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Shared decision making through reflective practice: part II.

Part I of this series reviewed background literature and considered descriptions of shared decision making, including the process and outcomes (Truglio-Londrigan, 2016). Part II now focuses on competencies of shared decision making with examples of the knowledge, behaviors, and attitudes needed if shared decision making is to be realized. It also demonstrates how self-reflective questioning assists the clinical nurse to integrate these competencies in practice.

Competencies for Shared Decision Making

Competencies necessary for shared decision making include reflective practice, nurse-patient relationship, communication, assessment, cultural knowing, teaching and learning, ethical knowing, interprofessional practice, and negotiation (Truglio-Londrigan, 2013; Truglio-Londrigan, Slyer, Singleton, & Worral, 2014; Truglio-Londrigan, 2015).

Reflective Practice

As nurses and patients contemplate care decisions together, they should reflect throughout the process. Self-reflection is a multistage process including awareness of an uncomfortable feeling or thought; critical analysis of the situation, including questioning; and development of a new perspective (Atkins & Murphy, 1993). Schon (2006) introduced the concepts of reflection-in-action and reflectionon-action for reflective practice. Reflection-in-action promotes the belief healthcare providers may "think about what we are doing" (p. 54) while doing it. While healthcare providers and patients individually and collectively think about what they are doing, they also are " the process, evolving their way of doing it" (p. 56). Reflection-on-action takes place after the interaction, as healthcare providers think about a past project, "a situation they have lived through, and they explore the understandings they have brought to their handling of the case" (p. 61). Nurses need to reflect on their knowledge, behaviors, actions, attitudes, and responses to others while considering how others are responding to them. Self-reflective questioning facilitates nurses' ability to gain greater clarity in practice as they see themselves in relation to their patients and the shared decision-making process.

Zoffmann, Harder, and Kirkevold (2008) identified the need for patient and provider reflection that ultimately uncovers person-specific information needed for shared decision making. Authors noted how patients' reflections were equally important to gain insight into their own world and decisions to be made. Competencies for communication are discussed below and provide insight on how nurses may assist patients with their reflections. Nurses' reflective practice begins with questions. What do my patients see, hear, and understand? How am I responding to my patients?

Competency: Nurse-Patient Relationship

Hildegard Peplau (1952) provided a framework for nurses' understanding of the nurse-patient helping relationship as the nexus from which all interactions emerge, creating personal-social growth. Millard, Hallett, and Luker (2006) stressed the importance of the nurse-patient relationship as the vehicle for the exchange of necessary information for shared decision making. They suggested a need exists for nurses to "devote more time to relationship-building in nursing practice" (p. 143) and to "pay attention to the quality and nature of the relationships they have with their patient" (p. 149). The quality of this relational partnership is characterized by Gallant, Beaulieu, and Carnevale (2002) as a "power-with" (p. 154) relationship in which power is shared as two individuals work together. This power balance is in opposition to a relationship in which the patient feels disempowered and lacks '"the right' to be involved in healthcare decisions" (Peek et ak, 2009, p. 1136).

These ideas open dialogue on the type of skills needed to become competent if shared decision making is to be implemented and sustained. Being knowledgeable about the phases of the nurse-patient relationship thus is important. Equally important is the nurse's ability to reflect on the quality and nature of the relationship. To assist in the achievement of this type of relationship, important reflective questions include the following: How do I feel about being in a participatory relationship in which there is shared decision making? How comfortable am I in a nurse-patient relationship in which there is a balance of power?

Competency: Communication

Developing an effective nursepatient relationship through communication is key to achieving shared decision making. Communication is intrinsic to the nursepatient relationship in all stages. It is so much more than what is portrayed by communication models of sender, receiver, and feedback. Nurses communicate to come to know the patient, retrieve information, determine what the patient knows and does not know, counsel, coach, and teach. The nurse also must be competent in communicating with families and other members of the interprofessional team. Effective communication is needed to build trust. Hupcey, Penrod, Morse, and Mitcham (2001) noted the topic of trust is embedded in conversations in the nursing literature about the nurse-patient relationship. Johns (1996) discussed the concept of trust as both process and outcome. As a process, it is dynamic, evolutionary, and developmental, and begins when a patient enters a relationship with a nurse. At the outset, the patient may perceive risk because he or she does not know if the nurse will do or perform as needed. A sense of trust determines if the patient will be open to the nurse and engage in shared decision making (Matthias, Salyers, & Frankel, 2013; Truglio-Londrigan, 2013; Truglio-Londrigan et al., 2014).

To create the shared decision-making experience, the nurse must be competent in communication skills. This in turn strengthens the nurse-patient relationship and creates the context for sharing. Part of this patient-centered communication involves the nurse's ability to communicate continual patient support, counseling, and coaching (Coulter & Collins, 2011). When communication is effective, the patient is aware the nurse is listening and being attentive, supportive, and available. The nurse also uses communication skills to foster reflection by the patient, family, or other team members (Zoffmann et al., 2008). Being knowledgeable about models of communication is important; however, nurses also must engage in self-reflective questioning so they may see beyond the static depiction portrayed by these models and understand the depth of the communication process. Reflective questioning in this regard may include the following: How do I feel about participatory communication? How do I feel about the time needed to communicate in an environment where time as a resource may be limited?

Competency: Assessment

Assessments provide information to guide nurses' decisions and create a shared decision-making environment. Questions about age, sex, family, educational level, illness, and impact of illness on dayto-day living may reveal factors that influence active participation in shared decision making (Clark et al., 2009). For example, some evidence suggests younger individuals may be more favorable to shared decision making than older persons. In addition, individuals with limited education and literacy, or those experiencing a severe illness, may be more inclined to have the healthcare provider take the more active role (Clark et al., 2009; Salmond, 2015; Shalowitz & Wolf, 2004). Performing an assessment, however, facilitates a practice not based on assumptions or broad strokes. Conducting assessments provides nurses with information to share with patients. This sharing is important to ensure, for example, an older adult who wishes to be engaged in decision making has the opportunity to do so and is not overlooked based on age. Furthermore, assessments will identify patient preferences and help nurses create a climate in which shared decision making is driven by the patient. Not every individual may want to participate actively in shared decision making; assessments offer these patients the opportunity to make their desires known (Lown, Hanson, & Clark, 2009).

Being knowledgeable about different types of assessments and how to gather information is important for practicing nurses. However, nurses must engage continually in questions that provide a deeper understanding of gathered information. Self-reflection questions (What am I hearing? Seeing? What does this information mean for the patient?) followed by a return to the patient for input ensures a practice based not on assumptions but on participation and shared decision making.

Competency: Cultural Knowing

Culture has been defined as "the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life-ways, and all other products of human work and thought characteristic of a population of people that guide their world view and decision making" (Purnell, 2013, p. 6). An individual's worldview involves perceptions, interpretation, and understanding (Clarke, McFarland, Andrews, & Leininger, 2009; Davidheiser, 2008; Leininger & McFarland, 2002). This worldview affects how a person makes decisions. Nurses who work with a patient must be aware of and understand the patient's worldview and its possible effects on his or her engagement in shared decision making. This information informs nurses of the importance of the previous competency (assessment) and illustrates the interrelatedness among the competencies of shared decision making. Working with patients and families, nurses must come to know, recognize, and support their ideas, values, and beliefs (Salzburg Global Seminar, 2010) and remain aware of the potential for variations. The Cultural Competencies Documents for Baccalaureate, Graduate and Doctoral Education published by the American Association of Colleges of Nursing (2016a, 2016b) offered a framework for cultural competencies. Campinha-Bacote (2002) also presented the process of a cultural competence model which addresses cultural awareness, knowledge, skill, encounters, and desire. Reflective questions to assist nurses in attaining cultural competence leading to shared decision making include the following: How do I feel about the ideas, values, and beliefs of patients not in alignment with my own?

Competency: Teaching and Learning

Florin, Ehrenberg, and Ehnfors (2008) discussed the knowledge gap that exists between nurses and patients as a barrier to patients sharing in decisions. The idea of a knowledgeable patient needing information about his or her conditions and options for health management has been identified as a strategy to facilitate shared decision making (Coulter & Collins, 2011; National Voices, n.d.; The Health Foundation, 2012). The nurse-patient relationship can be the vehicle that allows information exchange to occur to address the knowledge gap. Millard and coauthors (2006) further discussed this information exchange as the "concomitant power transfer from nurse to patient and vice versa" (p. 143). Education for shared decision making was a major theme for Truglio-Londrigan (2013), including the importance of understanding what the patient needed to know. Furthermore, the assessment will help nurses determine how to deliver the needed information. Knowledge about what information to deliver and how to deliver it is derived from ongoing assessments and evaluations. Nurses' reflective questioning about how they feel when they become involved in the process of closing that knowledge gap includes the following: How important is it for me to know my patients have the information they need to share in decisions? How do I feel about sharing the information?

Competency: Ethical Knowing

According to Stewart and Belle Brown (2001), practicing in a patient-centered care environment marked by shared decision making requires a shift in how nurses see and work with patients. Patients are no longer viewed as passive. This idea presents certain challenges for nurses. For example, the shared decision-making experience may create conflict between ethical principles of autonomy and beneficence. As nurses relinquish authority to create a participatory practice with shared decision making, a patient's goals, preferences, and values may compete with the healthcare provider's goals. Moulton and King (2010) addressed this conflict by noting a possible balance between autonomy and beneficence. Nurses need to be aware of theories and models that may assist them to achieve this balance. For example, the work of Gilligan (1995, 2005) focused on caring and relationship that may facilitate a complementary vision toward shared decision making. Being knowledgeable about different ethical models and principles is important, but nurses must be able to delve deeper and engage in reflective questioning. This is particularly important when patients, who are knowledgeable and have the necessary information, decide in opposition to best practice. Reflective questioning may include the following: How do I feel when decisions do not agree with my own ideas, values, and beliefs? How do I feel when patients and families make decisions not based in best practice?

Competency: Interprofessional Practice

Traditionally, shared decision-making models focused on the dyad of the nurse and the patient. Models have been expanded recently to reflect the existence of interprofessional teams working with the patient, family, professional groups, and community-based organizations. The Interprofessional Shared Decision-Making Model (IPSDM) (Legare et al, 2011a, 2011b) is one example of a model for this collaborative decision sharing. The IPSDM challenges all providers to enhance their competencies to include understanding the roles, responsibilities, and expertise of other professions. Korner, Ehrhardt, and Steger (2013) discussed the need to strengthen teamwork skills, such as cooperation, coordination, and collaboration. Resources to support these decision-making models may be necessary. For instance, education programs and organizations can include teamwork, consensus building, decision aids, and outside professional guidance. Additional information that highlights core shared decision-making competencies for an interprofessional collaborative practice is found in the work of the Interprofessional Education Collaborative Expert Panel (2011). Reflective questions to assist nurses in attaining competencies of interprofessional practice for shared decision making include the following: How do I feel about working in teams? How do I feel about sharing information?

Competency: Negotiation

Conflict generally involves two or more individuals who may be in opposition to one another, primarily due to differences in values, beliefs, perceptions, and motivations (Almost, 2006; Segal & Smith, 2013). Within the context of shared decision making among nurses, patients, and/or interprofessional team, conflicts may arise (Coulter & Collins, 2011). Perceived opposition creates a climate in which individuals may feel threatened, triggering emotions (Brinkert, 2011) and thus compounding the conflict. Working through and resolving the conflict may require creative problemsolving approaches and negotiation (Coulter & Collins, 2011).

Negotiation may be a method to resolve conflict (Roberts & Krouse, 1988). It is seen as a process of communication (Dandry Aiken, 2004) that leads to common ground and an understanding of another's ideas (Oien, Steihaug, Iversen, & Raheim, 2010). Billings (2011a) identified the importance of being aware of potential conflict as soon as possible and being proactive by scheduling meetings where clear communication, information sharing, and working together lead to negotiation, consensus, and resolution of conflict (Billings, 2011b). This proactive strategy increases satisfaction among family and patients.

Conflict may be uncomfortable for many nurses. Further complicating the experience is the limited understanding of the process of negotiation by many nurses. Ultimately, the primary challenge is to accept conflict, recognize its existence, and engage in negotiation leading to a resolution. Nurses should challenge themselves and raise reflective questions to achieve greater clarity. Possible reflective questions include the following: How do I feel when there is conflict? How do I respond to conflict?

Nursing Implications

A shared decision-making practice requires the achievement of competencies. Nurse educators in academic and practice settings have the challenge and responsibility to ensure competencies are developed and implemented throughout the curriculum. Practicing nurses also hold responsibility and accountability to question their practice moment by moment, day by day, challenging themselves in their determination to achieve these competencies. The implications for a practice based in shared decision making require nurses to:

* Reflect upon their practice and acknowledge their ideas, values, and beliefs about shared decision making, power balance, and power sharing.

* Identify and eliminate barriers to shared decision making and work with the patient to develop strategies that illustrate the patient's ideas, values, and beliefs.

* Develop effective, efficient ways to provide information to patients so they can make informed decisions.

* Participate in organizational committees and advocate for shared decision making by encouraging resource allocation for consultations and educational resources. Case study practice examples that illustrate these competencies and corresponding questions are provided in Table 1.


The process and potential outcomes of shared decision making were described. The competencies that facilitate shared decision making also were presented. The knowledge, behaviors, and attitudes to achieve these competencies along with a reflective approach were highlighted. Every practicing nurse is responsible to determine if he or she holds these competencies, and seek ways to strengthen and integrate them into practice. To this end, self-reflective questions are essential. Self-reflective questioning assists nurses in their ability to gain greater clarity in their relation to patients and further facilitates the shared decision-making process. Equally important is nurses' willingness to work with organizations to ensure resources that support shared decision-making practice.


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Billings, J.A. (2011a). The end-of-life family meeting in intensive care part I: Indications, outcomes, and family needs. Journal of Palliative Medicine, 14(9), 1042-1050. doi:10.1089/jpm.2011.0038

Billings, J.A. (2011b). The end-of-life family meeting in intensive care part II: Family-centered decision making. Journal of Palliative Medicine, 14(9), 1051-1057. doi:10.1089/jpm.2011.0038-b

Brinkert, R. (2011). Conflict coaching training for nurse mangers: A case study of a two-hospital health system. Journal of Nursing Management, 19(1), 80-91. doi:10.1111 /j.1365-2834.2010.01133.x

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Clarke, P.N., McFarland, M.R., Andrews, M.M., & Leininger, M. (2009). Caring: Some reflections on the impact of the culture care theory by McFarland & Andrews and a conversation with Leininger. Nursing Science Quarterly, 22(3), 233-239. doi:10.1177/08943184 09337020

Clark, N.M., Nelson, B.W., Valerio, M.A., Gong, M., Taylor-Fishwick, J.C., & Fletcher, M. (2009). Consideration of shared decision making in nursing: A review of clinicians' perceptions and interventions. The Open Nursing Journal, 3, 65-75.

Coulter, A., & Collins, A. (2011). Making shared decisions-making a reality: No decision about me, without me. London, England: Foundation for Informed Medical Decision Making.

Dandry Aiken, T. (2004). Legal, ethical, and political issues in nursing (2nd ed.). Philadelphia, PA: F.A Davis Company.

Davidheiser, M. (2008). Race, worldviews, and conflict mediation: Black and white styles of conflict revisited. Peace and Change, 33(1), 60-89.

Florin, J., Ehrenberg, A., & Ehnfors, M. (2008). Clinical decision-making: Predictors of patient participation in nursing care. Journal of Clinical Nursing, 17(21), 2935-2944.

Gallant, M.H., Beaulieu, M.C., & Carnevale, F.A., (2002). Partnership: An analysis of the concept within the nurse-client relationship. Journal of Advanced Nursing, 40(2), 149-157.

Gilligan, C. (1995). Flearing the difference: Theorizing connection. Hypatia, 10(2), 120-127.

Gilligan, C. (2005). Images of relationship. North Dakota Law Review, 87(4), 693-727.

Hupcey, J., Penrod, J., Morse, J., & Mitcham, C. (2001). An exploration and advancement of the concept of trust. Journal of Advanced Nursing, 36(2), 282-293.

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Educational Collaborative.

Johns, J. (1996). A concept analysis of trust. Journal of Advanced Nursing, 24(1), 7683. doi :10.1046/j. 1365-2648.1996. 16310.x

Korner, M., Ehrhardt, H., & Steger, A.-K. (2013). Designing an interprofessional training program for shared decision making. Journal of Interprofessional Care, 27(2), 146-154. doi:10.3109/ 13561820.2012.711786

Legare, F., Stacey, D., Briere, N., Desroches, S., Dumont, S., Fraser, K., ... Aube, D. (2011a). A conceptual framework for interprofessional shared decision making in home care: Protocol for a feasibility study. BMC: Health Services Research, 11(23), 1-7. doi: 10.1186/1472-6963-11-23

Legare, F., Stacey, D., Pouliot, S., Gauvin, FP., Desroches, S., Kryworuchko, J., ... Grahm, I. D. (2011b). Interprofessionalism and shared decision-making in primary care: A stepwise approach towards a new model. Journal of Interprofessional Care, 25(1), 18-25. doi:10.3109/13561820.2010.490502

Leininger, M., & McFarland, M.R. (Eds.), (2002). Transcultural nursing: Concepts, theories, research & practice (3rd ed.). New York, NY: McGraw Hill.

Lown, B.A., Hanson, J.L., & Clark, W.D. (2009). Mutual influence in shared decision making: A collaborative study of patients and physicians. Health Expectations, 12(3), 160-174. doi:10. 1111 /j.1369-7625.2008.00525.X

Matthias, M.S., Salyers, M.P, & Frankel, R.M. (2013). Re-thinking shared decisionmaking: Context matters. Patient Education and counseling, 91(2), 176-179. doi:10.1016/j.pec.2013.01.006

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Moulton, B., & King, J.S. (2010). Aligning ethics with medical decision-making: The quest for informed patient choice. Journal of Law, Medicine & Ethics, 38(1), 85-97.

National Voices, (n.d.). Prioritizing person-centered care: Supporting shared decision-making. London, England: Author.

Oien, A.M., Steihaug, S., Iversen, S., & Raheim, M. (2010). Communication as negotiation processes in long-term physiotherapy: A qualitative study. Scandinavian Journal of Caring Sciences, 25(1), 53-61. doi: 10.1111/j.1471-6712. 2010.00790.x

Peek, M.E., Wilson, S.C., Gorawara-Bhat, R., Odoms-Young, A., Quinn, M.T., & Chin, M.H. (2009). Barriers and facilitators to shared decision-making among African-Americans with diabetes. Journal of General Internal Medicine, 24(10), 1135-1139. doi: 10.1007/sl 1606-009-1047-0

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Shalowitz, D.I., & Wolf, M.S. (2004). Shared decision-making and the lower literate patient. Journal of Law, Medicine & Ethics, 32(4), 759-764.

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Truglio-Londrigan, M., Slyer, J., Singleton, J., & Worral, P. (2014). Aqualitativesystematic review of internal and external influences on shared decision-making in all health care settings. Joanna Briggs International Database of Systematic Reviews and Implementation Reports, 12(5), 121-194.

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Truglio-Londrigan, M. (2016). Shared decision making through reflective practice: Part I. MEDSURG Nursing, 24(4), 260-264.

Zoffmann, V., Harder, I., & Kirkevold, M. (2008). Person-centered communication and reflection model: Sharing decision-making in chronic care. Qualitative Health Research, 18(5), 670-685. doi:10.1177/1049732307311008

Marie Truglio-Londrigan, PhD, RN, is Professor, Pace University, College of Health Professions, Lienhard School of Nursing, Pleasantville, NY.
Practice Examples and Reflective Questions

Practice Example                            Reflective Questions

K.R., a nurse and member of the quality     As you read the
and safety team, was reflecting on the      practice-based
process of informed consent.                example, what
Her past experience with informed           competencies do you
consent caused her to question if her       see present?
patients were informed adequately and
knowledgeable about risks associated        Reflect on your
with procedures or other options.           practice. Do you
K.R. believed informed consent was an       identify with K.R.'s
example of shared decision making.          concerns?
She brought her concerns to the quality
and safety team to identify best            If so, what are some
practices for the informed consent          steps you can take in
process that could be facilitated by        your own organization?
shared decision making. The team's
members include an array of
interprofessionals as well as members
of the local community and past patients.
The goal of this initiative was to
develop an informed consent process to
ensure discussion of the patient's
condition that warrants a decision for
a particular procedure, potential risks
and benefits of the choice, alternative
options and their potential outcomes,
the impact each choice would have on
the patient's lifestyle and
responsibilities, congruence of each
choice in relation to patient
ideas/values/beliefs, along with the
necessary education for the patient to
share in the informed choices to
consent or not to consent.

A.T. is a 50-year-old intellectually        As you read the
disabled adult who does not have the        practice-based
ability to engage in decision making.       example, what
Her legal guardian is her sister T.T.,      competencies do you
who recently was diagnosed with breast      identify?
cancer. A family history prompted T.T.
to receive genetic counseling. Genetic      Reflect on your
testing showed T.T. was BRCA-positive.      practice. If you are
Results initiated a discussion that         called to care for A.T.,
included A.T.'s group home professionals    what shared decision-
(nurse, social worker, psychologist), as    making competencies
well as her primary care provider and       would you use?
the family's spiritual advisor.
An initial decision was made to             What would be a
complete genetic testing for A.T. as        challenge for you?
well. The genetic test results confirmed
she was also BRCA-positive. The question    How would you
for T.T. and A.T.'s healthcare providers    advocate for A.T. and
concerned possible next steps, if any.      her family to ensure
The team met again for further              shared decision
consultation and reflection. The end        making?
result of this consultation was the
decision to remove A.T.'s ovaries to
achieve some level of risk reduction.
The healthcare providers also believed
she would be able to tolerate the
procedure given her physical, emotional,
psychological, and cognitive abilities.
A.T. was scheduled for an oophorectomy.
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Title Annotation:Expert Practice
Author:Truglio-Londrigan, Marie
Publication:MedSurg Nursing
Article Type:Report
Date:Sep 1, 2016
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