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Overcoming Engagement Barriers to Shared Decision-Making

Clinicians must determine patient preferences in order to overcome engagement barriers to shared decision-making.

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By Sara Heath

- Despite industry calls for better shared decision-making, patient engagement barriers make that goal easier said than done.

In a recent paper from the Baylor College of Medicine, author J.S. Blumenthal-Barby explains that shared decision-making can lead to positive results, including an improved patient experience, more patient activation, and overall better health and treatment outcomes.

However, clinicians must overcome several patient engagement barriers to achieve meaningful shared decision-making.

“While patients’ desire for such involvement has been shown to vary by individuals, number of treatment options, and treatment certainty, there is agreement that it is generally lower than desired,” Blumenthal-Barby wrote.

Barriers include individual patient barriers and contextual barriers, Blumenthal-Barby maintained.

READ MORE: Patient Engagement Interventions Boost Shared Decision-Making

Individual barriers

Individual barriers include limited patient education, language barriers, and cultural disparities.

When patients do not have sufficient patient education, they cannot participate in an engaging discussion about their health, Blumenthal-Barby explained. In addition to having a limited understanding of one’s own health status, lacking patient education can also keep patients from asking relevant questions about their treatment.

Improving patient education can likewise be challenging, considering the breadth of information necessary for meaningful shared decision-making and providers’ difficulties in determining patient understanding.

Language barriers present similar challenges to shared decision-making. Patients with low English proficiency are less likely to understand their health information as their peers, and may face a lack of communication or miscommunication during the care encounter.

READ MORE: How to Include Patient Preferences in Shared Decision-Making

“While limited understanding should lead to follow-up questions, in these cases the language barriers result in an inability and reluctance to become involved in the decision and situation at hand. It may also lead to disengagement from care altogether,” Blumenthal-Barby noted.

Healthcare professionals may also face cultural barriers that keep them from engaging in strong, shared decision-making with their patients.

“A major cause for reluctance to becoming involved in medical decision making is individuals’ culture and values, including the culture of submissiveness and viewing health care providers as authority figures,” Blumenthal-Barby wrote.

These disparities can be especially problematic in patients whose cultures emphasize unquestioning respect for authority figures, and can affect patients across generations and demographics.

Contextual barriers

READ MORE: Patient Satisfaction and HCAHPS: What It Means for Providers

Contextual challenges are largely related to time. For example, many appointments do not allow for patient-provider conversations or patient questions, thus barring stakeholders from engaging in shared decision-making.

Additionally, clinical testing timelines can keep patients from sharing in informed decision-making. If patients are not given adequate time between receiving test results and selecting a time-sensitive treatment, they may defer the decision to the clinician.

Strategies for strong shared decision-making

When combined, individual and contextual barriers can lead to a difficult care encounter for both patients and providers.

However, according to Blumenthal-Barby, providers can overcome many of these barriers through long-term organizational initiatives or simple patient-provider communication improvements.

Clinicians should first ask patients how they want to be engaged in their healthcare. Some patients may want to be highly involved in shared decision-making, while others prefer their clinician take the driver’s seat.

“Patients should be asked what role they want to play or what model they prefer,” Blumenthal-Barby advised. “More research is needed to identify patients whose preference for low involvement is authentic—in other words, on when to ‘nudge’ patients towards more involvement.”

Additionally, clinicians should ask patients about what they already know about their health, as well as their beliefs about their healthcare.

When informing patients about their care, clinicians should use multiple methods including statistics, diagrams, and words. Providers should check patient understanding by asking patients to “teach back” complex health concepts.

Providers can facilitate patient memory retention by encouraging the use of tape records and note taking during appointments, and also allow for open access to clinician notes.

Providers should also consider decision-making aids during the clinical encounter.

Each of these strategies should be deployed within an open, patient-centered hospital culture, Blumenthal-Barby wrote.

“Expressing values can be primed by having patients complete values clarification exercises. Creating a social norm that this is acceptable (‘normative messaging’) is imperative,” Blumenthal-Barby advised.

“All of these initiatives work to create a ‘2-way street’ between patients and providers. Cultural influences are an important consideration in the expression of values and questions.”

Healthcare facilities should also facilitate better timing for shared decision-making by requiring clinicians to keep electronic patient charts up to date. Clinicians may also consider using telehealth to communicate test results where necessary.

When patients and providers do face time-sensitive decisions, providers should advocate for family engagement to help support the patient.

Ultimately, these strategies should work toward better incorporating the patient into shared decision-making, a hallmark of meaningful patient engagement.

“Researchers and clinicians should be motivated to find ways to engage patients on the ethical imperative that many patients prefer to be more engaged in some way, shape, or form; patients have better experiences when they are engaged, and engagement improves health outcomes,” Blumenthal-Barby concluded. “Reminding ourselves of those goals can help further the work of patient engagement.”

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