Enhancing interprofessionalism in shared decision-making training within homecare settings: a short report

ABSTRACT

Training in shared decision-making (SDM) often focuses solely on dyadic relationships between one healthcare provider and one patient. However, many healthcare decisions often involve two or more health professionals. These decisions warrant utilizing an interprofessional shared decision-making (IP-SDM) approach which enables patients and their caregivers to face difficult decisions around care together. Most existing SDM training programs fall short when building interprofessional (IP) competencies and require an approach that integrates IP with SDM. This short report discusses the creation and trial implementation of three enhanced education tools (a video, role-play exercise with decision aid, and an IP observation aid) for an IP-SDM workshop focused on helping homecare teams collaborate with seniors and their caregivers throughout the decision-making process. We developed and implemented these tools in eight study sites of a larger randomized control trial to test the training workshop for homecare teams. The workshop and tools helped participants overcome interprofessional challenges in their work. Participants evaluated the tools and workshop, which offered guidance to better translate teachable IP collaboration competencies within SDM.

KEYWORDS:

• Interprofessional education
• continuing professional development
• shared decision-making
• seniors
• home care
• interprofessional care

Introduction

Seniors face complex health problems requiring collaboration between multiple health professionals. In homecare settings, interprofessional (IP) collaborations are critical to establishing shared understandings of seniors’ needs and make comprehensive responses. Furthermore, for care to be patient-centric, seniors and their caregivers must be included in care discussions to ensure their goals and preferences are considered. This type of collaboration is called the interprofessional shared decision-making (IP-SDM) approach (Legare et al., 2011). This approach proves particularly applicable in homecare settings, where multiple members of the homecare team collaborate with seniors to discuss options, evaluate risks, and make decisions that consider best available options and senior preferences. As with the traditional dyadic approach to SDM, professionals and care teams require training in the IP-SDM approach if it is to be routinely practiced.

Collaborative teamwork requires attaching time and value to role clarification, resolving IP conflict, sharing leadership and understanding team dynamics (CIHC, 2010). Currently, very few SDM training programs have an IP focus and provide little guidance for converting these elements into teachable competencies. We created a 3.5 hour workshop to build competencies in both SDM and IP collaboration. We adapted and added to an existing new IP- SDM training for homecare teams by tailoring components of the workshop (video, role-play exercise with decision aid, interpretive aid, and role-play manual) using the IP-SDM conceptual model (Figure 1) to align with the IP-SDM approach (Legare et al., 2011). IP-SDM is a process whereby two or more health professionals collaborate with a client to identify and discuss options in making healthcare decisions (Legare et al., 2011). Thus, we designed a multi-phase process to develop and test the interpretive aid consisted of a theory-based IP-SDM video observation grid for teaching IP-SDM to participants. This short report describes the workshop development process, the tools utilized and how we adapted the training module for improved efficacy. This manuscript presents workshop findings and considerations for future IP-SDM training programs.

Figure 1. Study flow showing the steps for the design, implementation and assessment of the IP-SDM intervention among IP home care teams.

Methods

Team and timeline

An expert interdisciplinary committee of clinician-scientists, a healthcare manager, researchers, a social worker, family doctor, and nurse met regularly between September 2014 and February 2015 to co-develop workshop components. There were no patients on the committee, however caregivers co-developed the decision aid central to the workshop.

Conceptual frameworks

Three frameworks guided workshop component development and modification. First, the IP-SDM approach model outlines the key steps in the SDM process (1. agreeing on the decision being made; 2. exchanging information; 3. clarifying preferences and values; 4. discussing option feasibility; 5. eliciting preferred choices; 6. making a decision; 7. implementing that decision) and illustrates how the patient, their family and IP teams can interact at each step to make shared decisions and arrive at positive outcomes (Legare et al., 2011). Second, the National Interprofessional Competency Framework (NICF) (Canadian Interprofessional Health Collaborative (CIHC), 2010) defines four main IP competency domains (role clarification, conflict resolution, team functioning and collaborative leadership) and provides descriptors for how these domains translate into specific IP practices. Finally, we based the overall layout of workshop components on the Theory of Planned Behavior (TPB) (Ajzen, 1991) and our assessment of each team’s intentions to adopt the IP-SDM approach.

IP-SDM video

We revised and refilmed an existing SDM video (Stacey et al., 2014) in order to integrate scenes highlighting teamwork among different homecare professionals (a social worker, nurse, and physiotherapist). The video and training components were developed in French, then translated into English to reach English speakers bilingual teams. The updated 19-minute video showed a senior and her daughter making a decision about whether to remain at home or move to a residential care facility. It showcased different members of the homecare team working together to support the senior and her daughter at different moments throughout the decision-making process, while exemplifying the four key IP competency domains of the NICF. As we wished to offer the tutorial in both French and English, the video was refilmed using professional bilingual actors to maintain consistency between the two versions.

IP observation aid

Using a systematic theory-driven development process, we created an aid to accompany the video entitled GO-VIP (Grid to ObserVe IP-SDM) (See Supplementary File). This one-page aid contained 15 questions based on the IP-SDM and the NICF models. It highlighted the IP aspects applied by the homecare team during the decision-making process. Participants also used it as a resource during group discussions to reflect on their own IP collaboration experiences.

IP role-play

Inspired by best practices (Streiner & Norman, 1995) in developing effective role-play, we developed a scripted role-play scenario and decision aid to guide participants through the exercise. This allowed participants in the workshop to re-enact a similar situation to that in the video, practicing the IP-SDM approach. Research team members facilitated the role-play activity and showed how multiple professionals can engage and support decision-making in similar settings.

Workshop assessment

Participants completed a survey to evaluate the workshop. Before and after the workshop, participants rated their confidence using the decision aid and the IP-SDM approach with their clients and in their clinics. Evaluation scales were set from 0–10 (“none” to “extremely strong”) using a retrospective pre/post intervention method (Yank, Laurent, Plant, & Lorig, 2013).

Results

A total of 219 participants attended the workshops offered to eight IP homecare teams in Quebec City. Participants included social workers, nurses, occupational therapists, clinical coordinators, health and social services assistants, physiotherapists, therapeutic health technicians, registered respiratory therapists, psychologists, a manager and a dietitian. Participants rated their confidence at an average of 8/10 (range 5–10) when using the IP-SDM approach and supporting seniors during the decision-making process.

Out of 219 participants, 164 rated the workshop as ‘excellent’ and 51 as ‘good’. For the video vignette presentation and group discussion, 121 participants rated them as ‘excellent’, 95 as ‘good’, and 2 as ‘weak’. The role-play exercise and discussions took an average of 90 minutes, with 150 participants rating it and the decision aid as ‘excellent’, and 67 as ‘good’. Qualitative comments from participants commended the workshop and indicated that the role-play exercise, decision aid and video vignette were equally appreciated. Health and social services assistants particularly appreciated the workshop as their input is often overlooked. These assistants believe they should be involved in the IP-SDM process due to their daily interactions supporting seniors with personal and hygiene needs, and may better understand the senior’s health, abilities and wishes. Criticisms of the workshop were few but included not enough time for the exercise and difficulty stepping into the role of another healthcare professional without background information or prompts.

Discussion

The workshop’s purpose was to train homecare professionals in using the IP-SDM approach to support seniors when making decisions about the best location of care. ‘Best location’ takes into account the senior’s wishes, input from their caregiver(s) and/or family, and the senior’s capacity and health. This method of training facilitates discussion and practical training amongst IP healthcare teams. The suite of new IP-enhanced SDM training tools addressed challenges IP teams face in applying both SDM and IP-SDM in regular practice. The video, IP observation aid, and role-play exercise with the decision aid allowed participants to re-enact their interprofessional and/or shared decision-making experiences within different roles; for example, a medical physician in a social worker role. However, this exercise presented a challenge in knowing how other professionals practice or approach decision-making (e.g. social worker vs. geriatric nurse).

Ultimately, we found that while participants are generally excited about adopting SDM in their interactions with seniors, they do still face barriers (organizational, time restraints, etc.) with the IP aspect. This suggests a future direction for IP-SDM implementation could be developing another tool to improve IP collaboration (e.g. a separate team building or communication exercise). Additionally, homecare workers or health and social service assistants should also be included in IP-SDM discussions, as they may have a better understanding of family dynamics and patient wishes than practitioners may. These individuals can help practitioners contextualize the needs of patients and should be considered part of the team.

Conclusion

This workshop aimed to increase SDM capacities among IP teams by addressing the varied understandings among healthcare professionals and how they approach SDM. Adopting the IP-SDM approach helps combine essential IP competencies with SDM practices that focus on individual healthcare providers collaborating with the patient. While our workshops were strongly supported by homecare team managers, we found that it was difficult to demonstrate in the workshop  the managerial support and leadership necessary to implement the approach a challenging limitation to include in the workshop. The challenge was in simulating the level of commitment clinics must have to implement IP-SDM as standard practice. Addressing this issue requires conceptual innovation, behaviour change theory and adaptability mechanisms for varied organizational contexts.

Declaration of interest

The authors report no conflicts.

Data Availability

Data and components for this study can be made available by request to the corresponding author.

Acknowledgments

The authors thank Mary Zettl for revising this manuscript for publication.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website.

Additional information

Funding

This research was funded by Canadian Frailty Network, supported by Government of  Canada's Networks of Centres of Excellence (NCE) Program. It was formerly known as the Technology Evaluation in the Elderly Network, TVN.