It takes two to remove rugs: using shared decision making

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Hello readers,
So sorry I have been quiet of late, I have been working hard getting to grips being a locum OT in an accident and emergency department. Every day has been challenging. There certainly have been highs, where I feel that I may just be ‘getting it’ and lows where I feel that I know nothing and that I should go and sit in the corner with the dunce hat on. And of course the highs feel absolutely amazing and the lows make me feel awful. It’s in the lows that I feel I shouldn’t be writing an OT blog as I quite clearly don’t know what I’m talking about. This, I am sure will go on for a while, the trick I think, is to stay positive and try and remember that with every day I get better at being an OT and day by day there should be more highs that lows. I’ve also been for a few job interviews and think that my time as a locum has really helped me come across better to the panel.

Anyway today’s work efforts got me thinking about shared decision making (SDM) again. I had done a lot of this on my elective placement in intermediate care. Today I had two patients where, at the start, we had differing views on what was the best course of action for them and I had to find some way of coming to a compromise (yes I am being deliberately vague for confidentiality reasons). Some people may feel that I need to be more assertive. However putting myself into the shoes of the other person, I would like to feel in control of decisions about my treatment.  Consent must be gained for our interventions and if you are thinking about rehab for a client, if you don’t really get their engagement, it won’t be a productive time for them as they won’t be as motivated to work towards their goals or take on board your recommendations.

Shared decision making is, well, the patient and health professional making a decision about treatment together. The therapist supports the patient with their decision-making using counselling and coaching methods to find out what they want. This hopefully enables the patient to make informed decisions about the treatment that they want (Advancing Quality Alliance [AQuA], 1013). According to the Mental Capacity Act, everyone has the right to make their own decisions even if others would think of them as unwise or eccentric. In my experience as an OT and OT student these decisions have been things like: to return home, not wanting carers/strangers in the house, wanting to be given the chance to try to live independently between care calls , being able to go to the toilet by themselves, wanting to have their bed upstairs or not wanting use a commode. When making shared decisions we need to explain the pros, cons and provide patients with information on risk of these their possible choices (COT, 2010; Health and Care Professions Council [HCPC], 2012b) to agree the right decision for them (if they had capacity).

Embedding SDM into the National Health Service (NHS) is central to the implementation of “no decision about me, without me” (Department of Health [DH], 2010, p. 3; NHS, 2012a) as this technique promotes patient centred care and empowers the client in making decision about their treatment (Charles, Gafni, & Whelan, 1997). Think about it: if the patient makes the decision then they are more likely to engage with our interventions. This really echoes our occupational therapy philosophy: working in partnership with the client respecting their choice and right to make decisions about their treatment (College of Occupational Therapists [COT], 2010).

An illustrated example, the OT’s enemy: the tiny rug.

OK, so OT favourite, you’re doing an environmental assessment at a patients house. There are lots of little tiny rugs dotted about the place. Rather than telling the patient that they need removing and then you going around the house picking them up. Let’s face it, deep down you know as soon as your back is turned, they are putting all the tiny, tiny rugs back. The shared decision making approach would be would be advising them that the miniature carpets can be a falls risk so they may want to consider removing them. No? You don’t? OK, how about some non-slip backing on them? All the prettiness of rugs but reducing the risk of falling-OK not as much as removing them, but perhaps it’s a good compromise. No? Ok, it’s your home and your choice but it may increase your risk of falls (making sure that in the notes, you’ve documented that you have explained the pros, cons and risks of the option). A rather simple way of looking at a treatment option but hopefully you get the point.

On elective placement, I was grateful to be inducted into the ways of SDM as it’s a lesson that I will take with me throughout my whole OT career. I found that interventions were more meaningful and I was able to forge a really positive relationship with clients. It wasn’t always easy, but at least I knew I was doing something meaningful for the client. I remember one terrifying time having to hold strong justifying my decisions to an agitated family who wanted me to say that the best thing for their family member was to go into 24 hour care whereas I knew my client wanted to be given the chance to at least try to live independently at home between care calls and I supported them to do this.

I still need to develop my SDM skills further by discussing the advantages and disadvantages of all treatment options with patients (Legare et al., 2010). To help me do this I can use SDM tools that have been developed for this purpose (AQuA, 2013; NHS, 2012b; Options Grid, n.d. I could also complete the free SDM e-module to develop my skills needed to support patient in their decision making (E-learning for Healthcare, n.d.) which outlines the skills needed to develop effective SDM consultations.

Helpful short videos

This video is a must-watch. Very moving and gets the point across brilliantly.

I would love to hear your thoughts on shared decision making and also any experiences of new grads and how you are getting on with your first OT job. Also good luck to the OT freshers starting in a couple of weeks.

References and useful links

Advancing Quality Alliance. (2013). Shared decision making: information for professionals. Retrieved 15 May, 2014, from http://www.advancingqualityalliance.nhs.uk/sdm/information-for-health-professionals-what-is-shared-decision-making/

Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science and Medicine, 44(5), 681-692. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/

College of Occupational Therapists (2010). Code of ethics and professional conduct. London: College of Occupational Therapists.

College of Occupational Therapists. (2011). Professional standards for occupational therapy practice: record keeping. Retrieved 20 May, 2014, from http://www.cot.co.uk/standards-ethics/record-keeping

Coulter, A., & Cleary, P.D. (2001). Patients’ experiences with hospital care in five countries. Health Affairs, 20 (3), 244-252. doi: 10.1377/hlthaff.20.3.244

Department of Health. (2010). Equity and excellence: liberating the NHS. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf

E-learning for Healthcare. (n.d.). Shared decision making. Retrieved 16 May, 2014, from http://www.e-lfh.org.uk/programmes/shared-decision-making/

Health and Care Professions Council. (2012b). Standards of proficiency occupational therapists. Retrieved from http://www.hpc-uk.org/assets/documents/10000512Standards_of_Proficiency_Occupational_Therapists.pdf

Légaré, F., Ratté, S., Stacey, D., Kryworuchko, J., Gravel, K., Graham, I.D., & Turcotte, S. (2010). Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews, 12(5), CD006732. doi: 10.1002/14651858.CD006732.pub2.

Makoul, G., & Clayman, M.L.(2006). An integrative model of shared decision making in medical encounters. Patient Education and Counseling, 60(3), 301-12. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/

Mental Capacity Act 2005

National Health Service. (2012a). Shared decision making. Retrieved 15 May, 2014, from http://sdm.rightcare.nhs.uk/about/about-the-nhs-shared-decision-making-programme/

National Health Service. (2012b). Shared Decision Making Sheets. Retrieved 15 May, 2014, from, http://sdm.rightcare.nhs.uk/shared-decision-making-sheets/

Option Grid. (n.d.). Retrieved 15 May, 2014, from http://www.optiongrid.org/

The Health Foundation. (2013). Implementing shared decision making. Retrieved from http://www.health.org.uk/public/cms/75/76/313/4174/Implementing shared decision making.pdf?realName=avl2hn.pdf

Weston, W.W. (2001). Informed and shared decision-making: the crux of patient centered care. Canadian Medical Association Journal,165(4), 438-9.

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