Chapter 4 Shared Decision-Making Skills in Practice
Whilst client-centred therapy was first developed by Carl Rogers (Rogers 1939), it was not perhaps until the development of health promotion in the 1980s when the role of people in controlling and developing their own care became more prominent in international health care (WHO 1984). Within occupational therapy, client-centred practice was initially driven by Canadian Occupational Therapists (Canadian Association of Occupational Therapists/Department of National Health 1983), but has since become internationally recognized and embedded in ethical codes of conduct (COT 2005, COTEC 1996). Parker (2006) described practitioners views of client-centred practice as ranging from ‘quite simple’ to ‘daunting’. But what is client-centred occupational therapy?
Various definitions of client-centred occupational therapy exist. Law et al (1995) provided the first definition describing it as, ‘an approach to providing occupational therapy which embraces a philosophy of respect for and partnership with people receiving services. It recognises the autonomy of individuals, the need for client choice in making decisions about occupational needs, the strengths clients bring to an occupational encounter and the benefits of client therapist partnership and the need to ensure that services are accessible and fit the context in which a client lives’ (p. 250). Key features of client-centred occupational therapy that emerged from the work of Law et al (1995) included:
Later, Sumsion (2000) conducted research with British occupational therapists and developed the following definition of client-centred occupational therapy,
‘Client-centred occupational therapy is a partnership [author’s emphasis] between the client and the therapist that empowers the client to engage in functional performance and fulfils his/her roles in a variety of environments. The client participates actively in negotiating goals which are given priority and are at the centre of assessment, intervention, and evaluation. Throughout the process, the therapist listens to and respects the clients’ values, adapts the interventions to meet the clients’ needs and enables the client to make informed decisions’ [author’s emphasis] (p. 308).
Building on this definition, Parker (2006) drew out the following key features of client-centred occupational therapy:
Clear similarities can be seen between the key features highlighted by Law et al (1995) and Parker (2006). Of particular relevance to the subject of this chapter, however, is the concept of ‘Partnership’, which is clearly highlighted in both definitions and summary features, and ‘informed decision making’ which appears in Sumsion’s (2000) definition and in Parker’s (2006) summary.
Delivering client-centred practice is easier said than done. Maitra and Erway (2006) conducted a study of client and occupational therapist perceptions of client-centred practice. They aimed to, ‘conduct a comparative study of the perceptual involvement of clients and occupational therapists in the shared decision making [author’s emphasis] process in health care facilities in the United States’ and secondly, ‘to investigate whether there is a difference in the shared decision making [author’s emphasis]’ (p. 300). Whilst a relatively small study (11 occupational therapists and 30 clients were interviewed) interesting findings arose. The study indicated that whilst practitioners did involve clients in the process of goal setting and treatment planning, a perceptual gap existed between the samples in relation to practitioners’ use of client-centred practice and shared decision making: Clients did not always feel as if they participated in shared decision making, whilst practitioners believed they delivered it. Maitra and Erway’s (2006) work is of interest as it nicely highlights the daily challenges of undertaking client-centred practice and clearly links the concept of client-centred practice to the centrality of partnership working and shared decision making by practitioners and their clients.
Whilst occupational therapy literature is now replete with literature about client-centred practice, very little has been written about shared decision making. Yet a great deal has been written about shared decision making in the broader health-care literature (see for example Bekker et al 1999, Charles et al 1997, Bugge et al 2006), and is of relevance to occupational therapy practice today.
Shared decision making is one of many decision-making models in the health-care literature. Before describing shared decision making in more detail, it is worth considering some of the other major models of decision making in practice. Principle amongst these are the paternalistic model, the physician (or in this context practitioner) as agent model, and the informed decision-making model (Charles et al 1997).
The paternalistic model of decision making assumes that patients (as the word itself suggests) are passive recipients of care. This model is clearly outlined in the work of Talcott Parsons (1902–1979), an American sociologist, who conceptualized the sick role (Parsons 1952); which clearly positions professionals as experts and patients (as the word itself suggests) as passive receivers of care. However, this definition is, as the vast literature of informed and shared decision-making literature within medicine illustrates, no longer an accurate blanket description of medical decision making in practice. Occupational therapists too followed this model for some time (Wilcock 2002) until professional philosophical tensions moved the profession largely away from this model of decision making. However, whilst the profession’s overarching philosophy of care has changed, paternalistic practice can still be found – even in practitioners who express the desire to be client-centred (Daniëls et al 2002).
The following models of decision making have emerged, to a certain extent, as a reaction to the paternalistic model (Levine et al 1992, Deber 1994).
In the practitioner as agent model (a phrase adapted from the more commonly referred to physician as agent model (Charles et al 1997)) the professional retains overall control of the decisions that are made. However, in this model there is a clear expectation that the practitioner will work to gain a comprehensive understanding of their clients’ preferences, desires and values and form their action plan on the basis of what they consider the client would desire. Despite the good intentions of a practitioner to deliver the care that a client desires, this model of decision making remains incongruous with the philosophy of current occupational therapy practice. However there may be times when this model is the closest one is able to get towards partnership working (see Vignette 4.1).
Vignette 4.1
Mark is a 9-year-old boy with severe learning difficulties. He lives at home with his parents, his 13-year-old sister and 11-year-old brother. Mark attends his local special needs school and his teacher has reported that he wanders around, has difficulty concentrating and frequently interrupts other children from their tasks. In the playground he often appears isolated from others. The school has requested an occupational therapy assessment to see how best to help Mark.
The occupational therapist visited Mark at school. As Mark has significant communication difficulties it was not possible to meaningfully interview him to understand his perspective and views. Instead the occupational therapist observed him in the classroom and playground over several sessions and interviewed his teacher. The occupational therapist also visited Mark at home, observed his behaviour over two sessions and interviewed his family. Mark’s family reported that he is able to participate in a range of activities at home and when the occupational therapist watches Mark at home being given support by his siblings he is observed to be able to maintain his concentration for longer periods in play-type activities. The occupational therapist discusses options with Mark’s family and teacher and with their agreement develops an intervention plan that engages Mark in small-group work within the classroom and supported play with peers in the playground. After 2 weeks of implementation of this plan, Mark is observed by the occupational therapist to be concentrating for longer periods in the classroom and socializing more in the playground. Mark’s teacher reports that he appears more settled and disturbs the other children less.
‘An informed decision is one where a reasoned choice is made by a reasonable individual using relevant information about the advantages and disadvantages of all possible course of action and in accord with the individual’s beliefs’ (Bekker et al 1999: 1). Within an informed decision-making model, a practitioner’s role is primarily about information sharing from the practitioner to the client, but it is argued that whilst clients wish to gain as much information about their condition or interventions as possible (Bekker et al 1999), they do not consistently wish to be solely responsible about the decisions they make (Charles et al 1997). Informed decision making has potential, and has been provided, in occupational therapy practice (see Vignette 4.2), but it is not ideal for everyone: some clients will lack capacity to make informed decisions (Sumsion 2000), whilst others lack the desire and will not wish to take on such responsibility.
Vignette 4.2
Barry is an 86-year-old gentleman. He has lived alone since the death of his wife 6 years ago. His main interests are his garden, his cat and meeting his friends once a week for a pub lunch. Barry was admitted to his local hospital after falling at home. He fell in the kitchen after tidying up his dinner and had lain all night on the floor until being discovered by his daughter when she arrived the following morning to take him shopping. On arrival at hospital it was noted that Barry’s blood sugar levels were poor (he has diabetes), he had fractured his left hip, and was badly shaken by the experience.
Barry has made a better physical recovery than expected and both he and the physiotherapists are happy with the progress he is making. His daughter and some of the clinical team, however, remain concerned that he will not be able to cope with living at home independently and fear he will fall again.
The occupational therapist carries out an assessment with Barry using the Canadian Occupational Performance Measure (Law et al 1994). This assessment highlights that getting out of bed, walking distances, and bending down are some of the main occupational performance difficulties he is currently experiencing. Barry rates these activities highly (8–9) as they are necessary for him to continue to carry out the activities he is used to. Barry rates his current performance of these activities as 3, 2, 2, respectively and his satisfaction as a consistent 2. The occupational therapist also presents Barry with some key figures and facts about the known dangers of returning home, for a gentleman of his age, after having a fractured hip. Barry considers all this information, but decides that despite his occupational performance difficulties and the potential dangers of returning home alone, that he will in fact return to his house. For Barry the risk of future falls does not outweigh the risk of loss of identity, role and routine that he feels giving up his home would entail. The occupational therapist designs an intervention plan to assist Barry to improve his areas of occupational performance difficulties and visit his house to carry out an environmental assessment.
The shared decision-making model is increasingly put forward as the ideal decision-making process (Charles et al 1997). It is the middle ground between paternalism and practitioner as agent, which both take control away from the client, and informed decision making; which, while empowering the client through the provision of information also transfers the responsibility of interventions decisions: a responsibility many prefer not to have (Charles et al 1997).
It is important that practitioners ask clients what sort of involvement they wish to have in their care and intervention (that is whether they wish practitioners to make (and communicate) decisions for them), whether they as clients wish to make informed decisions based on information from practitioners, or whether to participate in a shared decision-making model of care.
Certain features of a decision-making process are required for it to be classified as a ‘shared’ decision. A shared decision must:
But how do you practise shared decision making? There are a wide variety of interventions that, when used appropriately, assist in making shared decisions. Three key interventions that are typically considered to support shared decision making are described in depth elsewhere in this book: goal setting (Chapter 8), the therapeutic use of self (Chapter 9) and educational skills (Chapter 11). However there are various features of all therapeutic relationships that can either build or diminish the potential for shared decision making in practice. (Braddock et al 1997, Edwards and Elwyn 1999, Elwyn et al 2000, 2005a).
The first stage in developing shared decision making is to establish a therapeutic partnership with the client (see Chapter 9 for further information). This is particularly important when working with people who have long-term conditions. As Montori et al (2006) highlighted, a key characteristic of shared decision making in practice with people who have long-term conditions is ‘ongoing partnership between the clinical team (not just the clinician) and the patient’ (p. 25). Once the relationship has been established, then practitioners should work to understand what type of role the client wishes to have within the relationship: Do they wish to see the professional as agent? Do they wish to be informed decision makers? Do they wish to partake in shared decision making? These issues have to be communicated and understood very carefully: Clients are unlikely to immediately understand what you mean if you were to ask them a question such as ‘What type of decision-making capacity do you wish to have in this relationship?’! This information needs to be gained through careful discussion with the client. It can often be more helpful to understand clients’ preferred format by presenting a series of options (see Vignette 4.3). However it should also be remembered that clients may prefer different types of decision-making models depending on the nature of the decision being made, their current health status, and the consequences of the decision in question. Clients decision-making preference is a dynamic concept that has to be continually understood and responded to by practitioners.
Vignette 4.3
Bethany is a 20-year-old woman. She is currently taking a year out of her psychology degree at University. She was diagnosed with chronic fatigue syndrome 8 months ago. Her symptoms commenced following a glandular-fever-type illness and her recovery has been hampered since by severe and disabling fatigue, lack of concentration, low mood and poor concentration.
The occupational therapist visited Beth at home to carry out an assessment of her needs. Due to Bethany’s condition it was necessary to carry out the assessment over several sessions, as Bethany was only able to concentrate for short periods of time and tired quickly. Initially Bethany was very hesitant of becoming involved with the occupational therapist as she was concerned that she would be ‘made’ to do things she didn’t want to, or didn’t have the energy to complete. The occupational therapist spent her initial meetings with Bethany listening to her talk about her life, condition, the difficulties she currently faced and her hopes and desires for the future. As well as information gathering, a central task of these sessions was to build up Bethany’s trust in the occupational therapist. Towards the end of the fourth session Bethany told the occupational therapist that whilst she did want to get better, she remained hesitant to engage in any active intervention as she feared she would lose control and become more sick. The occupational therapist reassured Bethany that her approach, and the approach of her team, was very much one of working together with clients. Bethany was told that she had control of how she wished to involve her clinical team; if she wished them to tell her what to do, to give her advice, or to collaborate in making decisions together, as a core part of the whole team. Bethany appeared keen to work together with the team: she found the idea of them telling her what to do scary, but also did not want the responsibility of making all the choices herself. Bethany was reassured that she could be actively involved in all the decisions about her care and she would not be made to do anything she didn’t want to.
Hesitantly at first, Bethany agreed to commence goal setting with her occupational therapist. Goals were set weekly and agreed upon together by both Bethany and her occupational therapist. It took several weeks of trial and error to set achievable goals that were in Bethany’s words ‘challenging enough, but not too much’. This was achieved through Bethany giving good feedback to the occupational therapist, in whom she had built increasing trust, and deciding together what the next appropriate goal should be.
Problem definition is, in effect, a process of assessment (see Chapter 6 for further information). It is through the assessment process that practitioners and clients exchange information about a particular situation or problem. Assessment, and therefore problem definition, requires a two-way exchange of information. The practitioner must provide all the information about relevant intervention options, and clients should share all their relevant history and their values relating to the potential intervention options presented by the practitioner. However, despite the relatively straight forward nature of the information exchange described above, research highlights that both practitioners and clients do not always share all the relevant knowledge with each other (Bugge et al 2006). Whilst a study of the non-exchange of information has not been conducted within the context of occupational therapy, its occurrence across a broad range of clinical environments (Bugge et al 2006) suggests that it will be no different in an occupational therapy context either (see Vignette 4.4).
Vignette 4.4
Tim is a 54-year-old married businessman with two grown-up children. Two months ago he had a stroke that left him with muscle weakness (especially in his left arm), slightly slurred speech and some loss of sight. Tim received stroke rehabilitation as an inpatient and was discharged 2 weeks ago. He has now been referred for continued community stroke rehabilitation at home. The occupational therapist visits Tim at home to see how he is doing. Tim’s wife Sheena is present throughout the visit. During the interview they all discuss Tim’s activities of daily living, leisure activities and return to work.
What neither Tim nor his occupational therapist mention is Tim’s sexual relationship with his wife.
The occupational therapist knows, from the discharge notes that she received, that Tim did mention worries about this at an early stage, to an occupational therapist during a kitchen session, but that this had not been taken forward by her or any member of the clinical team. The visiting occupational therapist does not mention it as she is uncertain of how to raise the subject (or indeed if she should raise the subject) in the presence of his wife, furthermore she is not sure what she could recommend, or even if Tim still has concerns in this area of life.
Tim is indeed still concerned about his sexual relationship with his wife. In fact it is his main concern; he has been able to discuss or began to address all the other issues. Tim does not mention it because he is unsure what his wife would think of him for discussing these issues with a younger lady (the occupational therapist), was unsure of how to raise the subject and maintain his composure and was not even certain if the occupational therapist was the right person to talk to as the one in the hospital had not appeared that interested when he mentioned it during a kitchen session one day! The occupational therapy interview ends and a continuing rehab package is agreed by both the practitioner and Tim. His sexual dysfunction issues were not discussed and remain Tim’s biggest source of anxiety and concern.
In Bugge et al’s (2006) study the following reasons were given by clients and practitioners for not exchanging relevant information during clinical encounters.
Clients’ rationale for not exchanging information:
Practitioners’ rationale for not exchanging information:
None of these reasons seem outwith the realm of possibility within an occupational therapy encounter. It is therefore essential that all possible steps are taken to ensure that all the necessary information is exchanged between a client and their practitioner. A key step to ensure accurate problem definition is the active employment of the therapeutic use of self (see Chapter 9) as well as techniques such as active questioning of the client to see if they wish to ask anything that you have not already discussed.
At first glance, including clients in a shared decision-making process seems like an obvious statement to make; it wouldn’t be shared if you didn’t! Indeed occupational therapy ethical guidelines state that (except in exceptional circumstances, such as mental health legislation), ‘Clients have a right to make choices and decisions about their own health care’ (p. 6). Yet how easy is it to truly achieve this in practice? Several studies illustrate the negative perceptions of clients’ involvement and participation in their own rehabilitation and illustrate the challenges of achieving true participation in practice (Doolittle 1992, Becker and Kaufman 1995, Daniëls et al 2002). Such is the discrepancy of philosophy and practice, that achieving true client participation in the decision-making processes of their care has been claimed to be more ‘rhetoric than reality’ (Lewis 2003: 4). However the challenges of involving clients in meaningful participation must remain the goal of every practitioner. True participation and shared decision making are more likely to occur when practitioners ensure clients understand their problems, explore their worries, fears or expectations, discuss options and make collaborative decisions.
It is vital that clients, as well as practitioners, understand their problems and what, if any, decisions are required. In order to achieve this, practitioners must ensure that they communicate with all clients in a manner that builds confidence and rapport (see Chapter 9) and in language that is easy to follow and in the preferred media of the client (see Chapter 11). Building positive therapeutic engagement and educating clients are both essential skills that are required if a client is to understand their problems and the decisions that are required. However the routine nature of building therapeutic relationships and educating clients’ results in the complexity of truly achieving this is in practice being often overlooked (see Vignette 4.5).
Vignette 4.5
Carlo is a 10-month-old boy. He was born 4 weeks early and was noted to have low birth weight with asymmetric growth retardation on delivery. A diagnosis of mild cerebral palsy was made at a later date following an MRI scan.
Carlo’s development is being closely monitored by a paediatric community physiotherapist, paediatric community occupational therapist and consultant paediatrician. Carlo had been seen by his physiotherapist for several weeks before the occupational therapy service receives a referral and arranges to visit him. The occupational therapist visits Carlo’s home at the same time as the physiotherapist, in order to carry out some joint working and to lessen the burden of health-care professionals visiting the house each week. However, whilst Carlo’s parents were informed why the physiotherapist was visiting, they never received an explanation as to why the occupational therapy referral had been made and this was not clearly explained by the occupational therapist when she visited.
During a series of joint visits the occupational therapist assesses Carlo’s motor, process and communication skills and observes his response to a variety of stimuli. However, because of the nature of these visits, the occupational therapist never explained to Carlo’s parents exactly why she was there, what she was looking for, and what she had to offer that was different to the physiotherapist. Because of this, Carlo’s parents were puzzled about her role and what she was doing when she visited. To them, despite the complexity of analysis that the occupational therapist was undertaking, it just appeared as if she was there to hold toys for the physio!
Engaging in therapeutic assessment and interventions can be anxiety provoking for clients. Anxiety negatively affects a client’s ability to concentrate. This in turn can reduce clients’ abilities to exercise choice and engage in partnership working. Practitioners can help to reduce clients’ level of anxiety by explicitly eliciting and discussing with clients their worries, fears and expectations, about their health and care generally, and of occupational therapy in particular. Time and space should be given throughout sessions to allow clients to ask questions. It can also be useful to explicitly ask clients if they have any concerns (see Vignette 4.6).
Vignette 4.6
Teresa is a 44-year-old woman who has suffered from depression for the last 12 years. She has been ‘signed off’ sick from her work for the last 3 months and has been referred to a return-to-work project by her job centre. Her initial appointment at the project is with an occupational therapist. When the occupational therapist commences his initial interview (a standard format of questions the project asks all new referrals) Teresa appears very anxious and responds to the practitioner’s questions with the minimal of information. At a certain point the occupational therapist stops what he is doing and puts down his forms. He suggests to Teresa that it may be most helpful if she could start first of all by telling him all she thought he should know about her life and illness and how she felt about being referred to the project. Teresa responded well to this strategy and spoke openly about her life before she was diagnosed with depression as well as the impact the illness had had on her life and the life of her family. Teresa discussed how work had previously been a very important part of her life: not only financially, but also socially. Teresa had worked as a seamstress in several clothing factories and had enjoyed the ‘buzz’ and collegiality of working in these settings. Since being ‘signed off’ work, Teresa has missed these aspects and would love to regain these aspects of her life. Having engaged Teresa more fully within the interview, and having seen her relax as she spoke, the occupational therapist then asked Teresa if she had any particular views or concerns about attending the project. Teresa reported that she had lost a great deal of confidence since being ‘signed off’ and feared that if she returned to work (and in the process lost her government benefits) she may not manage to maintain her productivity at levels she used to, which could result in her dismissal and significant loss of income upon which she and her family depended. The occupational therapist was then able to discuss the work of the project in further detail and how they had managed similar situations in the past.
Practitioners should discuss with their clients the differing therapeutic options that are available. Interventions have at least two options, as the option to do nothing is always available and ethically should be supported if that is the desire of the client (COT 2005). Discussing options enables clients to fully participate in the decision-making process and can also reduce the fear of the unknown, as clients who discuss available options will have a greater knowledge of what each intervention entails. A useful method of discussing potential interventions with clients is to discuss the ‘pros and cons’ (or advantages and disadvantages) of each option (See Chapter 10 for further information) (see Vignette 4.7).
Vignette 4.7
Lucy was referred to occupational therapy by her consultant psychiatrist following discussion at the weekly community mental health team meeting. She is 27 years old and lives with her parents and two younger brothers. She was recently discharged home after being admitted to an acute psychiatric ward for 2 months after being diagnosed with bipolar disorder and concern from her consultant psychiatrist and family that she may self harm.
During the occupational therapy initial interview it became clear that Lucy was upset by her medical diagnosis and her recent experience of admission. Following her discharge Lucy felt that it was difficult to get back into her old routine and she had lost confidence in doing things she previously found simple. Until 6 months ago Lucy had attended college, where she had been studying business management. Lucy reported that she had previously been enjoying the course. When asked about her other interests she replied that she enjoys watching television, swimming and using the internet. Lucy stated that in the future she hoped to run her own business.
The occupational therapist discussed the idea of Lucy returning to study as a goal they could work towards. Lucy was initially hesitant about working towards this as she was unsure if she would be able to manage – though at the same time she was unable to say what she did want to do. Lucy agreed with the occupational therapist that it would be a good idea to look at the pros and cons of working towards returning to college. Together Lucy and her occupational therapists sat down and drew up a list of the pros and cons of working towards returning to college. Having done this, Lucy felt that doing nothing would only lead her to increase her isolation, whilst she said she could see from the pros and cons sheet that working towards returning to college would not bind her to that choice, but would help her to take her first steps towards recovery and regaining the life she once had. She was still uncertain that she would make it back to college, but agreed that it was worth working towards just now.
Having worked your way through each of the stages above, it is necessary to make choices and decisions about the direction of intervention. Fortunately few of the decisions made by occupational therapists and their clients in practice have irreversible consequences; though some decisions (for example major environmental alterations to a client’s house or the decision to enter a nursing home) will be less easily reversed than others (for instance developing an activity schedule with a client who is depressed). Nevertheless making decisions for and with clients is a significant event. Clients should be asked if they wish further time to consider intervention options and (wherever possible) it should be made clear that such decisions are open to review and can be altered if the client wishes to at a later date.
Given the centrality of the client in occupational therapy, and the policy imperatives to increasingly involve clients in their care, shared decision making has now become increasingly relevant in health care and occupational therapy is no exception.
Occupational therapy is internationally recognized as having a client-centred philosophy, yet research into the practitioner–client partnership has shown that delivering client-centred practice is challenging and there is a dissonance between the theory of client-centred practice and partnership working in practice (Daniëls et al 2002, Maitra and Erway’s 2006).
The previous section described shared decision making, as a method of ensuring client-centred practice, and outlined ways in which practitioners can work to ensure that clients are involved in their care to the level they wish to be and are facilitated to participate in shared decision making with practitioners when so desired. As shared decision making is both a recognized ‘good’ of practice and a challenging concept to deliver, practitioners should measure the degree of participation and shared decision making they deliver in practice as a routine core process measure. In this way they will truly be able to state whether or not they are being client-centred.
Client’s satisfaction with their involvement, participation and shared decision making should be routinely included as part of practitioners’ process evaluations. Ideally this should occur whilst the practitioner and client are still working together, so that changes can be made if the client does not feel that there is an adequate partnership. It can feel awkward asking clients for feedback on one’s clinical performance. But questions such as, ‘Is there anything I am not doing that you would like me to do?’ can provide opportunities for clients to raise concerns about your style of partnership working. This can be achieved through interview, though clients may not feel free to be honest in their evaluation, or by questionnaire which provides some distance between the practitioner and client and may enable some clients to be more honest. Client’s evaluations of practitioners are, however, fraught with difficulty as they may feel pressured to be overly positive or not report concerns they have for fear it would further affect their relationship. More objective measures of shared decision making are therefore highly desirable.
The OPTION scale is an objective observational measure of shared decision making in practice (Elwyn et al 2005b). It has been developed to evaluate the extent to which shared decision making occurs within a therapeutic encounter. Whilst originally developed in primary care, the tool has been developed as a measure of any health-care consultation (Elwyn et al 2005b) and would be suitable to measure an occupational therapy contact when options are being considered and/or decisions made: for example during an intervention planning session.
In order to score the OPTION scale practitioners are required to record a session, with the clients permission, which is then listened to and rated using the OPTION scale.
The OPTION scale measures the extent to which a client is involved in the decision-making process within a session (Elwyn et al 2005b). The scale itself consists of 12 items which are each rated over a five-point scale ranging from ‘The behaviour is not observed’ to the ‘behaviour being exhibited to a very high standard’ (Elwyn et al 2005b: 93). The psychometric properties of the measure have been researched and it has been shown to be a reliable and valid method of measuring the degree of shared decision making that occurs in a clinical encounter (Elwyn et al 2005b). Further, research into the OPTION scale has highlighted that, ‘…practitioners with no previous training in shared decision making achieve very low levels of patient involvement in decision making’ (Elwyn et al 2005b: 58).
Client-centredness has been the clarion call of occupational therapists since the early 1980s. Occupational therapy has built itself up to be focused on individual client autonomy, based on client choice, and centred on partnership working (Law et al 1995, Sumsion 2000, Parker 2006, Sumsion 2006). However delivering client-centred occupational therapy has been acknowledged as daunting (Parker 2006) and the perceptual gap that exists between the rhetoric and the reality of practice has been researched and reported (Daniëls et al 2002, Maitra and Erway 2006).
Different models of decision making, and their contribution to client-centred practice, have been described within this chapter. Whilst some models of decision making (such as the informed decision-making model) should rightly be recognized as being client-centred, shared decision making (Charles et al 1997) was presented as a model which is gaining wide endorsement and popularity as a useable method of working in partnership with clients in a wide range of settings. A range of shared decision-making interventions, with practice scenarios to illuminate the concepts being discussed were then presented.
Shared decision making, though increasingly researched within health care in general, has been surprisingly under researched within the context of occupational therapy. As an approach to decision making it has a great deal to offer clinicians who wish to narrow the gap between the rhetoric and reality of client-centred occupational therapy practice.
Becker G, Kaufman SR. Managing an uncertain illness trajectory in old age: patients’ and physicians’ views of stroke. Medical Anthropology Quarterly. 1995;9:165-187.
Bekker H, Thornton JG, Airey CM, et al. Informed decision making: an annotated bibliography and systematic review. Health Technology Assessment. 3(1), 1999.
Braddock CH, Edward KA, Hasenberg MH, et al. Informed decision making in outpatient setting: time to get back to basics. The Journal of the American Medical Association. 1997;282:2313-2320.
Bugge C, Entwhistle V, Watt IS. The significance for decision making of information that is not exchanged by patients and health professionals during consultations. Social Science and Medicine. 2006;63:2065-2078.
Canadian Association of Occupational Therapy/Department of National Health and Welfare. Occupational therapy guidelines for client centred practice. Toronto, Canada: Canadian Association of Occupational Therapists, 1983.
Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science and Medicine. 1997;44(5):681-692.
College of Occupational Therapists. The Code of Ethics and Professional Conduct for Occupational Therapy. London: College of Occupational Therapists, 2005.
Council of Occupational Therapists in the European Countries. Available at. Code of Ethics and Standard of Practice. 1996. http://cotec-europe.org/organisation/ethics.htm. Accessed on 21 November 2007
Danëls R, Winding K, Borell L. Experiences of occupational therapists in stroke rehabilitation: Dilemmas of some occupational therapists in inpatient stroke rehabilitation. Scandinavian Journal of Occupational Therapy. 2002;9:167-175.
Deber R. Physicians in health care management: 7. The patient–physician partnership: Changing roles and the desire for information. Canadian Medical Association. 1994;151:171.
Doolittle ND. The experience of recovery following lacunar stroke. Rehabilitation Nursing. 1992;17:122-125.
Elwyn G, Edwards A, Kinnersley P, et al. Shared decision making and the concept of equipoise: the competence of involving patients in health care choices. British Journal of General Practice. 2000;50:892-897.
Elwyn G, Hutchings H, Edwards A, et al. The OPTION scale: measuring the extent that clinicians involve patients in decision making tasks. Health Expectations. 2005;8:34-42.
Elwyn G, Edwards A, Wensing M, et al. Shared Decision Making. In Measurement using the OPTION instrument. Cardiff, UK: Cardiff University; 2005.
Law M, Baptiste S, Carswell A, et al. Canadian Occupational Performance Measure. Toronto, UK: Canadian Association of Occupational Therapists, 1994.
Law M, Baptiste S, Mills J. Client-centred practice: what does it mean and does it make a difference? Canadian Journal of Occupational Therapy. 1995;62(5):250-257.
Levine MN, Gafni A, Markham B, et al. A bedside decision instrument to elicit a patient’s preference concerning adjuvant chemotherapy for breast cancer. Annals of Internal Medicine. 1992;117(1):53-58.
Lewis L. Is ‘participation’ all just rhetoric?. Mental health nursing. 2003. Available at http://findarticles.com/p/articles/mi_qa3949/is_200311/ai_n9322083 Accessed on 21 November 2007
Maitra KK, Erway F. Perception of client-centred practice in occupational therapists and their clients. The American Journal of Occupational Therapy. 2006;60(3):298-310.
Montori VM, Gafni A, Charles C. A shared treatment decision making approach between patients with chronic conditions and their clinicians: the case of diabetes. Health Expectations. 2006;9(1):25-36.
Parker. The client-centred frame of reference. In: Duncan EAS, editor. Foundations for Practice in Occupational Therapy. Edinburgh, UK: Elsevier/Churchill Livingstone; 2006:193-216.
Parsons T. The Social System. Glencoe, UK: Free Press, 1952.
Rogers CR. The clinical treatment of the problem child. Boston, UK: Houghton Mifflin, 1939.
Sumsion T. A revised definition of client-centred practice. British Journal of Occupational Therapy. 2000;63(7):15-21.
Sumsion T. Client-Centred Practice in Occupational Therapy. Edinburgh: Churchill Livingstone, 2006.
Wilcock A. Occupational for Health. A journey from prescription to self health, Volume 2. London:College of Occupational Therapists. 2002.
World Health Organisation. Discussion document on the concept and principles of health promotion. Canadian Public Health Association Health Digest. 1984;8L:101-102.