There are some particular approaches, skills and techniques that health professionals can use for better shared decision making.
Shared decision making is the conversation that happens between a patient and their health professional to reach a healthcare choice together. It involves the health professional utilising particular approaches, including structuring the consultation to cover the key stages in shared decision making, building rapport with the patient and using shared decision making skills and techniques.
In good shared decision making, clinicians avoid making decisions prematurely based on their own or patients’ prior preferences, whether these relate to a particular treatment or for the health care professional to make a decision for them. They explain that it is not possible to make a good decision until options and the possible benefits and risks have been discussed in relation to what is important to the patient. The aim is to reach a good decision that is made jointly, once the patient is fully informed and their values and preferences have been considered.
Key stages in shared decision making
A helpful approach is to structure the shared decision making process into three key stages1
 Source of model: Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, Cording E ... [et al]. Shared decision making: a model for clinical practice (paper under review). Journal of General Internal Medicine; 2012.
- Choice talk: introducing the patient to the fact there are choices they can make about their treatment and management
- Option talk: describing the options available, sometimes using decision support materials to help present and discuss the evidence in terms of potential benefits, risks and consequences
- Decision talk: helping patients explore their personal preferences and to use these, together with the evidence, to make an informed decision
In real life, these stages are often not a linear process, but are component parts of a good shared decision making conversation, underpinned by use of decision support materials where applicable.
Training for health professionals
Training for health professionals is a core component of effectively implementing shared decision making. It helps individual practitioners to develop their clinical practice and it helps teams and organisations to develop and embed a culture of shared decision making by:
- Building understanding and ownership of the philosophy underpinning shared decision making which values patients’ experiences and preferences and recognises that these need to be reflected in approaches to their care.
- Providing approaches, skills and techniques that can be used in clinical practice to support better shared decision making. This includes simple changes in practice, such as changing the wording from “I think we should do this for you…” to “It seems that you are leaning towards this option – let me just check that I understand why this is your preference.”
It is relevant to all those who support patients to make decisions about their care and treatment, including medics, Clinical Nurse Specialists, Practice Nurses and Allied Health Professionals.
Training materials developed by sites working on the Health Foundation’s MAGIC programme are available to download from this site.
Different approaches to training and development
Teams working on the Health Foundation’s MAGIC programme found that the training approach needed to be tailored to different teams and health professionals. Examples of how they did this include:
- As it became clear that the approach to shared decision making consultations is necessarily different between primary and secondary care, the training was targeted to these different settings and tailored accordingly.
- As health professionals in secondary care were more likely to attend a shorter session, the original three-hour training was modified to retain the same core components but in a two-hour workshop.
- Running whole team training sessions – for example. to cardiology and orthopaedic teams as well as to general practices – enabled teams to consider together their approach to embedding shared decision making into their clinical area and pathways. This worked particularly well in primary care, where primary care clinicians and their teams were used to attending training in this way, but can be more difficult to arrange in a secondary care setting.
- Training needs to be responsive to clinical demands and competing priorities. Training sessions are often held out of hours or are ‘piggy-backed’ onto existing meetings to reduce the need to miss clinical sessions.
- Learning sets are a popular format for learning and development in primary care. In the pilot sites, these sessions concentrated on providing information, coaching and support to a number of staff from practices involved in implementing shared decision making. This model proved valuable to those who attended, with the majority reporting that the learning set was a useful forum for building their knowledge and skills about shared decision making, sharing ideas and gaining an insight into what others were doing. The meetings also enabled those involved to be briefed on the progress of the programme as a whole, as well as sharing their own experience of shared decision making and considering next steps in implementation. In addition, those who attended appreciated time away from everyday distractions to concentrate on the topic.
Who should deliver the training
In the Health Foundation’s MAGIC programme, initially senior clinicians delivered the training, and this peer influence combined with their credibility proved successful. However, it is unlikely to be sustainable in the long term, and an alternative is incorporating it into the existing corporate training arrangements in place in your organisation, for example the training and development offered via the Human Resources department.
Elements of the training that can be measured comparatively easily and so quality assured include:
- Quality of delivery
- Participant satisfaction with the training
However, assessing the impact of the training can be complex.
- When assessing their competence before attending the training, many clinicians believe they are ‘already doing it’, so score themselves highly in any pre-training assessment. One site found that after the training, lots of participants said knowing what they know now, they would have scored themselves lower. As a result they have introduced a question into their post-course evaluation: ‘how would you rate your old self?’
- It is difficult to measure any change or improvement in the consultation from a patient perspective, as patients generally rated their clinician highly. This in turn means that it is difficult to demonstrate to clinicians that patients want different from what they’re getting.
- Assessing the longer term impact of training on health professionals’ practice is difficult. One of the MAGIC sites asks participants to complete a self-assessment of their knowledge, skills and beliefs prior to training and then again at six to eight weeks post training. A key questions asks participants what they consider to be the Most Significant Change in their consulting behaviour since attending the training. It has been hard to encourage people to return these surveys, but those that have been received have shown a very positive impact on practice.