Providers are encouraged to view patients with chronic disease as ??partners?? in their care, and to collaborate with them in developing care plans. Yet there is little guidance in how collaboration should occur, and little evidence that collaborative care improves patient outcomes. Related models and measures of patient centred care and shared decision making have not been developed specifically for the context of chronic disease care. This thesis aimed to develop a theoretical understanding of how providers and patients make decisions in chronic disease care planning, how patients experience involvement in care planning, and to develop a measure of patient involvement. It consists of two studies: a qualitative study to develop a grounded theory of decision-making in diabetes care planning, and a scale development and psychometrics study. The qualitative study involved 29 providers and 16 patients with diabetes. It found that providers were concerned with a process described as ??managing patient involvement to do the right thing??, while patients were concerned with ??being involved to make sure care is appropriate??. This led to the theory of ??delivering respectful care??, a grounded theory that integrates provider and patient perspectives by showing how providers and patients can resolve their concerns while achieving mutually acceptable outcomes. Central to this theory is the process of finding common ground, while the key conditions are provider responsiveness and an ongoing, trusting and respectful provider-patient relationship. The Collaborative Care Planning Scale (CCPS), based on these findings, is a patient self-report scale that measures patients?? perceptions of involvement in care planning. After piloting the CCPS was tested amongst 166 patients with diabetes. Exploratory factor analysis resulted in a 27-item scale comprising two factors: ??receiving appropriately personalised care?? and ??feeling actively involved in decision-making??. Psychometrics tests revealed the CCPS has adequate internal consistency and test-retest reliability, and findings support construct validity. ??Delivering respectful care?? enriches understanding of the nature of collaboration in chronic disease care, and identifies those elements necessary to ensure patients receive best possible care. The CCPS provides the means for measuring what patients say they value, and is thus an important measure of quality chronic disease care.

Providers are encouraged to view patients with chronic disease as ??partners?? in their care, and to collaborate with them in developing care plans. Yet there is little guidance in how collaboration should occur, and little evidence that collaborative care improves patient outcomes. Related models and measures of patient centred care and shared decision making have not been developed specifically for the context of chronic disease care. This thesis aimed to develop a theoretical understanding of how providers and patients make decisions in chronic disease care planning, how patients experience involvement in care planning, and to develop a measure of patient involvement. It consists of two studies: a qualitative study to develop a grounded theory of decision-making in diabetes care planning, and a scale development and psychometrics study. The qualitative study involved 29 providers and 16 patients with diabetes. It found that providers were concerned with a process described as ??managing patient involvement to do the right thing??, while patients were concerned with ??being involved to make sure care is appropriate??. This led to the theory of ??delivering respectful care??, a grounded theory that integrates provider and patient perspectives by showing how providers and patients can resolve their concerns while achieving mutually acceptable outcomes. Central to this theory is the process of finding common ground, while the key conditions are provider responsiveness and an ongoing, trusting and respectful provider-patient relationship. The Collaborative Care Planning Scale (CCPS), based on these findings, is a patient self-report scale that measures patients?? perceptions of involvement in care planning. After piloting the CCPS was tested amongst 166 patients with diabetes. Exploratory factor analysis resulted in a 27-item scale comprising two factors: ??receiving appropriately personalised care?? and ??feeling actively involved in decision-making??. Psychometrics tests revealed the CCPS has adequate internal consistency and test-retest reliability, and findings support construct validity. ??Delivering respectful care?? enriches understanding of the nature of collaboration in chronic disease care, and identifies those elements necessary to ensure patients receive best possible care. The CCPS provides the means for measuring what patients say they value, and is thus an important measure of quality chronic disease care.

Sergiovanni (1994) believed that the rationale for shared decision making is that those who are closest to students are best equipped to make educational decisions to improve instructional programs. Liontos (1994) believed that change is most likely to be effective and lasting when those who implement it feel a sense of ownership and responsibility for the process. Building level administrators along with general and exceptional education teachers play a vital role in making educational practices a reality in schools (Kilgore, 2011). The administrator must have adequate knowledge of what the practices entail and how to mobilize staff so these educational practices are implemented effectively. In order to embrace the philosophy of inclusion, teachers must eliminate the focus on labels of students and make students with disabilities and support needs the determining factors in the provision of services and placement settings. This requires the school staff to shift paradigms when determining how best to meet the needs of students with disabilities. The overall purpose of this study was to determine whether or not general and exceptional education teachers working together had an impact on the inclusion process. These two groups of teachers collaborated to address challenges that students meet in the general educational setting. Their goal was to provide the best possible learning experience for students with disabilities in the least restrictive environment. While this study only took into account the challenges and successes of one school, in one school district, it is a glimpse of what other teachers, general and exceptional education are facing in inclusive settings. Results of the study showed that collaboration between general and exceptional education teachers clearly resulted in greater teacher efficacy. These teachers believed that they could make a positive difference. Teachers who exhibited this confidence were more likely to engage in collaboration. Some of the general education teachers who had the strongest desire for collaboration and worked closely with an exceptional education teacher exhibited a number of positive traits that led to more effective inclusion instruction. With this in mind, it is important for educational leaders to do all that they can to provide professional training and development to offer ideas and instances of collaboration to help the students with disabilities and teachers involved in educating them.

Shared decision making (SDM) is rarely used in pediatric clinical practice. The purpose of this dissertation was to explore factors influencing SDM implementation in pediatric clinical practice. We conducted three studies that were guided by the Ottawa Model of Research Use (OMRU): Study 1 was a systematic review using Cochrane methods and the Mixed Methods Appraisal Tool to determine pediatric SDM barriers and facilitators from multiple perspectives. Eighty studies, of low to high quality, were included. At each OMRU level, frequently cited barriers were: option features (decision), poor quality information (innovation), emotional state (adopter), power relations (relational), and insufficient time (environment). Frequently cited facilitators were: lower stake decisions (decision), agreement with SDM (adopter), high quality information (innovation), trust and respect (relational), and SDM tools/resources (environment). Across participant types, frequently cited barriers were: insufficient time (healthcare providers (HCP)), option features (parents), power imbalances (children), and HCPs’ SDM skills (observers). Frequently cited facilitators were: good quality information (HCPs) and agreement with SDM (parents/children). Study 2 was a post-test design that evaluated SDM knowledge and acceptability of learners who completed the Ottawa Decision Support Tutorial (ODST). Most learners were HCPs (62%). Overall, ODST learners had a median knowledge test score of 8/10 (IQR = 7-9; n=6604) and 90% reported good or excellent impressions (n=4276) after completing the tutorial. Few learners suggested improvements. Study 3 used mixed methods to evaluate pediatric HCPs’ perceived SDM barriers and facilitators after training (ODST plus workshop). Participants completed a SDM barrier survey (n=60; 88% response rate) and semi-structured interview (n=11). Their intention to use SDM was high (mean score = 5.6/7, SD=0.8). However, 90% of respondents reported minimal SDM use after training. Main barriers were lack of buy-in (adopter level) and time constraints (environmental level). Healthcare providers wanted a team-based approach to SDM training (training level). Adopters face numerous and diverse barriers to SDM use, before and after SDM training. Pediatric HCPs who completed the ODST were knowledgeable about SDM. Despite positive intentions, training alone was insufficient to achieve routine SDM use. These findings can inform intervention development to promote SDM implementation in pediatric clinical practice.

Background: The process of shared decision making (SDM), a key component of interprofessional (IP) practice, provides an opportunity for the separate and shared knowledge and skills of care providers to synergistically influence the client / patient care provided. The aim of this study was to understand how different professional groups perceive IPSDM, their role as effective participants in the process and how they ensure their voices are heard. Methods: A sequential explanatory mixed methods design was used consisting of a realist review of the literature about IPSDM in intensive care, a survey of the IP team (n=96; RR-81.4%) about collaboration and satisfaction with the decision making process in NICU, semi-structured interviews with a sample of team members (n=22) working in NICU, and observation of team decision making interactions during morning rounds over a two week period. A tertiary care NICU in Canada was the study setting. Findings: The study revealed a number of key findings that are important to our increased understanding of IPSDM. Healthcare professionals’ (HCP) views differ about what constitutes IPSDM. The nature of the decision (triage, chronic condition, values sensitive) is an important influencing factor for IPSDM. Four key roles were identified as essential to the IPSDM process: professional expert, leader, synthesizer and parent. IPSDM involves collaboration, sharing, weighing and building consensus to overcome diversity. HCPs use persuasive knowledge exchange strategies to ensure their voices are heard during IPSDM. Buffering power differentials and increasing agreement about best options lead to well-informed decisions. A model was developed to illustrate the relationships among these concepts. Conclusions: Findings from this study improve understanding of how different members of the team participate in the IPSDM process, and highlight effective strategies to ensure professional voices are heard, understood and considered during deliberations.

Background: The process of shared decision making (SDM), a key component of interprofessional (IP) practice, provides an opportunity for the separate and shared knowledge and skills of care providers to synergistically influence the client / patient care provided. The aim of this study was to understand how different professional groups perceive IPSDM, their role as effective participants in the process and how they ensure their voices are heard. Methods: A sequential explanatory mixed methods design was used consisting of a realist review of the literature about IPSDM in intensive care, a survey of the IP team (n=96; RR-81.4%) about collaboration and satisfaction with the decision making process in NICU, semi-structured interviews with a sample of team members (n=22) working in NICU, and observation of team decision making interactions during morning rounds over a two week period. A tertiary care NICU in Canada was the study setting. Findings: The study revealed a number of key findings that are important to our increased understanding of IPSDM. Healthcare professionals’ (HCP) views differ about what constitutes IPSDM. The nature of the decision (triage, chronic condition, values sensitive) is an important influencing factor for IPSDM. Four key roles were identified as essential to the IPSDM process: professional expert, leader, synthesizer and parent. IPSDM involves collaboration, sharing, weighing and building consensus to overcome diversity. HCPs use persuasive knowledge exchange strategies to ensure their voices are heard during IPSDM. Buffering power differentials and increasing agreement about best options lead to well-informed decisions. A model was developed to illustrate the relationships among these concepts. Conclusions: Findings from this study improve understanding of how different members of the team participate in the IPSDM process, and highlight effective strategies to ensure professional voices are heard, understood and considered during deliberations.

Background: The process of shared decision making (SDM), a key component of interprofessional (IP) practice, provides an opportunity for the separate and shared knowledge and skills of care providers to synergistically influence the client / patient care provided. The aim of this study was to understand how different professional groups perceive IPSDM, their role as effective participants in the process and how they ensure their voices are heard. Methods: A sequential explanatory mixed methods design was used consisting of a realist review of the literature about IPSDM in intensive care, a survey of the IP team (n=96; RR-81.4%) about collaboration and satisfaction with the decision making process in NICU, semi-structured interviews with a sample of team members (n=22) working in NICU, and observation of team decision making interactions during morning rounds over a two week period. A tertiary care NICU in Canada was the study setting. Findings: The study revealed a number of key findings that are important to our increased understanding of IPSDM. Healthcare professionals’ (HCP) views differ about what constitutes IPSDM. The nature of the decision (triage, chronic condition, values sensitive) is an important influencing factor for IPSDM. Four key roles were identified as essential to the IPSDM process: professional expert, leader, synthesizer and parent. IPSDM involves collaboration, sharing, weighing and building consensus to overcome diversity. HCPs use persuasive knowledge exchange strategies to ensure their voices are heard during IPSDM. Buffering power differentials and increasing agreement about best options lead to well-informed decisions. A model was developed to illustrate the relationships among these concepts. Conclusions: Findings from this study improve understanding of how different members of the team participate in the IPSDM process, and highlight effective strategies to ensure professional voices are heard, understood and considered during deliberations.

Background: The process of shared decision making (SDM), a key component of interprofessional (IP) practice, provides an opportunity for the separate and shared knowledge and skills of care providers to synergistically influence the client / patient care provided. The aim of this study was to understand how different professional groups perceive IPSDM, their role as effective participants in the process and how they ensure their voices are heard. Methods: A sequential explanatory mixed methods design was used consisting of a realist review of the literature about IPSDM in intensive care, a survey of the IP team (n=96; RR-81.4%) about collaboration and satisfaction with the decision making process in NICU, semi-structured interviews with a sample of team members (n=22) working in NICU, and observation of team decision making interactions during morning rounds over a two week period. A tertiary care NICU in Canada was the study setting. Findings: The study revealed a number of key findings that are important to our increased understanding of IPSDM. Healthcare professionals’ (HCP) views differ about what constitutes IPSDM. The nature of the decision (triage, chronic condition, values sensitive) is an important influencing factor for IPSDM. Four key roles were identified as essential to the IPSDM process: professional expert, leader, synthesizer and parent. IPSDM involves collaboration, sharing, weighing and building consensus to overcome diversity. HCPs use persuasive knowledge exchange strategies to ensure their voices are heard during IPSDM. Buffering power differentials and increasing agreement about best options lead to well-informed decisions. A model was developed to illustrate the relationships among these concepts. Conclusions: Findings from this study improve understanding of how different members of the team participate in the IPSDM process, and highlight effective strategies to ensure professional voices are heard, understood and considered during deliberations.

This thesis examines strategies to address the inappropriate proton pump inhibitor (PPI) use. A scoping review was conducted to examine patient preferences and values towards PPI initiation and continued treatment, as well as their attitudes towards reducing PPI use (deprescribing). Symptom control (reflux, heartburn) was a driver for patients to seek treatment. Patients were concerned about symptoms returning if they reduced their PPI use but were interested in using less medication if possible. Patients were open to discussing PPI reduction and valued clear communication about rationale and potential benefits/harms. As such, shared and informed decision-making (including eliciting patient values) is important in the choice to continue a PPI or try deprescribing. A decision-support tool for clinicians, aimed at the decision to continue a PPI versus try deprescribing, was implemented over 12 months in one long-term care home in Ottawa. The tool led to a non-statistically significant decrease in PPI use after it was implemented, but PPI usage began to gradually increase after six months. Strategies to sustain use of deprescribing initiatives are needed. Finally, a consult patient decision aid (PtDA) was developed and piloted in three Ottawa area clinics, and aimed to facilitate shared decision-making surrounding the decision to continue or try to reduce a PPI during a healthcare visit. Based on a sample of 12 patients, the consult PtDA increased knowledge about the decision and increased decisional confidence. After receiving the consult PtDA, 8/12 (75%) patients chose to reduce their PPI use and 4/12 (25%) chose to continue their PPI.

Lung cancer is the most common cause of cancer-related deaths in the United States. Prevention and early detection of lung cancer are imperative in decreasing lung cancer mortality. Screening for lung cancer with low-dose computed tomography (LDCT) decreases lung cancer by 20%. Several organizations introduced lung cancer screening (LCS) guidelines in 2013, including Centers for Medicare and Medicaid (CMS) and the United States Preventive Services Task Force. However, LCS participation for eligible patients remains low, due in part to the complexity of the LCS process. The goal of this practice improvement project was to increase the knowledge of rural primary care providers regarding LCS guidelines and the related CMS requirements and to increase their confidence in initiating shared decision-making (SDM) discussions. An educational intervention consisting of a LCS educational session and a toolkit was implemented in two rural clinics. Providers at both clinics reported a benefit to the educational intervention. Pre-, immediate post-, and two-month post-education surveys were collected to evaluate the impact of the educational intervention, including provider knowledge of LCS guidelines and CMS requirements, and confidence in SDM. Project results demonstrated an increased knowledge of LCS guidelines and CMS requirements with the greatest knowledge at immediate post-education and a high level of knowledge remaining at two months post-education. A small, nonsignificant, increase in provider confidence in initiating SDM discussions occurred. At both clinics, data collected through chart audit demonstrated an improvement in documentation needed to determine LCS eligibility and increased the percentage of patients identified at high risk for lung cancer and thus, eligible for LCS. At one clinic these changes were significant. The data were further examined for SDM discussions and referrals for LDCT or to specialist for LCS with one clinic increasing SDM documentation and LDCT referrals post-education. In conclusion, although further research is needed in implementation processes of LCS, specifically in consistent documentation to improve determination of LCS eligibility of patients, this practice improvement project found education increased provider knowledge and ability to complete requirements needed to improve LDCT screenings for lung cancer.