Possibilities and power during early Head Start Home visits: Comparing family- and home visitor-opened decision-making.

Decision-making by families and professionals about how to support children's development is an integral aspect of home visits. This study investigated home visit decision-making in a US program for families experiencing poverty, Early Head Start (EHS), through the following questions: What types of decisions do home visitors and families make about children's development during EHS home visits? How and to what extent do home visitors and families participate during these decisions? A convergent mixed methods research design was implemented to investigate participation through frequency counts and discourse analysis of home visit transcripts. Home visitor participants were four women, three white and one Black. Twelve families participated (12 mothers, 2 fathers). Parents identified as white (n = 8), Black (n = 3), and multiracial (n = 3; Black and white). One parent was a bilingual Arabic and English speaker. A total of 66 decisions about children's development were identified, with 49 decisions initiated by home visitors and 17 initiated by families. Although families talked more and took on active roles when they initiated (i.e., opened) decisions, home visitors predominantly controlled decision-making. Quantitative and qualitative participation differed only in the beginning of family-opened decisions, and home visitors gradually took more control.

La toma de decisiones por parte de familias y profesionales acerca de cómo apoyar el desarrollo de los niños es un aspecto integral de las visitas a casa. Este estudio investigó la decisión de hacer visitas a casa en el programa de Estados Unidos para familias que viven en pobreza, "De un comienzo temprano" (Early Head Start), a través de las siguientes preguntas: ¿Qué tipo de decisiones toman las visitadoras a casa y las familias acerca del desarrollo de los niños durante las visitas a casa del programa "De un comienzo temprano?" ¿Cómo y hasta qué punto las visitadoras a casa y las familias participan durante la toma de estas decisiones? Se implementó un diseño convergente mixto de métodos de investigación para investigar la participación por medio de conteos frecuentes y análisis de las transcritas conversaciones de la visita a casa. Las visitadoras a casa que participaron fueron cuatro mujeres, tres blancas y una de raza negra. Doce familias participaron (12 mamás, 2 papás). Los progenitores se identificaron como blancos (n = 8), negros (n = 3) y multirraciales (n = 3, negros y blancos). Uno de los progenitores era hablante bilingüe de árabe e inglés. Se identificó un total de 66 decisiones acerca del desarrollo de los niños, de las cuales 49 fueron iniciadas por las visitadoras a casa y 17 por las familias. Aunque las familias hablaron más y asumieron un papel activo cuando hablaban primero sobre las decisiones (v.g., cuando abrían la conversación), las visitadoras a casa predominantemente controlaron la toma de decisiones. La participación cuantitativa y cualitativa difirió sólo al principio de las decisiones iniciadas por las familias y las visitadoras a casa gradualmente asumieron mayor control.

Übersichtsarbeiten / Review Articles. Voreingenommenheiten und Wahrnehmungsverzerrungen (Bias) in der psychiatrisch-psychotherapeutischen Versorgung von Kindern und Jugendlichen mit intellektueller Beeinträchtigung.

Bias in Mental Health Care of Children and Adolescents with Intellectual Disabilities Implicit and explicit bias and distortions of perception are partly responsible for the unequal and significantly deficient psychotherapeutic and psychiatric care situation for children and adolescents with intellectual disabilities and additional behavioral problems. The extent to which these biases influence misdiagnoses and treatment errors, refusals and exclusions from professional care, and grossly hostile rejections of people with disabilities requires empirical evidence (Bartig et al., 2021). The fact that all forms occur - probably to a considerable extent - contradicts the ethical principles of the medical and psychotherapeutic profession. In order to avoid misdiagnosis and treatment as a result of bias, this must be openly addressed. Selfawareness, supervision and second views, the concept of working diagnosis and, above all, the full application of child and adolescent psychiatric standards help to reduce bias.

[Critical care nurses' decision-making regarding verification of blindly inserted gastric tubes: A cross-sectional questionnaire study]. / Entscheidungsfindung von Intensivpflegefachpersonen zur Verifikation blind applizierter Magensonden.

Critical care nurses' decision-making regarding verification of blindly inserted gastric tubes: A cross-sectional questionnaire study Abstract: Background: The placement and verification of the correct position of blindly applied gastric tubes is regularly performed by nurses in clinical practice. International guidelines recommend a radiological verification as a "first-line" method or if pH measurement is not possible. For Germany, neither evidence-based recommendations nor current data are available. Question: Which methods are used by nurses in German intensive care units for verification of the correct position of blindly applied gastric tubes and how do they assess the reliability of different methods? Methods: Multicenter questionnaire survey. Intensive care units in a non-probability, citeria-based sampling of hospitals in and around Cologne, Germany were included. One nurse was included per participating ward. Analyses were mostly descriptive. Results: In 22 hospitals, 38 wards agreed to participate and 32 (84%) responded to the survey. Auscultation of the upper abdomen with simultaneous air insufflation and aspiration of gastric secretions are frequently used methods for determining the position of gastric tubes. Participants consider auscultation, aspiration of gastric secretions, and radiological control as reliable methods. Conclusions: The findings are in contrast to international recommendations and support the need for evidence-based best practice recommendations and training. Likewise, there is a need for research on feasible bedside methods.

[Justification of nurses' interventions for skin cleansing and skincare: Qualitative results of the SKINCARE-Pilot study]. / Begründung pflegerischer Maßnahmen zur Hautreinigung und Hautpflege.

Justification of nurses' interventions for skin cleansing and skincare: Qualitative results of the SKINCARE-Pilot study Abstract. Background: Skin care interventions are core tasks of nursing. Various factors influence the implementation of evidence-based care. Aims: To explore the perspectives of nursing staff on the relevance of skin care interventions in long-term care settings and the justification of clinical decisions about the application of such interventions. Methods: Qualitative part of a mixed methods study in three long-term-care facilities, consisting of short interviews with nursing staff members directly after nursing assistance with personal hygiene, focus group discussions with nursing staff members, and semi-structured interviews with nursing managers. The data were analyzed by means of content analysis. Results: The sample (N = 30) comprises 10 short interviews, 3 focus groups (n = 17), and 3 individual interviews. Nurses predominantly assigned a high relevance to nursing support in personal hygiene. As a basis for their decision-making, residents' needs and preferences, nurses' personal knowledge as well as own experiences and preferences were reported. Evidence-based sources of knowledge were hardly mentioned. The availability of skin cleansing and skin care products, staff and time resources, and nurse-physician cooperation were identified as influencing factors. Conclusions: Decisions about nursing support in personal hygiene seem poorly informed by evidence-based sources for clinical decision-making. Evidence-based decision support could facilitate the use of appropriate nursing interventions.

[The desire and the experience of participation among children and adolescents in inpatient mental healthcare]. / Wunsch und Erleben von Partizipation für Kinder und Jugendliche in der stationären Psychiatrie.

The desire and the experience of participation among children and adolescents in inpatient mental healthcare Abstract. Objective: Children have the right to participate in decisions that affect them. However, the stages and domains of participation relevant within inpatient child and adolescent psychiatry have rarely been empirically investigated. The present study closes this research gap. Method: A prospective, multicenter, questionnaire-based survey was conducted. The questionnaire comprised 100 items, summarized in 16 scales, to assess the desire and the experience of participation. The data were quantitively evaluated. Results: 81 children and adolescents from 5 psychiatric hospitals took part in the study. Overall, they wished more participation than experienced. The higher the level of participation, the greater the difference was between wish and reality. The desire for participation is particularly high for decisions regarding communication with family and friends. The largest difference between desire and experience related to respectful and trusting interaction with patients, and for female patients, this difference was even higher. Conclusion: Participation means more than informed consent. There is still potential for expanding participation in child and adolescent psychiatry, especially at higher levels of participation and concerning decisions about communication with family and friends. A respectful and trusting interaction with patients, regardless of age, sex, or illness, is fundamental.

Effectiveness of an attachment-based intervention for the assessment of parenting capacities in maltreating families: A randomized controlled trial.

Even though Parenting Capacity Assessments (PCAs) are essential for child protection services to support placement decisions for maltreating families, presently no evidence-based PCA protocols are available. In this randomized controlled trial, we tested the quality of an attachment-based PCA protocol based on Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD). We recruited 56 parent-child dyads (Mage children = 3.48 years) in Dutch family residential clinics that conduct PCAs to support placement decisions. After pretest, families were randomized to receive the Regular Assessment Procedure (RAP) (n = 28), or an additional assessment based on VIPP-SD (n = 28). An immediate post-test and a 10-month follow-up were conducted. Multilevel models showed that therapists felt equally confident about their recommendations regarding child placement for both groups and that they equally often modified their initial placement recommendations. Moreover, children in the VIPP-SD group did not show fewer behavior problems and did not experience recurring child maltreatment less often than children in the RAP group. Thus, we found no evidence that PCAs incorporating the VIPP-SD protocol outperformed PCAs as usual. We discuss possible explanations why in the current study VIPP-SD did not seem to add to the quality of the RAP.

A pesar de que las Evaluaciones de Capacidad de Crianza (PCA) son esenciales para los servicios de protección al niño para apoyar las decisiones de dónde colocarlo por razones de familias maltratadoras, en el presente no se encuentran disponibles ningún protocolo PCA basado en la evidencia. En este ensayo controlado al azar, pusimos a prueba la calidad de un protocolo PCA basado en la afectividad para lo cual nos basamos en la Intervención de Video Informativo para promover una Crianza Positiva y Disciplina Sensible (VIPP-SD). Reclutamos 56 díadas de progenitor-niño (edad promedio de los niños = 3.48 años) en clínicas residenciales de familias holandesas que utilizan las PCA para apoyar las decisiones de dónde colocar. Después del pre-examen, las familias fueron asignadas al azar para recibir el Procedimiento de Evaluación Regular (RAP) (n = 28), o una evaluación adicional basada en VIPP-SD (n = 28). Se llevaron a cabo un examen posterior inmediato y un seguimiento a los 10 meses. Los modelos de niveles múltiples mostraron que los terapeutas se sintieron igualmente confiados acerca de sus recomendaciones con respecto a dónde colocar al niño en ambos grupos y que ellos igualmente modificaron a menudo su recomendación inicial de dónde colocarlo. Es más, los niños en el grupo VIPP-SD no mostraron menos problemas de conducta y no experimentaron maltrato infantil recurrente menos a menudo que los niños en el grupo RAP. Por tanto, no encontramos evidencia de que las PCA que incorporan el protocolo VIPP-SD tuvieran mejores resultados que las PCA en su forma usual. Discutimos posibles explicaciones de por qué en el presente estudio los VIPP-SD no parecieron agregar nada a la calidad de RAP.

Contexte: Des interventions favorables et ciblées pour les familles sont nécessaires afin d'optimiser l'ajustement parental et la relation parent-bébé conformément à un diagnostic précédant de risque neurodéveloppemental pour les bébés. Buts: Le but de cette revue systématique était de déterminer l'efficacité des interventions pour l'amélioration de l'ajustement psychologique et le bien-être pour les parents ayant un bébé ayant été diagnostiqué comme ayant ou étant à risque d'avoir un trouble neurodéveloppemental. Méthodes: La stratégie de recherche du Cochrane Review Group a été suivie avec une recherche des essais contrôlés du Registre Cochrane Central, de PubMed, CINAHL, PsycINFO, et Embase entre juillet et décembre 2017. La qualité méthodologique des articles inclus a été évaluée au moyen de l'échelle de la base de données de preuve de physiothérapie (PEDro Physiotherapy Evidence Database) par deux évaluateurs indépendants. Résultats: Douze études ont rempli les critères d'inclusion. Un petit nombre d'essais de grande qualité ont révélé une efficacité modérée à importante de la réduction chez les parents de symptômes psychologiques indésirables de trauma et de stress des parents. Des améliorations importantes dans les symptômes de dépression et d'anxiété ont émergé lors de follow up post intervention à plus long terme (6 mois-8 ans). Conclusions: On constate un soutien prometteur pour l'efficacité de certaines interventions à réduire les symptômes psychologiques de mésadaptation chez les parents avec des bébés diagnostiqués comme étant à risque d'un trouble neurodéveloppemental. D'autres ECR de qualité d'intervention psychologiques portant sur les conditions plus grandes de risque neurodéveloppemental sont nécessaires.

Wann und wie berücksichtigen Intensivpflegende Schmerz im Behandlungsprozess von Patientinnen und Patienten auf der Intensivstation? - Eine qualitative Studie.

When and how do intensive care nurses consider pain in the treatment process of ICU patients? A qualitative study Abstract. Background: Pain management is important in the therapeutic spectrum of the intensive care unit. However, guideline recommendations are not consistently implemented. Strategies in clinical reasoning and decision-making regarding pain are hardly described. AIM: Guided by the question "When and how do intensive care nurses consider pain in the treatment process of patients with impaired consciousness and cognition?", we wanted to explore their patterns of thought and decision-making in the context of pain management. METHODS: As part of a Mixed Methods research program on pain assessment in nonverbal intensive care patients we performed a secondary analysis of data from the qualitative substudy using qualitative content analysis according to Mayring. RESULTS: Pain plays an important but subordinate role in the treatment process. After vital functions have been initially stabilized, intensive care nurses assess patients' consciousness and cognition in order to receive further information directly from them. Intensive care nurses differentiate between pain, anxiety, stress and discomfort. Their decisions are based on experience and intuition. CONCLUSIONS: Education promotes intensive care nurses' knowledge and awareness in pain management. Observational pain assessment instruments provide valid information. They support an analytical approach and thus the development of competence in clinical reasoning and decision-making.

[Information and support needs of women planning an abortion according to counselling regulations in Germany - A qualitative study]. / Informations- und Unterstützungsbedarfe von Frauen bei geplantem Schwangerschaftsabbruch nach Beratungsregelung in Deutschland ­ eine qualitative Studie.

BACKGROUND: For women seeking legal abortion care, access to information and care options is not transparent in Germany. This can affect health and complicate the decision-making process. In its guideline, the WHO recommends the use of evidence-based information to enable women to make informed decisions. This qualitative study aims to assess preferences and decisional needs of women in Germany. METHOD: For the needs assessment, a qualitative study based on semi-structured guided interviews was conducted with pregnancy conflict counsellors and women who terminated a pregnancy in the past five years in Germany. These data were supplemented with social media group postings of women with pregnancy conflict experiences. All data were analysed using content-structuring analysis according to Kuckartz. RESULTS: Three women who had undergone an abortion and two pregnancy conflict counsellors were interviewed. In addition, 89 posts from a closed social media group were analysed. Three main categories were identified: women's categorisation in value systems, factors influencing the experience of the care process and information needs of women facing conflict situations in connection with their pregnancy ("pregnancy conflict"). Abortion is considered to be stigmatised, so women rarely use existing counselling services. Overall, there is a high need for information and support among those seeking care. Concerns exist, especially with regard to the methods of abortion. The results of the study also indicate a burden caused by fragmented care, which requires a high degree of self-organisation of women. DISCUSSION: The care situation in Germany does not meet the recommendations of the WHO guideline on safe abortion. The results indicate that care close to home and with an abortion procedure that meets women's individual preferences and thus complies with their self-determination has not yet been achieved in Germany. CONCLUSION: Neutral and evidence-based information could be helpful to enable women to make informed decisions and reduce anxiety. It would also be desirable to increase the opportunities for women to talk about their experiences in a protected environment.

Involving Voters and Consumers in Decision-Making about the Health Care System - The Swiss Case: A Review.

BACKGROUND: Behind the principle of involving users and voters directly in decision-making about the health care system are ideas relating to empowerment. This implies a challenge to the traditional view that scientific knowledge is generally believed to be of higher value than empirical knowledge, as it is the case with CAM. The objectives of this review are (a) to show that this assumption disregards the fact that CAM is as scientific as conventional medicine but has different basic assumptions what the world is being made of and consequently uses different/adapted scientific methods; (b) to demonstrate how a perspective of the history of medicine and science as well as direct democracy mechanisms such as stipulated in the Swiss constitution can be used to achieve the acceptance of CAM in a modern medical health care system. A public health care system financed by levies from the population should also reflect the widely documented desire in the population for medical pluralism (provided that therapeutical alternatives are not risky). Otherwise, the problem of social inequality arises because only people with a good financial background can afford this medicine. SUMMARY: From the perspective of scientific theory and the history of science, the answer to the question of whether complementary medicine and conventional medical procedures must provide proof of efficacy according to a uniform scientific is quite controversial according to epistemologically oriented studies on this issue. KEY MESSAGES: This review found strong evidence for involving voters and consumers directly in decision-making about the provision of CAM in the health care system. It also seems necessary to step back in the debate on evidence-based medicine, taking a history of medicine and science perspective, as the role which the proper method occupies and plays in medicine is defined by the scientific nature of the world view.Hinter dem Grundsatz, Nutzer und Wähler direkt in die Entscheidungsfindung über das Gesundheitssystem einzubeziehen, stehen Vorstellungen von Empowerment. Dies impliziert eine Infragestellung der traditionellen Ansicht, dass wissenschaftliches Wissen im Allgemeinen als wertvoller angesehen wird als empirisches Wissen und erprobte Erfahrung, wie es bei der Komplementärmedizin der Fall ist. Die Ziele dieser Übersichtsarbeit sind: (a) zu zeigen, dass diese Annahme die Tatsache außer Acht lässt, dass die Komplementärmedizin ebenso wissenschaftlich ist wie die Schulmedizin, aber von anderen Grundannahmen ausgeht, wie die Welt beschaffen ist, und folglich andere/angepasste wissenschaftliche Methoden anwendet; (b) aufzuzeigen, wie eine medizin- und wissenschaftsgeschichtliche Perspektive sowie Mechanismen der direkten Demokratie, wie sie in der Schweizer Verfassung vorgesehen sind, genutzt werden können, um die Akzeptanz der Komplementärmedizin in einem modernen medizinischen Gesundheitssystem zu erreichen. Ein öffentliches, durch Abgaben der Bevölkerung finanziertes Gesundheitssystem sollte auch dem vielfach dokumentierten Wunsch der Bevölkerung nach medizinischem Pluralismus Rechnung tragen (sofern die therapeutischen Alternativen nicht riskant sind). Andernfalls stellt sich das Problem der sozialen Ungleichheit, weil sich nur Menschen mit einem guten finanziellen Hintergrund diese Medizin leisten können.

MMpowerment: Empowering patients with multiple myeloma for shared decision-making by developing an intervention to integrate personal preferences into digital care pathways.

OBJECTIVE: As part of a quality improvement initiative in the context of value-based health care we aimed to optimize the shared decision-making (SDM) process in the care pathway for Multiple Myeloma as part of a digital care pathway (DCP). For this, more insight was needed in health care professionals' (HCPs') perspectives on SDM, and how SDM elements could be addressed in a DCP for MM to facilitate HCPs' performance of SDM. METHODS: HCPs were interviewed as per the theory of planned behaviour and the model of organizational context and SDM (phase 1). Multidisciplinary development sessions were organized to discuss concepts of the solution with HCPs (phase 2). The solution was evaluated with two patients from the quality improvement team. RESULTS: In phase 1, ten interviews were held. HCPs' attitudes and the subjective norm towards SDM were positive, and the intention to perform SDM was high. The clinical environment (physical context, disease characteristics, assumptions about patient characteristics, and workflows) for MM posed challenges on the actual SDM behavior. Education and use of the DCP to create awareness of SDM were seen as possible facilitators for SDM. A prepared and active patient would facilitate the SDM process. In phase 2, three concept solutions were developed before arriving at the final solution. The final solution consisted of three elements to incorporate SDM steps in the DCP: 1) creating patient awareness and activation with two questions about their preferences prior to a consultation, 2) visualisation of preferences centrally in the DCP to trigger HCP to discuss them, 3) monitoring and improving SDM with patient-questionnaires after decision-making. Patients and HCPs were willing to implement it. CONCLUSION: HCPs intention to engage in SDM was high, but their actual behaviour was challenged by the clinical environment. A 3-element DCP-based intervention was developed to increase SDM. PATIENT OR PUBLIC CONTRIBUTION: Input on the solution was obtained from end-users including two patients and ten healthcare professionals.

Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country.

We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.

Why real world outcome information is indispensable in making treatment decisions for multiple myeloma.

OBJECTIVE: A next step in value-based healthcare (VBHC) is to use outcome information (OI) to inform patients about (personalized) outcomes of care in order to support decision-making processes. We aimed to explore multiple myeloma (MM) patients' and caregivers' views on communication of OI and (shared) decision-making (SDM). METHODS: Focus groups with MM patients and caregivers. Main topics were experiences and needs with information provision, communication, decision-making, and use of OI. Focus groups were audiotaped, transcribed verbatim and analyzed in an iterative process by two researchers using open coding. Member checks were performed. RESULTS: Two focus groups were held with 11 patients (91% male, M=71 years old) and 10 caregivers (89% partners). Information needs were different per moment in the disease trajectory and purpose. Patients were implicitly involved in decisions, but they were not always aware of options and no active weighing of values took place. Outcome information was mostly provided on an individual level, to monitor disease progression and initiate decisions about the need for changes in ongoing treatment regimens (follow-up treatment lines). Patients appreciated the current process of information provision and decision-making, but prefer more option awareness, a bigger role in decision-making and more OI to 1) weigh outcomes for decision-making; 2) get insight in their care trajectory; and 3) compare with other patients. CONCLUSIONS: Participants were satisfied with information provision and decision-making, but they were only implicitly involved in decisions. Real world OI derived from VBHC improvement cycles for MM may fulfil MM patients' and caregivers' information needs and support treatment decision-making.

Advance Care Planning in the Philippines: A continuing narrative of advocacy.

This article discusses the current state of Advance Care Planning (ACP) in the Philippines, where the health system operates within a fragmented environment, with mixed private and public provisions. Despite some attempts to introduce legislation to foster ACP implementation, patient autonomy remains subordinate to family values and physician authority within the Southeast Asian culture. The article also highlights how the COVID-19 pandemic has challenged the norms of the global healthcare force and pushed Palliative Medicine specialists to take on stronger roles in the battle lines against health-related suffering. The Palliative Care Consultants, advocates along with Philippine Society of Hospice and Palliative Medicine (PSHPM) and Hospice Philippines Inc. have been playing a significant role in promoting and supporting ACP through education and training, advocacy, research and development, networking and collaboration.

Real-world experience implementing Advance Care Planning in the Asia-Pacific: ACP in Japan.

Promoting Advance Care Planning (ACP) in the super-aged society of Japan has become increasingly important for supporting older adults to continue to live in the community until the end of life. To promote ACP further in Japan, Japanese family-centered decision-making and high-context culture need to be taken into account. Therefore, we describe the environmental and historical backgrounds surrounding ACP in Japan, and based on the results, introduce research and education programs regarding its implementation.

Advance Care Planning in the Netherlands.

The Dutch health care system fosters a strong public health sector offering accessible generalist care including generalist palliative care. General practitioners are well positioned to conduct ACP, for example, to continue or initiate conversations after hospitalization. However, research shows that ACP conversations are often ad hoc and in frail patients, ACP is often only initiated when admitted to a nursing home by elderly care physicians who are on the staff. Tools that raise awareness of triggers to initiate ACP, screening tools, information brochures, checklists and training have been developed and implemented with funding by national programs which currently focus on implementation projects rather than or in addition to, research. The programs commonly require educational deliverables, patient and public involvement and addressing diversity in patient groups. A major challenge is how to implement ACP systematically and continuously across sectors and disciplines in a way that supports a proactive yet person-centered approach rather than an approach with an exclusive focus on medical procedures. Digital solutions can support continuity of care and communication about care plans. Solutions should fit a culture that prefers trust-based, informal deliberative approaches. This may be supported by involving disciplines other than medicine, such as nursing and spiritual caregiving, and public health approaches.

Advances in Shared Decision Making in Brazil: The role of patient autonomy in curriculum reform, health system and clinical care.

Clinical practice in Brazil has rapidly transformed. Doctor-patient relationships are the focus of these transformations, either within health policies or in the context of medical training. The Brazilian Curriculum Guidelines have emphasized the doctor-patient relationship as part of medical skills and competences, based on patient-centered care. In this article, we present the political advances in patient-centered care. In addition, we address an overview of the Brazilian status quo of decision aids tools. Finally, we share experiences in curriculum reform for the advances of communication skills and the interfaces with narrative medicine and the arts in curricular medical training as a means to advance towards the practice of shared decision making.

Shared Decision-making in the U.S.: Evidence exists, but implementation science must now inform policy for real change to occur.

Shared decision making (SDM) is defined as an approach in which clinicians and patients share the best available evidence when faced with the task of making decisions, and in which patients are supported to consider options to achieve informed preferences [1]. Over the past decade, SDM has been increasingly recognized as a component of value-based care in the US. There is greater acceptance overall that SDM is a key strategy for achieving patient-centered care, enhancing patient safety, and achieving the triple aim of better health, better care, and lower costs [2]. Essential elements of SDM include recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence on risks and benefits; and incorporating the patient's values and preferences into the decision [3]. This paper provides an update of our previous review of SDM in the US published in 2017. We describe changes in healthcare policies to support SDM at the federal and state levels, the integration of SDM into clinical practice, and the role of implementation science to advance SDM. Finally, we discuss potential next steps to inform policies for SDM and facilitate uptake of SDM in clinical practice.

Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients.

Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.

Where are we in shared decision-making in Italy? A brief updated review.

The aim of this paper is to provide an overview of the current state of the art concerning patient-centred care (PCC), shared decision-making (SDM), and patient involvement in health care in Italy, by updating the previous versions of the review. In the past 5 years some progress has been made towards a higher involvement of patients in their health care and patient-centredness into the national health care system. The updated scoping literature search focused on articles reporting primary data collected in Italy and showed a great increase in the number of publications. Nonetheless, the research efforts are still relatively sporadic compared to other countries especially as for evaluations of interventions and, most notably, they are not driven by a consistent effort to promote SDM and PCC in clinical practice.

Implementation of patient-centred care in Denmark: The way forward with shared decision-making.

LEGAL AND POLITICAL LANDSCAPE IN SHARED DECISION MAKING: Current Danish legislation empowers patients in securing their rights, but there are no present legislative developments in Denmark to support patient involvement. Policy initiatives within health care, however, show positive trends by, for example, including recommendations for shared decision making (SDM) in national clinical guidelines and the allocation of resources to fund projects in SDM. Within the last five years, three out of five regions have launched centers in patient involvement and SDM to focus on training, implementation of patient decision aids (PtDAs) and to foster the cultural change in SDM. A national dissemination of a template for easy building of PtDAs accessible via an online platform is one of the latest initiatives. THE WAY FORWARD: Although the political discourse on SDM is gathering speed, an unclear definition and purpose of SDM is a barrier to real-life implementation. Politicians, leaders and clinicians seem to be moving at different paces and in different directions and are lacking consensus on SDM as a paradigm requiring training, leadership and a patient-centered mindset. CONCLUSION: Many relevant initiatives are underway. However, SDM is also challenged by the lack of legislation and a central push for real SDM implementation in Denmark.