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.

Shared governance is a practice model that supports shared decision making between direct care nurses and their leaders. Developed from Kanter's theory of structural empowerment, shared governance allows employees to influence decisions made in an organization. Shared governance has been shown to increase nursing satisfaction, positively impact outcomes, and reduce nursing turnover. The purpose of this project was to examine the relationship between implementation of a system-wide, multihospital shared governance structure and registered nurse (RN) satisfaction, turnover, and perceptions of shared governance. The 3 sources of evidence used in the study were 2016-2017 organizational RN engagement survey results, 2016-2017 organizational RN turnover data, and RN perceptions of shared governance as measured by the Index of Professional Nursing Governance (IPNG) tool. Two similar hospitals within the system were selected for administration of the IPNG survey. Results showed that introduction of a multihospital shared governance structure had an impact on nursing turnover. The biggest change was in new nurse turnover, which reduced from a high of 32.10% to 27.30%. This 4.8% decrease translated in approximately $2 million in savings. A comparison of IPNG survey results showed that the hospital with lower turnover had higher perceptions of shared governance. The potential implications of these finding for social change could be an expansion of shared governance in the organization and social change in the region. Due to the relationship between shared governance and improved patient outcomes, a reduction in mortality and improvement in overall health could be seen for the 1 million patients served in these hospitals.

Introduction: Childbirth is an important time in a client and patient’s life. The pregnant client seeks to obtain as much control over their circumstance as possible. The more perceived control in childbirth by the client, the better the outcomes are for the client-newborn dyad. One way that clients obtain control during childbirth is by participating in clinical decision making with their healthcare providers. This research intended to study the ways in which OB residents and midwifery students engaged in the understanding, learning and application of shared decision making with clients and patients. Methodology: This study utilised a constructivist grounded theory approach to obtain data and formulate a theory using semi-structured interviews with five senior obstetrical residents and five senior midwifery students from Ontario. Results: Qualitative data revealed four themes and eight sub-themes. Our theory describes the way residents and students absorb, mirror, and perform shared decision making through an informal process of observation and experience throughout their training. Our theory further describes how support for students and residents creates the foundation for learning shared decision making. Support includes how the mentor minimizes the impacts of the hierarchy of power in medical and midwifery education, as well as increasing psychological safety for the learner. Conclusion: The study results support the exploration of future methods for the teaching of shared decision making to obstetrical residents and midwifery students. Participants of this study agreed that more training is needed for shared decision making, as well as training for the mentor to ensure learners are optimizing their experience. More training needs to be available for mentors to help reduce the negative impacts of the hierarchy of power, and to increase psychological safety for the learner. / Thesis / Master of Health Sciences (MSc) / This thesis examines the ways in which obstetrical residents and senior midwifery students learn, understand and apply shared decision making in their training. Shared decision making is a way in which health care providers can work collaboratively with their patients or clients to make decisions that are best for their health. Both obstetrical residents and midwifery students were asked about how they understood shared decision making, and the process by which they learn and perform shared decision making. Childbirth is full of uncertainty and fear. Shared decision making may be one way that the pregnant patient or client navigates through the fear by having some control over their decision making. Our study intends to help understand how obstetrical residents and midwifery students gather the skills they need to do shared decision making and how best to support learners with this skill set in the future.

Decision analysis is a quantitative approach to decision-making that could bridge the gap between decisions based solely on evidence and the unique values and preferences of individual patients, a feature especially important when existing clinical evidence cannot support clear recommendations and there is a close balance between harms and benefits for the treatment options under consideration. Low molecular weight heparin for the prevention of venous thromboembolism (VTE) during pregnancy represents one such situation. The objective of this thesis is to explore the use of a decision analysis intervention for shared decision-making for thromboprophylaxis during pregnancy. This thesis begins with a scoping review that explores the ways in which decision analysis has been used to inform shared decision-making encounters, highlighting key challenges for implementing and evaluating this type of intervention. This is followed by a protocol that presents the methodology of an explanatory sequential mixed methods pilot study for the Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP) tool. This tool was pilot tested through interviews of eligible women in Canada and Spain who were facing the treatment decision for the prevention of VTE in the antenatal period. While the tool was well received by patients, more effective ways of obtaining patient preferences and presenting the decision analysis results are required to enhance shared decision-making interactions. Finally, this thesis concludes with a reflection on the lessons learned from developing and evaluating a decision analysis intervention for shared decision-making. The insights from this research have informed the development of an integrated online shared decision-making tool for VTE in the antenatal period, which the DASH-TOP team plans to evaluate in a randomized controlled trial. It is hoped that this information will also provide guidance to researchers interested in developing or evaluating decision analysis interventions for other clinical decisions. / Dissertation / Doctor of Philosophy (PhD)

This study aimed to understand how parents’ experience of titration contributes to the adaptive tasks and coping skills associated with their child’s Attention Deficit/ Hyperactivity Disorder (ADHD) diagnoses. The primary research question asks: How does participation in the stimulant titration and Shared Decision-Making (SDM) process help parents create adaptive tasks and coping skills? The participants included 4 parents who have undergone the titration and SDM process as a part of treatment that addresses their child’s ADHD diagnosis. Analysis was conducted via an adapted grounded theory approach and resulted in 11 themes related to the core emergent theme of titration. Themes that were representative of the titration experience were related to the participant’s source of stress, cognitive appraisal of the ADHD diagnosis, adaptive tasks, coping skills, outcomes, and suggested improvements. The results have important implications for improving the titration process. The results also emphasize how titration has promoted adaptive tasks and coping skills which assisted participants to feel more in control and create a new sense of normalcy regarding their child’s ADHD diagnosis.

Bakgrund: Vården har under många år arbetat utifrån ett paternalistiskt synsätt, där sjukvårdspersonal varit den aktiva beslutsfattaren och patienten varit den passiva. Detta har inneburit att patientens autonomi, perspektiv och preferenser inte tagits tillvara. Det paternalistiska synsättet har gradvis gått över till en mer patientcentrerad vård, där patienten blir en del av vårdteamet. För att öka patientdelaktigheten och självbestämmande inom dagens vård, rekommenderas sjukvårdspersonalen att arbeta efter SDM-modellen, en modell som ska hjälpa både patient och sjukvårdspersonal att tillsammans komma fram till de olika beslut som ska tas i olika vårdsituationer. Syfte:  Att beskriva patienters upplevelser av Shared decision making inom den somatiska vården. Metod: En allmän litteraturöversikt med beskrivande sammanställning, baserad på sju stycken kvalitativa vetenskapliga artiklar. Resultat: Patienternas upplevelse av SDM-modellen delades in i tre huvudkategorier med två underkategorier. Resultatet visar vikten av att som patient få information på ett språk som är begripligt för att kunna agera beslutsfattare. Men även att som patient känna tillit till sjukvårdspersonal samt att känna sig respekterad och uppleva trygghet. Diskussion: Genom att sjukvårdspersonal arbetar med personcentrerad vård sätts fokus på patienten och ökar inte endast patientens delaktighet utan gör också att patientens autonomi respekteras. Det är sjukvårdspersonalens ansvar att delge patienter rätt information samt bjuda in till samtal för att öka patienters delaktighet i vårdsammanhanget.

Background: An increasing proportion of Canadian women are experiencing a Caesarean section (CS) and a subsequent repeat CS. While CS can be necessary and lifesaving for mothers and their infants in some situations, it is also associated with greater morbidity risks to women and infants than vaginal birth. Clinical practice guidelines recommend the involvement of pregnant women in making decisions about mode of birth and shared decision making improves the informed consent process. This research examines the factors that influence mode of birth after a previous CS. Methods: Two cross sectional descriptive studies and a prospective pre-post cohort study with control were conducted to investigate the high use of repeat CS at the levels of health care providers, maternity care clients, and the organizational structure of a birthing unit. 1. Interviews and surveys with obstetricians, family physicians, midwives, and nurses were conducted to investigate the attitudes, values, and perceptions that guide their care practices for clients with a previous CS. The specific research question was: What are the factors that influence the practices of maternity care providers (obstetricians, family physicians, midwives, and nurses) regarding mode of birth after a previous CS? Data was analyzed using iterative deductive and inductive coding. 2. Interviews and surveys were conducted during pregnancy and after giving birth with healthy women who have had a previous CS to explore their decision making processes regarding mode of birth after a previous CS. The specific research question was: How do women eligible for a VBAC make decisions about their upcoming mode of birth? A thematic framework approach was used for data analysis. 3. Data from the Better Outcomes Registry and Network (“BORN”) Ontario was analyzed to examine the effectiveness of a hospital based strategy on overall proportions of CS and within Robson groups 1, 2a, and 5. The Caesarean section reduction (CARE) strategy includes interventions that target health care providers, pregnant women, and hospital policies. Results: 1. Maternity care providers would recommend a vaginal birth after CS (VBAC) for healthy pregnant women with a previous CS. They had different perceptions of the safety of birth to the health of women and infants and different approaches to engage in decision making during consultation. Providers believed women make their decision about mode of birth outside of the clinical consultation and often prior to their subsequent pregnancy. 2. The main themes that influenced the decisions of maternity care clients about mode of birth were mothers’ experiential reasoning regarding mode of birth and recovery, experiential knowledge from significant others, scheduling of CS regardless of the mode of birth decision, rating and prioritizing risks, fear of risks, and decisional conflict. When women discussed the factors that impacted their decisions about mode of birth six to eight weeks after they had given birth, the main themes were the recovery experience and fear related to the mode of birth. A lack of time during consultation was identified as a major barrier inhibiting shared decision making, specifically among clients of obstetricians. Other barriers included reliance on routine obstetric practices that are not evidence based. 3. Proportions of CS decreased at the intervention hospital by 3.9% (p=0.0006), from 30.3% (n=964) in 2009/10 to 26.4% (n=803) in 2012/13. During the same time frame, proportions of CS in the control group were stable with 28.1% (n=23,694) in 2009/10 and 28.2% (n=23,683) in 2012/13. Within the Robson classification system, the proportions of repeat CS among all low risk women with a previous CS decreased at the intervention hospital by 5.6% (p=0.0044) from 84.3% to 78.7%. In the control group, also fewer women had a repeat CS over the study period, but the decrease was smaller with 3.9% (p<0.0001) from 84.5% to 80.6%. Conclusion: A true shared decision making process addresses the power imbalance between providers and women through an incorporation of the clinical expertise of providers and the experiential expertise of pregnant women before reaching a decision about mode of birth. The use of routine obstetric practices that are not evidence based inhibited women to make decisions about their mode of birth. The introduction of the CARE strategy to a hospital birthing unit was associated with improvements in proportions of CS and VBAC among low risk women.

This study is concerned with understanding decision-making in relation to out-of-authority educational placements for pupils with an Autistic Spectrum Condition (ASC) in one Local Authority (LA). The aims of this research were twofold. The first was to explore what factors have the greatest impact on the decision to educate pupils with an ASC outside the local authority. The second was to explore the perceptions of key informants about the process for deciding those placements. The study involved examining 24 pupil cases where out-of-authority ASC placements had been agreed and interviews with case-informants contributing to those placement decisions in order to analyse their beliefs and understandings about the processes of decision-making. The literature review highlights the limited research with regard to decision-making about pupils with Special Educational Needs (SEN) and draws examples from medical decision-making frameworks. Data analysis showed that two factors, complexity and range of pupil need and lack of LA provision to match the needs identified had the greatest influence on the decision to educate pupils outside the local authority. The response of the LA’s own schools, professionals and parents to those presenting needs as well as the consequent impact on the child/young person and others were recognised secondary factors. Case-informants offered a strong impression that for the majority of these pupils successful inclusion in their own LA would require increased and more integrated services in order to meet their identified needs. Data from the qualitative interviews provides a sense of the range of informants’ experiences relating to decision-making processes and the factors determining those perceptions. These related to whether the processes had been experienced as planned, were evidenced-based, child-focused and involved effective working with parents and other agencies. The findings, in part, reflect government concerns about the current statutory SEN framework and the case for change as made in the recent Green Paper (DfE, 2011). At a local level informants identified the need for a more explicit model of decision-making, ethically grounded with an emphasis for decision-making to be based on the holistic needs of the child and viewed that this would be better facilitated by having improved joint-working between services and stronger partnership engagement between the LA and parents/carers. Clinical professional-patient shared decision-making is discussed as a potential model which might be usefully applied to better understand and develop current SEN decision making.

No description available.

Background. Around 25-45% of elective total joint arthroplasty (TJA) for primary hip and knee osteoarthritis (OA) are of questionable appropriateness. -- Objective. To examine how appropriateness of elective TJA for hip and knee OA is determined. -- Methods and results. Multi-methods studies guided by the Knowledge-To-Action (KTA) framework and the six Hawker appropriateness criteria for TJA. Study 1 was an interpretive descriptive study exploring barriers and facilitators to using the Hawker appropriateness criteria for adults with knee OA. Nine semi-structured interviews with healthcare professionals and 14 with adults with a TKA revealed: a) 15 barriers (including difficulties in using criteria, lack of accessible conservative treatments, unreceptivity to practice change, clinical judgement limited to OA severity and age, patients receiving information after the decision is made); and b) one facilitator (providing research evidence to obtaining healthcare team buy-in). Study 2 was a systematic review identifying and appraising instruments to assess elective TJA appropriateness for adults with hip and knee OA. None of the 55 instruments met all the Hawker appropriateness criteria; the most included criteria were OA impact on quality of life and evidence of OA while the least included were trial of conservative treatments and elements of shared decision-making. There was limited evidence on psychometric properties. Study 3 was an environmental scan of online Canadian resources for adults with hip or knee OA considering TJA and healthcare professionals participating in the decision. The 73 patient resources were understandable for diverse health literacy levels, but only four were patient decisions aids. Thirteen healthcare professional resources typically recognized OA impact on quality of life, evidence of OA, trial of conservative treatments, and did not discuss elements of shared decision-making. -- Conclusion. When determining appropriateness of elective TJA for primary hip and knee OA, clinical practice and instruments typically focus on OA symptoms negatively impacting quality of life and radiographic evidence of OA, while trial of conservative treatments is less reported. The appropriateness decision-making process poorly acknowledges or supports patient preferences (e.g., shared decision-making). Appropriateness of elective TJA needs to be reconsidered and conceptualized in a way that supports early conservative treatments and patient-centred care.