Behaviour, barriers and facilitators of shared decision making in breast cancer surgical treatment: A qualitative systematic review using a 'Best Fit' framework approach.

BACKGROUND: Due to the diversity and high sensitivity of the treatment, there were difficulties and uncertainties in the breast cancer surgical decision-making process. We aimed to describe the patient's decision-making behaviour and shared decision-making (SDM)-related barriers and facilitators in breast cancer surgical treatment. METHODS: We searched eight databases for qualitative studies and mixed-method studies about breast cancer patients' surgical decision-making process from inception to March 2021. The quality of the studies was critically appraised by two researchers independently. We used a 'best fit framework approach' to analyze and synthesize the evidence. RESULTS: Twenty-eight qualitative studies and three mixed-method studies were included in this study. Four themes and 10 subthemes were extracted: (a) struggling with various considerations, (b) actual decision-making behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM. CONCLUSIONS: Patients had various considerations of breast surgery and SDM was not routinely implemented. There was a discrepancy between information exchange behaviours, value clarification, decision support utilization and SDM due to cognitive and behavioural biases. When individuals made surgical decisions, their behaviours were affected by individual-level and system-level factors. Therefore, healthcare providers and other stakeholders should constantly improve communication skills and collaboration, and emphasize the importance of decision support, so as to embed SDM into routine practice. PATIENT AND PUBLIC CONTRIBUTION: This systematic review was conducted as part of a wider research entitled: Breast cancer patients' actual participation roles in surgical decision making: a mixed method research. The results of this project helped us to better analyze and generalize patients' views.

Patient Characteristics and the Extent to Which Clinicians Involve Patients in Decision Making: Secondary Analyses of Pooled Data.

BACKGROUND: The occurrence of shared decision making (SDM) in daily practice remains limited. Various patient characteristics have been suggested to potentially influence the extent to which clinicians involve patients in SDM. OBJECTIVE: To assess associations between patient characteristics and the extent to which clinicians involve patients in SDM. METHODS: We conducted a secondary analysis of data pooled from 10 studies comparing the care of adult patients with (intervention) or without (control) a within-encounter SDM conversation tool. We included studies with audio(-visual) recordings of clinical encounters in which decisions about starting or reconsidering treatment were discussed. MAIN MEASURES: In the original studies, the Observing Patient Involvement in Decision Making 12-items (OPTION12 item) scale was used to code the extent to which clinicians involved patients in SDM in clinical encounters. We conducted multivariable analyses with patient characteristics (age, gender, race, education, marital status, number of daily medications, general health status, health literacy) as independent variables and OPTION12 as a dependent variable. RESULTS: We included data from 1,614 patients. The between-arm difference in OPTION12 scores was 7.7 of 100 points (P < 0.001). We found no association between any patient characteristics and the OPTION12 score except for education level (p = 0.030), an association that was very small (2.8 points between the least and most educated), contributed mostly by, and only significant in, control arms (6.5 points). Subanalyses of a stroke prevention trial showed a positive association between age and OPTION12 score (P = 0.033). CONCLUSIONS: Most characteristics showed no association with the extent to which clinicians involved patients in SDM. Without an SDM conversation tool, clinicians devoted more efforts to involve patients with higher education, a difference not observed when the tool was used. HIGHLIGHTS: Most sociodemographic patient characteristics show no association with the extent to which clinicians involve patients in shared decision making.Clinicians devoted less effort to involve patients with lower education, a difference that was not observed when a shared decision-making conversation tool was used.SDM conversation tools can be useful for clinicians to better involve patients and ensure patients get involved equally regardless of educational background.

Changes in intention to use an interprofessional approach to decision-making following training: a cluster before-and-after study.

BACKGROUND: Health professionals in home care work in interprofessional teams. Yet most training in decision support assumes a one-on-one relationship with patients. We assessed the impact of an in-person training session in interprofessional shared decision-making (IP-SDM) on home care professionals' intention to adopt this approach. METHODS: We conducted a secondary analysis of a cluster stepped-wedge trial using a before-and-after study design. We collected data among home care professionals from November 2016 to February 2018 in 9 health and social services centers in Quebec, Canada. The intervention was an in-person IP-SDM training session. Intention to engage in IP-SDM pre- and post-session (dependent variable) was compared using a continuing professional development evaluation scale (CPD-Reaction) informed by the Godin's Integrated Behavioral Model for health professionals. We also assessed socio-demographic and psychosocial variables (beliefs about capabilities, beliefs about consequences, social influence and moral norm). We performed bivariate and multivariate analysis to identify factors influencing post-intervention intention. We used the STROBE reporting guidelines for observational studies to report our results. RESULTS: Of 134 respondents who provided complete pairs of questionnaires (pre- and post-), most were female (90.9%), mean age was 42 (± 9.3) years and 66.9% were social workers. Mean intention scores decreased from 5.84 (± 1.19) to 5.54 (± 1.35) (Mean difference = -0.30 ± 1.16; p = 0.02). Factors associated with higher intention post-intervention were social influence (ß = 0.34, p = 0.01) and belief about capabilities (ß = 0.49, p < 0.01). CONCLUSION: After in-person IP-SDM training, healthcare professionals' intention to engage in IP-SDM decreased. However, the scope of this decrease is probably not clinically significant. Due to their association with intention, beliefs about capabilities, which translate into having a sense of self-competency in the new clinical behavior, and social influences, which translate into what important others think one should be doing, could be targets for future research aiming to implement IP-SDM in home care settings.

How Seeking Transfer Often Fails to Help Define Medically Inappropriate Treatment.

On September 1, 2023, Texas made important revisions to it its decades-old statute granting legal safe harbor immunity to physicians who withhold or withdraw life-sustaining treatment over the objection of critically ill patients' surrogate decision-makers. However, lawmakers left untouched glaring flaws in a key safeguard for patients-the transfer option. The transfer option is ethically important because, when no hospital is willing to accept the patient in transfer, that fact is taken as strong evidence that the surrogates' treatment requests fall outside accepted medical practice. But there are serious shortcomings in how the transfer option is carried out in Texas and many other states, which undermines the ethical usefulness of the process. We identify these shortcomings and recommend revisions to state statutes and professional guidelines to overcome them.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons.

BACKGROUND: Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS: The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS: Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS: Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

Do incidental positive emotions induce more optimistic expectations of decision outcomes? An empirical study from the perspective of event-related potential.

INTRODUCTION: Previous research has found that incidental emotions of different valences (positive/negative/neutral) influence risky decision-making. However, the mechanism of their influence on psychological expectations of decision outcomes remains unclear. METHODS: We explored the effects of different incidental emotions on the behavioral, psychological, and electrophysiological responses of individuals in risky decision-making through a money gambling task using a one-way (emotion type: positive, negative, neutral emotions) between-subjects experimental design. RESULTS: Individuals with positive emotions had significantly greater risk-seeking rates than those with negative emotions during the decision selection phase (p < .01). In the feedback stage of decision outcomes, individuals showed stronger perceptions of uncertainty in the decision environment under gain and loss feedback compared with neutral feedback, as evidenced by a more positive P2 component (i.e., the second positive component of an event-related potential). Positive emotions produced greater than expected outcome bias than neutral emotions, as evidenced by a more negative FRN component (i.e., the feedback-related negativity component). CONCLUSION: Our results suggest that positive emotions increase individuals' psychological expectations of decision outcomes. This study provides new empirical insights to understand the influence of incidental emotions on risky decision outcome expectations.

The power of meaningful numbers: Attorney guidance and jury deliberation improve the reliability and gist validity of damage awards.

OBJECTIVE: A mock jury experiment tested the effects of attorney guidance and jury deliberation to mitigate the challenges that civil juries face in assessing damages. HYPOTHESES: We hypothesized that two types of attorney guidance (per diem, per diem + lump sum), theoretically based in the Hans-Reyna model of jury decision making, would improve jury decision making compared with no guidance against five key benchmarks: injury assessment, validity, reliability, verbatim-gist coherence, and metacognitive experience. We expected that deliberation would increase reliability of, confidence in, and polarization of awards compared with predeliberation. METHOD: Community members (N = 317; 61% women; 86.1% White; Mage = 48.68 years) deliberated in 54 mock juries. Participants watched a videotaped trial involving an automobile accident in which two plaintiffs sustained concussions (one mild and one severe). The plaintiffs' attorney's closing arguments varied attorney guidance (no guidance, per diem, per diem + lump sum). Mock jurors provided individual judgments before deliberating as a jury and reaching group verdicts and awards. RESULTS: Juries performed well against benchmarks. Providing gist-based guidance with a meaningful award recommendation increased the validity of jurors' individual damage awards (η²p jurors = .03) and the reliability of jury damage awards (η²p jurors = .04; η²p jurors = .20); gist-based guidance without an award recommendation did not improve performance against benchmarks and increased perceptions of decision-making difficulty (η²p = .13). Deliberation increased reliability of (η²p = .17), confidence in (η²p = .02), and polarization of (d = 2.14) awards compared with predeliberation. CONCLUSION: Juries performed well against objective benchmarks of performance (injury assessment, validity, reliability, and verbatim-gist coherence), and deliberation improved performance compared with predeliberation decisions. Jury decisions were further influenced by attorney closing arguments (the guidance manipulation), especially when the attorney requests a lump sum, which can serve as a powerful influence on jury awards, mainly by setting an upper limit. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Exploring training, involvement and confidence: a study of healthcare professionals in decision-making capacity assessments.

AIM: To explore the training, involvement and confidence of healthcare professionals involved in decision-making capacity (DMC) assessments, and to compare any differences between those conducting and those involved in, but not conducting DMC assessments. METHOD: A 10-minute anonymous, online survey was conducted with both closed and open questions. A total of 78 participants completed the survey. RESULTS: Training was lacking in quantity and adequacy. Only 14.1% received formal training during and post their qualification and only 38.5% reported the right amount of training. Just over 55% reported having the right amount of involvement, with 18% having too much and 27% having not enough involvement. A significantly higher response was given for having too much involvement by those conducting DMC assessments (p=0.006), while those not conducting felt they do not have enough involvement (p<0.001). Only 25.6% (n=20) were very confident in being able to explain DMC to a patient. CONCLUSIONS: Healthcare professionals working in this area urgently require support in the form of formal training and defined roles. Given what can be at stake for an individual undergoing a DMC assessment, it is imperative that improvements are made to upskill the workforce and utilise expertise of all healthcare professionals.

Strategies to implement evidence-informed decision making at the organizational level: a rapid systematic review.

BACKGROUND: Achievement of evidence-informed decision making (EIDM) requires the integration of evidence into all practice decisions by identifying and synthesizing evidence, then developing and executing plans to implement and evaluate changes to practice. This rapid systematic review synthesizes evidence for strategies for the implementation of EIDM across organizations, mapping facilitators and barriers to the COM-B (capability, opportunity, motivation, behaviour) model for behaviour change. The review was conducted to support leadership at organizations delivering public health services (health promotion, communicable disease prevention) to drive change toward evidence-informed public health. METHODS: A systematic search was conducted in multiple databases and by reviewing publications of key authors. Articles that describe interventions to drive EIDM within teams, departments, or organizations were eligible for inclusion. For each included article, quality was assessed, and details of the intervention, setting, outcomes, facilitators and barriers were extracted. A convergent integrated approach was undertaken to analyze both quantitative and qualitative findings. RESULTS: Thirty-seven articles are included. Studies were conducted in primary care, public health, social services, and occupational health settings. Strategies to implement EIDM included the establishment of Knowledge Broker-type roles, building the EIDM capacity of staff, and research or academic partnerships. Facilitators and barriers align with the COM-B model for behaviour change. Facilitators for capability include the development of staff knowledge and skill, establishing specialized roles, and knowledge sharing across the organization, though staff turnover and subsequent knowledge loss was a barrier to capability. For opportunity, facilitators include the development of processes or mechanisms to support new practices, forums for learning and skill development, and protected time, and barriers include competing priorities. Facilitators identified for motivation include supportive organizational culture, expectations for new practices to occur, recognition and positive reinforcement, and strong leadership support. Barriers include negative attitudes toward new practices, and lack of understanding and support from management. CONCLUSION: This review provides a comprehensive analysis of facilitators and barriers for the implementation of EIDM in organizations for public health, mapped to the COM-B model for behaviour change. The existing literature for strategies to support EIDM in public health illustrates several facilitators and barriers linked to realizing EIDM. Knowledge of these factors will help senior leadership develop and implement EIDM strategies tailored to their organization, leading to increased likelihood of implementation success. REVIEW REGISTRATION: PROSPERO CRD42022318994.

Advance directives in the emergency department-a systematic review of the status quo.

BACKGROUND: Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient's wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings. OBJECTIVE: This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates. METHODS: We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded. RESULTS: A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9-27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6-79%) as well as their availability (1.1-48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital. CONCLUSIONS: Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.

Determinants of household decision making autonomy among rural married women based on Ethiopian demography health survey: a multilevel analysis.

INTRODUCTION: Decisions made at the household level have great impact on the welfare of the individual, the local community, as well as the welfare of the nation. Women's independent decision on reproductive health increases women's access to health information and utilization of reproductive services. This has great impact on maternal and child health outcomes. However, women in developing or low-income countries often have limited autonomy and control over their household decisions. Therefore the main purpose of this research project is to investigate the potential determinants of rural women's household decision making autonomy. METHODS: A multi level analysis was performed using the fourth Ethiopian Demographic and Health Survey (EDHS) 2016 data set. A weighted sample of 8,565 married rural women was included in the final analysis. Women were considered to be autonomous if they made decisions alone or jointly with their husband in all three household decision components. It was dichotomized as yes = 1 and no = 0. Multico linearity and chi-square tests were checked and variables which did not fulfill the assumptions were excluded from the analysis. Four models were fitted. Variables with p-value ≤ 0.25 in the bi-variable multilevel logistic regression were included in the multivariable multilevel logistic regression. The Adjusted Odds Ratio (AOR) with a 95% confidence interval (95% CI) was computed. Variables with a P-value of less than 0.05 in the multi-variable multilevel logistic regression were declared as statistically significant predictors. RESULT: A total of 8,565 weighted participants involved. From the total respondents, 68.55% (CI: 67.5%, 69.5%) of women had decision making autonomy. wealth index (poor: AOR: 0.84; 95% CI: 0.72, 0.97 and middle: AOR: 0.85; 95% CI 0.73, 0.98), literacy (illiterate: AOR: 0.75; 95% CI: 0.66, 0.86), respondents working status (Not working; AOR 0.68; 95% CI; 0.60, 0.76) ,who decides on marriage (parents: AOR 0.76; 95% CI; 0.67, 0.87), and proportion of early marriage in the community (high proportion of early marriage AOR: 1.35; 95% CI; 1.10, 1.72). CONCLUSION: Women decision making autonomy was significantly determined by women economic participation (their wealth and their working status), women's literacy, proportion of early marriage in the community and women's involvement in decision of their marriage. Improving women's economic participation and enhancing women's participation to decide on their marriage will enhance women's decision making autonomy.

Metacognitive evaluation of postdecisional perceptual representations.

Perceptual confidence is thought to arise from metacognitive processes that evaluate the underlying perceptual decision evidence. We investigated whether metacognitive access to perceptual evidence is constrained by the hierarchical organization of visual cortex, where high-level representations tend to be more readily available for explicit scrutiny. We found that the ability of human observers to evaluate their confidence did depend on whether they performed a high-level or low-level task on the same stimuli, but was also affected by manipulations that occurred long after the perceptual decision. Confidence in low-level perceptual decisions degraded with more time between the decision and the response cue, especially when backward masking was present. Confidence in high-level tasks was immune to backward masking and benefitted from additional time. These results can be explained by a model assuming confidence heavily relies on postdecisional internal representations of visual stimuli that degrade over time, where high-level representations are more persistent.