Medical Decision MakingDeveloping a dyadic OPTION scale to measure perceptions of shared decision making
Introduction
Although shared decision making in clinical encounters is clearly the result of an interaction between two individuals, attempts to measure this phenomenon have, so far, been limited to single viewpoints, most often from the viewpoint of an observer assessing a recording of the dialogue [1], [2]. Whilst such assessments have provided valuable information to researchers in the field, they are inevitably limited in that they are restricted to what is audible or observable. They take no account, nor can they, assess the perceptions of those who are involved in the process of understanding the nature of decisions, negotiating their role in the decision process, and taking action to deliberate and decide. Yet there is evidence that patients differ in their evaluations of such encounters, their perception of involvement is different to the perception of clinicians [3]. We have little information as to whether these ‘internal’ perceptions correlate with those of external observers, or indeed as to how this interdependence in dyadic interaction affects the outcome of the encounter [4], [5], [6]. There is a need therefore to develop a measure which attempts to address this research gap and which could provide more information about the perceptions of those engaged in these complex, negotiated encounters. For consultations that require participation in decision making, and in particular where attempts are made to share decisions, the interactions will require both parties to address the issues of decisional equipoise, compare the features of options and achieve consensus about the best actions: in short, to achieve ‘shared decision making’ [7].
Although the term ‘dyadic analysis’ is relatively novel in healthcare settings, there is a growing interest in the concept of interdependence in health communication research [8]. Statistical methods used to analyse data gathered from health care encounters, including those focused on shared decision making, typically assume independent actors. However, in contrast, dyadic analysis methods assume an interaction effect between the individuals involved, and, rather than skate over the issue of mutual influence, accept that non-independence should be investigated, and in some occasions, may be the main outcome of interest [9]. To facilitate these investigations, new or adapted measurement instruments are needed in order to allow assessments from dual, or more, perspectives. It is noteworthy how few instruments exist that are capable of providing such data in health care settings [10].
However, instruments do exist which have been designed to measure shared decision making in clinical practice, most often from a third observer point of view [1], [2], [11]. Two of the most widely used have been the Braddock scale, representing six elements of informed decision making [12] and the observer OPTION scale, developed to measure the extent to which clinicians involve patients in decision making [13], [14]. Both instruments require an independent, trained observer to rate achievement against defined competencies in audio or video-taped consultations. Although these tools have provided valuable data about decision making processes in clinical encounters, they are only able to represent external assessments: the perceptions of participants engaged in the interactions remain unavailable [4]. COMRADE [15] and the Perceived Involvement in Care (PICS) [16], are examples of instruments which aim to measure patients’ perception of involvement in decision making but neither were designed so that they could assess interdependence between participants in the encounter.
We conclude therefore that a gap exists and that in order to apply the concept of dyadic analysis to clinical encounters, particularly to those where we wish to study perceived involvement and interdependence in shared decision making encounters, we either need to develop new tools or adapt existing tools. We took the view that an instrument used to tackle this task should meet the following criteria: to have a sound developmental pathway, clarity about its measurement construct, and evidence of item development and feasibility testing [17]. We also propose that tools capable of providing data for dyadic analysis need to have items that are identical for all respondents. In other words, item phrasing should be identical when administered to the clinician or to the patient. If we asked clinicians and patients to respond to items that were slightly different, we would run the risk of giving rise to different interpretations. We also decided to base a new scale on an existing tool, namely observer OPTION, a scale that has been rigorously developed to assess the degree to which clinicians involve patients in shared decision making, has psychometric data to support its uni-dimensional nature [13], [14].
These principles guided the adaptation of observer OPTION [14], into a ‘dyadic’ version’ and the steps taken are reported in this article. The aim of this study was to develop a dyadic version of the OPTION tool which is acceptable and understood by both patients and physicians and provides a platform for analysing interdependence in the consultation, specifically with regard to the measurement of shared decision making. To achieve this aim, we conducted three cycles of cognitive debriefing interviews.
Section snippets
Design and participants
Using the observer OPTION tool as a starting point, an initial modified twelve item version was created (by GE), adapted so that the items could be read and completed by both patient and clinician at the end of a consultation. Potential ambiguities and difficulties in comprehension were anticipated and an interview schedule was prepared with suitable probes. Cognitive debriefing has become an accepted method in questionnaire development [18]. The goal of cognitive debriefing is to facilitate a
Participants characteristics
Between November 2007 and April 2008, 27 cognitive debriefing interviews were conducted, during each round of interviewing. Six members of the public and three clinicians with educational or research affiliations participated in each cycle of interviews. Table 1 shows the breakdown of participant characteristics. Half of the 18 public respondents were male; seven of the nine clinicians were male. In each round, three of the public respondents regularly read The Sun, The Daily Mail or the
Discussion
This study demonstrates that, although difficulties occurred, it was possible to modify the observer OPTION instrument to be an instrument capable of being completed by both clinicians and patients after a dyadic interaction. The cognitive debriefing interviews revealed five areas of interpretative difficulty, namely: construct clarity, syntactical and grammatical problems, contextual positioning of the instrument and issues of personal preference. Interestingly, despite the apparent
Conflict of interest
The authors report no conflicts of interest.
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