Murray Mary Ann, O'Connor Annette, Stacey Dawn, Wilson Keith G
Faculty of Health Sciences, School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada.
BMC Palliat Care. 2008 Apr 30;7:4. doi: 10.1186/1472-684X-7-4.
Most people prefer home palliation but die in an institution. Some experience decisional conflict when weighing options regarding place of care. Clinicians can identify patients' decisional needs and provide decision support, yet generally lack skills and confidence in doing so. This study aims to determine whether the quality of clinicians' decision support can be improved with a brief, theory-based, skills-building intervention.
The Ottawa Decision Support Framework (ODSF) guides an evidence based, practical approach to assist clinicians in providing high-quality decision support. The ODSF proposes that decisional needs [personal uncertainty, knowledge, values clarity, support, personal characteristics] strongly influence the quality of decisions patients make. Clinicians can improve decision quality by providing decision support to address decisional needs [clarify decisional needs, provide facts and probabilities, clarify values, support/guide deliberation, monitor/facilitate progress].
METHODS/DESIGN: The efficacy of a brief education intervention will be assessed in a two-phase study. In phase one a focused needs assessment will be conducted with key informants. Phase two is a randomized control trial where clinicians will be randomly allocated to an intervention or control group. The intervention, informed by the needs assessment, knowledge transfer best practices and the ODSF, comprises an online tutorial; an interactive skills building workshop; a decision support protocol; performance feedback, and educational outreach. Participants will be assessed: a) at baseline (quality of decision support); b) after the tutorial (knowledge); and c) four weeks after the other interventions (quality of decision support, intention to incorporate decision support into practice and perceived usefulness of intervention components). Between group differences in the primary outcome (quality of decision support scores) will be analyzed using ANOVA.
Few studies have investigated the efficacy of an evidence-based, theory guided intervention aimed at assisting clinicians to strengthen their patient decision support skills. Expanding our understanding of how clinicians can best support palliative patients' decision-making will help to inform best practices in patient-centered palliative care. There is potential transferability of lessons learned to other care situations such as chronic condition management, advance directives and anticipatory care planning. Should the efficacy evaluation reveal clear improvements in the quality of decision support provided by clinicians who received the intervention, a larger scale implementation and effectiveness trial will be considered.
This study is registered as NCT00614003.
大多数人更倾向于在家中接受姑息治疗，但却在医疗机构中离世。一些人在权衡护理地点的选择时会经历决策冲突。临床医生能够识别患者的决策需求并提供决策支持，但通常缺乏这样做的技能和信心。本研究旨在确定是否可以通过一种简短的、基于理论的技能培养干预措施来提高临床医生决策支持的质量。
渥太华决策支持框架（ODSF）指导一种基于证据的实用方法，以协助临床医生提供高质量的决策支持。ODSF提出决策需求[个人不确定性、知识、价值观清晰度、支持、个人特征]会强烈影响患者所做决策的质量。临床医生可以通过提供决策支持来满足决策需求[明确决策需求、提供事实和概率、阐明价值观、支持/指导思考、监测/促进进展]，从而提高决策质量。
方法/设计：一项简短教育干预措施的效果将在一项两阶段研究中进行评估。在第一阶段，将对关键信息提供者进行重点需求评估。第二阶段是一项随机对照试验，临床医生将被随机分配到干预组或对照组。基于需求评估、知识转移最佳实践和ODSF的干预措施包括一个在线教程；一个互动式技能培养工作坊；一个决策支持方案；绩效反馈以及教育推广。将对参与者进行以下评估：a）在基线时（决策支持质量）；b）在教程之后（知识）；以及c）在其他干预措施实施四周后（决策支持质量、将决策支持纳入实践的意愿以及对干预措施各组成部分的感知有用性）。将使用方差分析来分析主要结局（决策支持质量得分）在组间的差异。
很少有研究调查旨在协助临床医生增强其为患者提供决策支持技能的基于证据、理论指导的干预措施的效果。扩展我们对临床医生如何能够最佳地支持姑息治疗患者决策的理解，将有助于为以患者为中心的姑息治疗的最佳实践提供信息。所吸取的经验教训有可能适用于其他护理情况，如慢性病管理、预先指示和预瞻性护理规划。如果效果评估显示接受干预的临床医生所提供的决策支持质量有明显改善，将考虑进行更大规模的实施和有效性试验。
本研究已注册为NCT00614003。
