Ms Katie Mills

Aim:

To explore patients’ and community nurses’ perceptions and experiences of shared decision-making in the home.

Design:

Integrative review.

Data Sources

CINAHL, British Nursing Index, Psycinfo, Medline and Social Services Abstracts were searched for qualitative, quantitative and mixed methods papers published between 1st December 2001 and 31st October 2023.

Review Methods

A systematic search of electronic databases was undertaken using defined inclusion criteria. The included papers were appraised for quality using the Joanna Briggs Institute critical appraisal checklist for qualitative research. Relevant data was extracted and thematically analysed.

Results

14 papers comprising 13 research studies were included. Patients attached great importance to their right to be involved in decision-making and noted feeling valued as a unique individual. Communication and trust between the patient and nurse was perceived as fundamental. However, shared decision-making does not always occur in practice. Nurses described a tension in managing patients’ involvement in decision-making.

Conclusion

The findings demonstrate that although patients and community nurses appreciate participating in shared decision-making within the home, there are obstacles to achieving a collaborative process. This is especially relevant when there are fundamentally different perspectives on the decision being made. More research is needed to gain further understanding of how shared decision-making plays out in practice and to understand the tensions that patients and nurses may experience.

Implications for the profession and/or patient care

This paper argues that shared decision-making is more than the development of a relationship where the patient can express their views (though of course this is important). Shared decision-making requires acknowledgement that the patient has the right to full information and should be empowered to choose between options. Nurses should not assume that shared decision-making in community nursing is easy to facilitate and should recognise the tensions that might exist when true patient choice is enabled.

During the academic year (2013–14), nurse educator co-researchers met for an introductory workshop and then met regularly in pairs to facilitate each other's reflection. This provided an opportunity for nurse educators to reflect on identified issues linked to their role with a facilitative peer. Educators met three additional times in a Reflexive Learning Group (RLG), to gather data on their use of PRS. Audio-recordings from the RLGs were transcribed and analysed using Norton's (2009) thematic analysis framework. Co-researchers iteratively validated the data and an external validation group critically viewed the evidence.

Overall, seven themes were generated from the three research cycles. These were: PRS as a Valuable Affirming Experience; Time Issues; Facilitation- Support, Trust and Challenge; Developing a Flexible ‘Toolbox’; To Write or Not to Write; Drawing on Literature; and Requirement for Action.

Findings add new evidence regarding use of a flexible toolbox of resources to develop reflection and offer practical guidance on the development of PRS. Nurse educators often experienced similar concerns, and a facilitative supervision structure allowed co-researchers to positively explore these. Recognition of work pressures and requirement for time and space for reflection was highlighted, particularly regarding writing, and exploring the literature, to develop critical analysis of experiences. The importance of action as part of the reflective process was emphasised. Co-researchers reported positive personal change as well as the opportunity to highlight issues through their reflection for further action within the organisation.

The study adds constructive evidence for the use of reflection to explore professional work, make sense of experiences and develop positive action. It has transferability to a wider international audience interested in the development of reflection amongst colleagues and the use of insider research techniques to challenge and develop practice.