**6. Is shared decision-making the norm nowadays?**

If the benefits of SDM are not conclusively proven, with not all patients wanting it and being potentially time consuming, why are doctors encouraged through the health systems to engage in such a practice? Whether research findings are conclusive or not, there are some other convincing reasons. In the UK, practicing SDM is supported and encouraged by the General Medical Council, General Dental Council, and government policy. It is considered as an ethical and legal imperative and underpins government legislation [18]. The National Health System (NHS) of the UK, has recognized the importance of patient involvement in treatment decision and adopted SDM into the redesigned health-system through a recent Health and Social Care Act. The government has provided the legislation for SDM to become the norm. With the mantra 'no decision about me without me', SDM is now a statutory requirement for the commissioning board of the NHS and local clinical commissioning groups [19, 20].

In order to support developments in this area, a Shared Decision-Making Collaborative has been established in 2015. It comprises members from the statutory sector, patient and voluntary sector organizations and academia committed to thinking collectively about the role of SDM in UK health systems [21]. Throughout Europe there is an increasing awareness that patients should be allowed to play a crucial role in decision-making and care management. WHO is encouraging SDM practices as innovative strategies to support patient-centered health services and promote patient rights [22]. WHO indicates that most research on SDM in Europe has occurred in Northern European countries, however, the SDM approach may fit also the Mediterranean region with different socioeconomic and cultural factors and lower degree of patient empowerment and communication.

SDM is of international importance and is currently promoted in many health systems. The reasons for these changes include the expansion of patients' knowledge on different conditions and treatments through the internet and mass media and the increasing number of therapeutic options available. The increased preference for more active patient involvement, by both, the patient and the physician is also a key factor [23]. According to [24] SDM requires collaboration between patients and healthcare professionals who work together to select the appropriate management, treatment and support, based on patient preferences and needs, physician experience and evidence-based data. It can improve patient involvement in healthcare and help provide effective services.

One recent study by [25] on SDM in mental health services, reveals that this application is a continuous, dynamic, and difficult process that requires every mental health professional to internalize his characteristics, facilitate patient involvement, and create a culture of trust in the management process of treatment. It is reported that SDM balances the power and responsibility for creating safe care. This balance requires continuous thinking and evaluation of patient resources, constraints and need for assistance to give them the power (patient empowerment) and responsibility to be able to manage the different needs during various phases of illness and management. The patient's functionality may change over time, so, in order to ensure safe care, mental health professionals must always compensate for the strength and responsibility that the patient cannot maintain.

The main provisions for the implementation of SDM are that health professionals recognize that different medical situations require different approaches, as well as accepting SDMs as a key element of good practice [26]. It is understandable that healthcare professionals know that facilitating patient participation is important, as many patients either do not want to, or, are unable to participate in the recovery process. Grol et al. [27] report that patients need flexible services to accommodate their changing needs. It was argued that when patients have severe symptoms, they need care and less responsibility. When they have fewer symptoms, there is a growing need for empowerment, active participation, and more responsibility for decisionmaking. Most patients want to be more informed about their health status, investigation, and management options than they are routinely given by health professionals, and many would like a greater share in the process of making decisions about how they will be treated. Bastiaens et al. [28] have shown that, patients are dissatisfied when they are not being properly informed about their condition and the options for treating it. However, not all patients want to share in making the decisions. For example, older people or those with life-threatening conditions tend to be more likely to prefer to delegate decision-making to the doctor as described by [29].

As suggested, different cultures or settings may influence the degree of patient involvement in decision making. A survey [29] showed that a more paternalistic view of the doctor–patient relationship prevailed in Poland and Spain than Germany, Italy, Slovenia, Spain, Sweden, Switzerland and the United Kingdom. 91% of Swiss and 87% of Germans felt that the patient should have a key role in their management decision, either by sharing responsibility with the doctor or by being the primary decision-maker. This percentage was much lower in Polish and Spanish patients - 59% and 44% respectively.

Clinicians should always try to find patient preferences through effective communication. Stevenson et al. [30] highlighted that they need to encourage patients if they are to play an active role in decisions about their care. As a result of this encouragement, patients become more involved, their knowledge improves, their anxiety lessens, and they feel more satisfied. Encouraging patients to play an active role in decisions regarding their healthcare can ensure better compliance to their treatment and management appropriately tailored to the individual.

#### **6.1 How to evaluate the process of shared decision-making**

SDM can be categorized and evaluated at its various stages, namely, before the decision (e.g. role preferences), during the decision-making process (e.g. observed or perceived physician behavior) or the outcome of decisions (e.g. conflict of decisions, satisfaction). The process may also be evaluated by an external observer, the patient, or the physician. Measuring SDM using observational tools is laborious, costly and not conductive to rapid data feedback.

The OPTION instrument ("Observing Patient Involvement in Decision Making") is an important tool for assessing the extent to which clinicians actively involve patients in decision-making [31]. Barr et al. [32] emphasize that this is the most frequently used instrument for measuring patient involvement from an observer's viewpoint. It has been developed to evaluate shared decision making specifically in

#### *Shared Decision-Making towards a Higher Quality of Care: Is This the Norm? DOI: http://dx.doi.org/10.5772/intechopen.98752*

the context of general practice, but it is intended to be generic enough for use in all types of consultations in clinical practice. The OPTION scale is designed to assess the overall shared decision-making process. In summary, it examines whether problems are well defined, whether options are formulated, information provided, patient understanding, and role preference evaluated, and decisions examined from both the professional and patient perspectives [33]. Recently it has, been revised in a shorter form, which evaluates the SDM process from its observer's viewpoint to just five OPTION-5 elements. Another way to measure and evaluate SMD is the CollaboRATE scale [34]. This is a fast and frugal a three-item patient-reported measure of SDM. It is applicable to a wide range of clinical settings, especially in the primary care setting where varied and unanticipated decisions are made [35, 36].

However, there are only two ways to evaluate the perceptions of both the patient and the doctor using the same process and these are (a) the dyadic OPTION [37] and the SDM-Q-9 [38, 13]; the latter is a 9-point decision-making evaluation questionnaire was developed on a case-by-case basis and measures the extent to which patients are involved in the decision-making process: from the view of the patient (SDM-Q-9) and from the physician's perspective (SDM-Q-Doc). These two tools have been developed for use, both, in research and every-day clinical practice. Both versions can be applied equally for purposes of assessing and improving quality in healthcare.
