scholarly journals Delivering patient choice in clinical practice: a conversation analytic study of communication practices used in neurology clinics to involve patients in decision-making

2015 ◽  
Vol 3 (7) ◽  
pp. 1-170 ◽  
Author(s):  
Markus Reuber ◽  
Merran Toerien ◽  
Rebecca Shaw ◽  
Roderick Duncan
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Research Programme ◽  
Patient Choice ◽  
Legal Rights ◽  
Future Research ◽  
Important Lesson ◽  
Data Set ◽  
Option Listing ◽  
Communication Practices

BackgroundThe NHS is committed to offering patients more choice. Yet even within the NHS, the meaning of patient choice ranges from legal ‘rights to choose’ to the ambition of establishing clinical practice as a ‘partnership’ between doctor and patient. In the absence of detailed guidance, we focused on preciselyhowto engage patients in decision-making.ObjectivesTo contribute to the evidence-base about whether or not, and how, patient choice is implemented to identify the most effective communication practices for facilitating patient choice.DesignWe used conversation analysis to examine practices whereby neurologists offer choice. The main data set consists of audio- and video-recorded consultations. Patients completed pre- and post-consultation questionnaires and neurologists completed the latter.Setting and participantsThe study was conducted in neurology outpatient clinics in Glasgow and Sheffield. Fourteen neurologists, 223 patients and 120 accompanying others took part.ResultsPatients and clinicians agreed that choice had featured in 53.6% of consultations and that choice was absent in 14.3%. After 32.1% of consultations,eitherpatientorneurologist thought choice was offered. The presence or absence of choice was not satisfactorily explained by quantitatively explored clinical or demographic variables. For our qualitative analysis, the corpus was divided into four subsets: (1) patient and clinician agree that choice was present; (2) patient and clinician agree that choice was absent; (3) patient ‘yes’, clinician ‘no’; and (4) patient ‘no’, clinician ‘yes’. Comparison of all subsets showed that ‘option-listing’ was the only practice for offering choice that was presentonly(with one exception, which, as we show, proves the rule) in those consultations for which participantsagreed there was a choice. We show how option-listing can be used to engage patients in decision-making, but also how very small changes in the machinery of option-listing [for instance the replacement or displacement of the final component of this practice, the patient view elicitor (PVE)] can significantly alter the slot for patient participation. In fact, a slightly modified form of option-listing can be used to curtail choice. Finally, we describe two forms of PVE that can be used to hand a single-option decision to the patient, but which, we show, can raise difficulties for patient choice.ConclusionsChoice features in the majority of recorded consultations. If doctors want to ensure a patient knows she or he has a choice, option-listing is likely to be best understood by patients as an invitation to choose. However, an important lesson from this study is that simply asking doctors to adopt a practice (like option-listing) will not automatically lead to a patient-centred approach. Our study shows that preciselyhowa practice is implemented is crucial.Future researchFuture research should investigate (1) links between the practices identified here and relevant outcome measures (like adherence); (2) whether being given a choice is better or worse for patients than receiving a doctor’s recommendation, taking account of clinical and demographic factors; and (3) how our approach could be fruitfully applied in other settings.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

scholarly journals Evaluating nuanced practices for initiating decision-making in neurology clinics: a mixed-methods study

2018 ◽  
Vol 6 (34) ◽  
pp. 1-148 ◽  
Author(s):  
Markus Reuber ◽  
Paul Chappell ◽  
Clare Jackson ◽  
Merran Toerien
Keyword(s):  
Decision Making ◽  
Patient Satisfaction ◽  
Mixed Methods ◽  
Patient Choice ◽  
Self Report ◽  
Primary Study ◽  
Significant Difference ◽  
Report Data ◽  
Option Listing ◽  
Self Report Data

BackgroundWe report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another.ObjectivesTo (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making.DesignA mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision.Setting and participantsThe primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated.ResultsDistribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed.LimitationsA main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation.ConclusionsPatient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making.Future researchTo advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence).FundingThe National Institute for Health Research Health Services and Delivery Research programme.

scholarly journals Decision Making in Paediatric Care: an overview with reference to nursing care

2005 ◽  
Vol 12 (3) ◽  
pp. 223-238 ◽  
Author(s):  
Inger Hallström ◽  
Gunnel Elander
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Literature Review ◽  
Nursing Care ◽  
Best Interests ◽  
Future Research ◽  
Snowball Sampling ◽  
Paediatric Care

The purpose of this overview of published articles on decision making in paediatric care was to identify important aspects of its possible use in clinical practice and to obtain a base for future research. A literature review was undertaken utilizing snowball sampling to identify articles because of the diversity present within the area of decision making in paediatric care. The databases PubMed and CINAHL were used. The search was limited to articles published in English during the period 1994-2004. The analysis entailed a series of comparisons across articles, focusing on major areas of enquiry and patterns of results. Various levels of decision making are described because these seem to form a basis for how decisions are made. Concepts found to be of importance for decision making are described under the following headings: competence, the child’s best interests, knowledge, values and attitudes, roles and partnership, power, and economy. Further research is suggested.

Openness in university-industry collaboration: probing managerial perceptions

2015 ◽  
Vol 18 (4) ◽  
pp. 493-507 ◽  
Author(s):  
Heikki Moilanen ◽  
Mirje Halla ◽  
Pauli Alin
Keyword(s):  
Decision Making ◽  
Future Research ◽  
Structured Interviews ◽  
Managerial Decision ◽  
Data Set ◽  
Managerial Decision Making ◽  
Content Type ◽  
Intermediary Organizations ◽  
Managerial Perceptions ◽  
University Industry

Purpose – The purpose of this paper is to increase the understanding of decision making of managers of intermediary organizations in university-industry (UI) collaboration by probing managerial perceptions of openness in that context. Design/methodology/approach – The authors conducted 11 semi-structured interviews of managers of intermediary organizations in the context of UI collaboration. Using Grounded Theory, the authors analyzed how the managers talked about openness. Findings – The authors found that the managers perceived openness in four distinct ways: first, openness as driven by management of the relationship, second, openness as driven by bringing people together, third, openness as a driver of co-creation and fourth, openness as a driver of beneficial results. From these findings the authors induce a framework for perception of openness. Research limitations/implications – The findings are based on a relatively limited data set, which is a limitation of the study. Future research should study whether differences in perception of openness exist among different contexts or partners of UI collaboration. Practical implications – The findings can potentially provide useful guidance to managers in UI collaboration as to how better understand the important concept of openness in that context. Originality/value – This study addresses the lack of research on managerial perceptions on openness in the context in UI collaboration. Probing managerial perceptions of openness provides us with better understanding of managerial decision making in UI collaboration. The study contributes to scientific discussions on managerial perceptions of openness and to discussions on managerial decision making in UI collaboration.

scholarly journals Discriminating evidence accumulation from urgency signals in speeded decision making

2015 ◽  
Vol 114 (1) ◽  
pp. 40-47 ◽  
Author(s):  
Guy E. Hawkins ◽  
Eric-Jan Wagenmakers ◽  
Roger Ratcliff ◽  
Scott D. Brown
Keyword(s):  
Decision Making ◽  
Empirical Support ◽  
Real Data ◽  
Positive Outcome ◽  
Future Research ◽  
Recent Theory ◽  
Data Set ◽  
Evidence Accumulation ◽  
Gating Model ◽  
Noisy Information

The dominant theoretical paradigm in explaining decision making throughout both neuroscience and cognitive science is known as “evidence accumulation”—the core idea being that decisions are reached by a gradual accumulation of noisy information. Although this notion has been supported by hundreds of experiments over decades of study, a recent theory proposes that the fundamental assumption of evidence accumulation requires revision. The “urgency gating” model assumes decisions are made without accumulating evidence, using only moment-by-moment information. Under this assumption, the successful history of evidence accumulation models is explained by asserting that the two models are mathematically identical in standard experimental procedures. We demonstrate that this proof of equivalence is incorrect, and that the models are not identical, even when both models are augmented with realistic extra assumptions. We also demonstrate that the two models can be perfectly distinguished in realistic simulated experimental designs, and in two real data sets; the evidence accumulation model provided the best account for one data set, and the urgency gating model for the other. A positive outcome is that the opposing modeling approaches can be fruitfully investigated without wholesale change to the standard experimental paradigms. We conclude that future research must establish whether the urgency gating model enjoys the same empirical support in the standard experimental paradigms that evidence accumulation models have gathered over decades of study.

scholarly journals Patients' priorities for treatment decision making during periods of incapacity: quantitative survey

2014 ◽  
Vol 13 (5) ◽  
pp. 1165-1183 ◽  
Author(s):  
Annette Rid ◽  
Robert Wesley ◽  
Mark Pavlick ◽  
Sharon Maynard ◽  
Katalin Roth ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Financial Burden ◽  
Care Center ◽  
Tertiary Care ◽  
Treatment Decision ◽  
Treatment Decisions ◽  
Future Research ◽  
Quantitative Survey ◽  
Treatment Decision Making

AbstractObjective:Clinical practice aims to respect patient autonomy by basing treatment decisions for incapacitated patients on their own preferences. Yet many patients do not complete an advance directive, and those who do frequently just designate a family member to make decisions for them. This finding raises the concern that clinical practice may be based on a mistaken understanding of patient priorities. The present study aimed to collect systematic data on how patients prioritize the goals of treatment decision making.Method:We employed a self-administered, quantitative survey of patients in a tertiary care center.Results:Some 80% or more of the 1169 respondents (response rate = 59.8%) ranked six of eight listed goals for treatment decision making as important. When asked which goal was most important, 38.8% identified obtaining desired or avoiding unwanted treatments, 20.0% identified minimizing stress or financial burden on their family, and 14.6% identified having their family help to make treatment decisions. No single goal was designated as most important by 25.0% of participants.Significance of Results:Patients endorsed three primary goals with respect to decision making during periods of incapacity: being treated consistent with their own preferences; minimizing the burden on their family; and involving their family in the decision-making process. However, no single goal was prioritized by a clear majority of patients. These findings suggest that advance care planning should not be limited to documenting patients' treatment preferences. Clinicians should also discuss and document patients' priorities for how decisions are to be made. Moreover, future research should evaluate ways to modify current practice to promote all three of patients primary goals for treatment decision making.

scholarly journals Bargaining Power or Specialization? Determinants of Household Decision Making in Chinese Rural Migrant Families

SAGE Open ◽  
2020 ◽  
Vol 10 (4) ◽  
pp. 215824402098044
Author(s):  
Zicheng Wang ◽  
Yun Lou ◽  
Yi Zhou
Keyword(s):  
Decision Making ◽  
Bargaining Power ◽  
Decision Makers ◽  
Legal Rights ◽  
Structural Factors ◽  
Data Set ◽  
Household Decision ◽  
Household Decision Making ◽  
Female Migrants ◽  
Migrant Families

Family migration is a common integration process for rural migrants in contemporary China. However, discussions on intra-household decision making in dual-earner migrant families are limited. This study aims to address this gap. The data set from the Rural Urban Migration in China (RUMiC2008–2010) is employed to explore the determinants of household decision making. In addition, logit regression is performed to estimate the probability of wives acting as head of the household under different specifications, and the Blinder–Oaxaca–Fairlie decomposition is utilized to discuss gender differentials in decision-making responsibilities. Income and migration duration differentials between a wife and husband have important influences on the probability of being responsible for household decision making. The squared terms of wives’ and husbands’ income have inverted effects. The gender gap between household decision makers can be largely attributed to structural factors rather than observable characteristics, though bargaining power acts as the main contributor in explained parts. Bargaining theory can account for the probability of wives becoming the household decision maker, and the claim of the specialization approach is also confirmed. Gender inequality among household decision makers is largely attributed to structural factors, such as cultural/social norms, obstacles, or gender discrimination. The establishment of long-term effective mechanisms to improve employment quality for female migrants, the supply of basic public services, and protection of women’s legal rights in the household should be strengthened in the future to elevate the status of female migrants.

Cognitive biases and decision-making strategies in times of change: a systematic literature review

2020 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Chiara Acciarini ◽  
Federica Brunetta ◽  
Paolo Boccardelli
Keyword(s):  
Decision Making ◽  
Literature Review ◽  
Systematic Literature Review ◽  
Cognitive Biases ◽  
Future Research ◽  
Strategic Decisions ◽  
Data Set ◽  
Content Type ◽  
The Impact

PurposeIn a work environment marked by unprecedented complexity, volatility and ambiguity, managers must accomplish their objectives while navigating many challenges. This paper aims to investigate potential interrelations among environmental transformations, cognitive biases and strategic decisions. In particular, the purpose of the study is to crystallize the state of art on the impact of cognitive biases on strategic decisions, in the context of environmental transformations.Design/methodology/approachThe authors have conducted a systematic literature review to identify existing relevant work on this topic and to detect potential avenues for future research.FindingsThe findings highlight how decision-making is influenced and enabled by internal (e.g. perception) and external factors (e.g. digitalization). Specifically, the strategic role of cognitive biases appears to be crucial when investigating the related impact on strategic decisions in times of environmental transformation.Practical implicationsImplications are drawn for scholars and practitioners interested in evaluating the role of specific decision-making determinants for the formation and implementation of strategic decisions. In this sense, we stress that decision-makers need to manage their cognitive biases and select the right information out of a wide data set in order to adapt to environmental transformations.Originality/valueBy systematizing the literature review, potential interrelations among environmental transformations, cognitive biases and strategic decisions are identified. Furthermore, the primary phases that drive the decision-making process are proposed (analysis, decision, onboarding and control).

scholarly journals "Part of the Ritual": a Qualitative Study of Patient and Physician Perspectives on the Use of Anticoagulation for Improving Pregnancy Outcomes in Obstetrical Antiphospholipid Syndrome

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5804-5804
Author(s):  
Leslie Skeith ◽  
Marc A. Rodger ◽  
Shannon M. Bates ◽  
Carol Gonsalves ◽  
Taryn S. Taylor
Keyword(s):  
Decision Making ◽  
Antiphospholipid Syndrome ◽  
Research Funding ◽  
Pregnancy Loss ◽  
Patient Choice ◽  
Future Research ◽  
Clinical Equipoise ◽  
Final Decision ◽  
Maternal Risk ◽  
Taking Action

Abstract INTRODUCTION: Antiphospholipid syndrome is an acquired thrombophilia associated with recurrent pregnancy loss. Treatment with low-molecular-weight heparin (LMWH) and/or aspirin (ASA) during pregnancy to prevent future loss is based on limited trial data with mixed results. Given the clinical equipoise, we sought to understand how patients and physicians navigate the decision-making process for use of antepartum LMWH and/or ASA. This research is needed to inform the feasibility of future research that seeks to resolve the question of treatment efficacy in this patient population. METHODS: Following constructivist grounded theory (CGT) methodology, we interviewed 10 patients and 10 thrombosis physicians in Ottawa, Canada from January 2017 to March 2018. Patients were drawn from women included in the TIPPS (Thrombophilia in Pregnancy Prophylaxis Study) screening logs and from consecutive women attending a specialty Thrombosis Clinic who met the revised Sapporo/Sydney laboratory criteria and had at least 1 prior late loss or 2 early losses (<10 weeks gestation). Data collection and analysis occurred iteratively, in keeping with CGT methodology. RESULTS: Our analysis generated three predominant themes, present across both patient and physician interviews, which captured a patient-led decision-making experience: (1) Accepting Uncertainty, (2) Focusing on Safety and (3) Managing High Stakes. Many patients accepted the uncertainty of their situation; they felt hopeful but were also reluctant to expect a better pregnancy outcome. This was echoed in the physician interviews, which emphasized the uncertainty of LMWH/ASA in improving outcomes when counselling patients on their options. Both groups focused on the low-risk nature and safety of these medications. Patients focused on safety to the fetus, with little concern for maternal risk. Finally, patients and physicians acknowledged the high emotional burden and what was at stake: avoiding further pregnancy loss. Patients responded to their situation by taking action (i.e. using LMWH injections became a "ritual") whereas physicians reacted by removing themselves from the final decision and "[leaving] it up to the patient". CONCLUSION: In this setting of clinical equipoise and in the absence of serious safety concerns, decision-making around antepartum LMWH/ASA was largely directed by informed patient choice. These findings should be considered when designing future research on the role for LMWH/ASA in this population, as it suggests that the perceived benefits of treatment go beyond improving pregnancy rates. Rather, patients seem to derive psychological benefit from the process of taking action, even in the absence of a guaranteed good outcome. Disclosures Skeith: Leo Pharma: Honoraria; CSL Behring: Research Funding. Rodger:Biomerieux: Research Funding.

Women And Depression: Future Research, Clinical Practice, And Public Policy

2002 ◽  
Author(s):  
Carolyn M. Mazure ◽  
Laura J. Bierut ◽  
Steven D. Hollon ◽  
Susan G. Kornstein ◽  
Charlotte Brown
Keyword(s):  
Public Policy ◽  
Clinical Practice ◽  
Future Research
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