultation; improving patient knowledge, risk perception accuracy and patient-clinician communication; and reducing decisional conflict, feeling uninformed and inappropriate use of tests and treatments. Various approaches can be used to guide clinicians through the process. We elaborate on five simple questions that can be used: What will happen if the patient waits and watches? What are the test or treatment options? What are the benefits and harms of each option? How do the benefits and harms weigh up for the patient? Does the patient have enough information to make a choice? Although shared decision making can occur without tools, various types of decision support tools now exist to facilitate it. Misconceptions about shared decision making are hampering its implementation. We address the barriers, as perceived by clinicians. Despite numerous international initiatives to advance shared decision making, very little has occurred in Australia. Consequently, we are lagging behind many other countries and should act urgently.

Harm reduction and decision making among recreational ecstasy users

Recent research indicates that 3,4-methylene-dioxymethamphetamine (MDMA), also known as ‘ecstasy’, is becoming increasingly popular as an illicit drug among young people. This study investigated risk and harm reduction practices among recreational ecstasy users. A semi-structured interview with 40 participants was designed to investigate how ecstasy users identify and manage the harms associated with their drug use, and the underlying decision-making process. Overall, the participants identified both positive and negative effects. The reported positive effects predominantly centred around enhanced psychological, physiological and social experiences. However, there were a number of factors that contributed to regulating ecstasy use. These included specific in-group and out-group practices executed within the peer group, preventative harm-reducing practices, shared decision making, and shared responsibility for harm prevention. Recommendations for promoting harm reduction strategies and suggestions for future research are discussed.

Client leadership capacity on international projects : exploring the client's complex decision-making environment through a critical cultural political economy lens

The global construction environment offers stakeholders a range of opportunities but is characterised by a high level of risks and uncertainty. Internationalisation is a relatively new field of research in the AEC sector and past research has largely focused on explaining the behaviour of the industry itself. To date there has been little research investigating the client's leadership role. Much effort has been placed on positioning clients towards overall industry performance improvement, however, with little emphasis on the client's capacity to undertake their role. Clients establish the decision-making environment through key early critical decisions including procurement strategy and team membership. To a large extent they establish a unique culture that project team members need to work within and make decisions, which is the social and cultural embedding of the economic activities on projects. This theoretical paper is positioned within a PhD study which undertakes a cultural political economy perspective to investigate the client's central role in setting the boundaries within which decisions affecting budgets, quality, design, project organisational structure and team membership throughout the project lifecycle come to be made. A conceptual model for client leadership on international projects is developed based upon two contextual indicators which seeks to describe and explain the economic decisions clients make, which are deeply embedded in social relationships, shared meanings and cultural norms and the associated power and influence clients have on the political economy of international design and construction practice. This paper also seeks to develop a research question for future empirical testing.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study

AIMS AND OBJECTIVES: The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service.

BACKGROUND: There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice.

DESIGN: This study used a sequential exploratory design with data collected in 2014.

METHODS: A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation.

RESULTS: Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need.

CONCLUSION: Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making.

RELEVANCE TO CLINICAL PRACTICE: There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention.

Ethically defensible decision-making in health care: challenges to traditional practice

The concept of paternalism is deeply entrenched in health care. Decision-making about health care can be extremely difficult at times, and many competing interests may influence the outcomes. However, ethically defensible practice aligns itself with acknowledging the patient's prima facie right to be treated as an autonomous individual. This includes the patient's right to make informed decisions or to decide that other(s), such as the close family, should make decisions on his or her behalf. (author abstract)

Decision making in health care: limitations of the substituted judgement principle

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which decisions are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals.

Role of knowledge and ability in student nurses` clinical decision-making

Little is known about the acquisition of decision-making skills in nursing students as a function of experience and academic ability. Knowing how experience and academic skills interact may help inform clinical education programs and formulate ways of assessing students' progress. The aims of the present study were to develop a problem-solving task capable of measuring clinical decision-making skills in novice nurses at different levels of domain-specific knowledge; and to establish the relative impact on decision-making of domain-specific knowledge and general ability as determinants of the acquisition of decision-making skills. Three types of clinical problems of increasing complexity were developed. Sixty second-year and third-year student nurses with high and low academic scores were studied in terms of their ability to generate hypotheses for a hypothetical case, recognize disconfirming information and the need to access additional information, and diagnostic accuracy. The results showed that general academic ability and knowledge function partly independently in the acquisition of expertise in nursing. Academic ability affects decision-making in low complexity tasks, but as case complexity increases, domain-specific knowledge and experience determines decision-making skills. There are important differences in the way novices with different levels of knowledge and ability make clinical decisions and these can be studied by systematically increasing the complexity of the decision task. These results have implications for the way in which clinical education is structured and evaluated.

Hemodynamic team decision making in the cardiac surgical intensive care context

Purpose
The purpose of this study was to explore the extent and sources of variability of critical care nurses’ hemodynamic decision making as a function of contextual factors in the immediate 2-hour period after cardiac surgery.

Methods
A qualitative exploratory design with observation and interview was used. Eight critical care nurses were observed on different occasions in clinical practice for a 2-hour period. A brief interview immediately followed each observation to clarify observation data.

Findings
Analysis of the data revealed that patient management decisions were made both by individual nurses and by a team of nurses and health professionals. Team decision making (TDM) is described in this study as integrated or non-integrated and refers to an intra-professional nursing team. During displays of integrated TDM, the primary nurse, who was assigned to care for the patient, made most hemodynamic decisions and nurses who assisted the primary nurse deferred decisions. During displays of non-integrated TDM, nurses assisting the primary nurse assumed responsibilities for most patient-related decisions. Non-integrated TDM occurred more frequently when inexperienced cardiac surgical intensive care nurses were in the role of primary nurse, whereas integrated TDM was more common among experienced cardiac surgical intensive care nurses.

Conclusions
This observed variability can occur in multiple ways and in hemodynamic decision making has implications for patient outcomes as behaviors of non-integrated TDM led to nurses sensing a loss of control of patient management.

Naturalistic decision making: a model to overcome methodological challenges in the study of critical care nurses` decision making about patients` hemodynamic status

The quality of critical care nurses' decision making about patients' hemodynamic status in the immediate period after cardiac surgery is important for the patients' well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses' skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.

Sexual decision making in young women

Research over the last 30 years has examined the way in which young people make decisions about participating in sexual behaviours. This research is limited in that theoretical developments in the area have either not been subjected to empirical scrutiny, or are not consistent with empirical findings. The current study used a modified form of the Theory of Planned Behavior (TPB) as a theoretical position for a longitudinal exploration (over a 6-month period) of sexual decision making in a group of young adult women. One hundred and fifty-six young women aged between 18 and 21 years were involved in the study. Regression analysis were used to evaluate the predictors of intention to engage in six types of sexual behaviours at time 1, as well as experiences of these behaviours at time 2. The study found that intention to engage in sexual behaviour was reasonably well predicted using the constructs of TPB. However, behaviour was not well predicted using the variables in TPB, with the most important predictors of most sexual behaviours being past experience and perceived behavioural control, but not intention to engage in the behaviours. Implications of these findings and directions for future research are discussed.

A new interlink decision making index for making multi-criteria decisions

In this paper a mechanism that is the brain child of the authors, has been proposed to overcome the potential manipulation of results as a direct consequence of the applied weightings. It is known as the Interlink Decision Making Index

Piercing the decision-making sphere : happiness as the key to real shareholder participation

The purpose of this article is to explain why recent corporate governance reforms and initiatives proclaiming to enhance shareholder participation and elevate shareholder rights, do not go far enough. Indeed, it is suggested that corporate governance polices and reform programs, which have emerged across the world in response to a number of high-profile corporate collapses, act to re-emphasise the limited, 'passive' role which individual shareholders have traditionally experienced in public companies. Although increasing the amount information provided to shareholders about corporate decisions and strategies, and providing shareholders with a greater opportunity to participate in annual general meetings, do go some way in 'empowering' shareholders, it is argued that shareholders essentially remain passive observers, rather than becoming active participants. To become active participants, or corporate governance 'insiders " it is argued that corporate law needs to be directed at piercing the 'decision-making sphere' for individual shareholders in public companies. This involves accommodating an active role for shareholders in the actual decision-making processes of the corporation, rather than simply being informed of decisions that are made and being entitled to veto decisions at the annual general meeting. The second part of the article looks specifically at how the 'oppression' or 'unfair prejudice' remedy, the most commonly used shareholder remedy, is capable - if reformulated so that the pursuit of happiness, rather than vague notions of 'fairness' and 'justice' is the central objective of the remedy - of being used to influence a change of culture within public companies directed at facilitating an active participatory role for shareholders.