How can shared decision making for hypertension or heart failure be supported? A longitudinal qualitative study
Shared decision making is a process by which clinicians and patients work together to make healthcare choices. Implementing shared decision making has proven challenging. Research focused on shared decision making for hypertension or chronic heart failure is sparse. The aim of this study was to understand how patients with these two common conditions experience involvement in decision making during consultations, in order to understand how shared decision making for these conditions can be supported.
Twenty-four patients with either hypertension or chronic heart failure were recruited from five general practices. Patients with a range of ages and stages of hypertension / heart failure were sampled. All patients took part in in-depth baseline interviews. When patients had consultations, either at the GP surgery or in other healthcare settings, these were observed and audio-recorded, and afterward patients and healthcare professionals took part in interviews focusing on their experiences in the preceding consultation. Recorded data were transcribed verbatim. Data were analysed thematically using an inductive, constant comparison method. A coding frame was developed and applied to the data; as analysis continued broader categories became evident and these were gradually developed into themes.
All 24 patients took part in baseline interviews; forty consultations relating to 13 patient participants were observed. Patients’ lack of understanding of their health reduced their ability to report important symptoms and ask questions, and reduced their opportunities for involvement in healthcare decisions. Most consultations did not provide opportunities to increase patients’ understanding of their healthcare condition. Opportunities for involvement in decision making were reduced by the highly-structured nature of consultations, and consultation complexity. Highly-structured consultations were led by the healthcare professional and focused on biomedical tasks, limiting patients’ contributions to answering the healthcare professionals’ questions or asking questions when invited to do so. Few patients recalled discussions about treatments as decisions; rather they recalled being told that medications were necessary and accepting treatments that clinicians suggested to them. Choices regarding medications were rarely perceived. Typically, very little time during consultations was devoted to making decisions about treatment; there was little discussion of the potential benefits and dis-benefits of treatments (including side-effects), or of the patient’s preferences in relation to treatment. Decisions were distributed, i.e. different components of a decision were made over a series of different types of interactions with one or multiple practitioners.
Factors reducing patient involvement included the tendency of consultations to be routinized, task-focused and to pursue a biomedical agenda, limited health understanding of patients, the distributed nature of healthcare decisions, and the lack of explicit discussion about choice. If shared decision making is to be facilitated, these barriers need to be addressed.