Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA.
Psychiatr Rehabil J. 2012 Spring;35(4):305-14. doi: 10.2975/35.4.2012.305.314.
Patient-centered communication has been linked to patient satisfaction, treatment adherence and outcomes. Shared decision making (SDM) has been advocated as an important and ethically essential aspect of patient-centered care, but SDM has received relatively little attention in mental health care, despite studies indicating that consumers want to be involved in making decisions. This is particularly important in a recovery-oriented system, where consumers are active participants in their treatment and rehabilitation. Because medication management is a key component of recovery from severe mental illnesses, this study explores how consumers and providers make decisions in medication management consultations.
Four providers (3 psychiatrists, 1 nurse practitioner) and 40 consumers with severe mental illness (10 consumers per provider) were recruited from a community mental health center with a recovery-oriented focus. We directly observed 40 medication management appointments. Observations were audio recorded and transcribed. We used emergent thematic analysis to characterize decision making processes.
Providers initiated most decisions, although they often invited consumers to participate in decision making. Decisions initiated by consumers elicited a greater degree of discussion and disagreement, but also frequently resulted in consumers' preferences prevailing. Consultations generally exhibited more characteristics of person-centeredness than SDM.
While we observed a high degree of person-centeredness, SDM was not prevalent. Interventions helping consumers to take greater initiative when working with service providers may be helpful. For example, programs using tools such as peer instruction, Internet-based software, and individual case-manager instruction all have shown promise for enhancing SDM in mental health treatment. Further research is needed to determine the degree of SDM in other settings (e.g., with case managers) and the impact of SDM on consumers' recovery.
以患者为中心的沟通与患者满意度、治疗依从性和治疗效果相关。共享决策（SDM）已被倡导为以患者为中心的护理的一个重要且至关重要的方面，但在精神卫生保健中，SDM 相对较少受到关注，尽管研究表明消费者希望参与决策。在以康复为导向的系统中，消费者是其治疗和康复的积极参与者，这一点尤为重要。由于药物管理是从严重精神疾病中康复的关键组成部分，因此本研究探讨了消费者和提供者如何在药物管理咨询中做出决策。
从以康复为重点的社区心理健康中心招募了 4 名提供者（3 名精神科医生，1 名护士从业者）和 40 名患有严重精神疾病的消费者（每名提供者 10 名消费者）。我们直接观察了 40 次药物管理预约。观察结果进行了录音和转录。我们使用新兴主题分析来描述决策过程。
提供者发起了大多数决策，尽管他们经常邀请消费者参与决策制定。消费者发起的决策引发了更多的讨论和分歧，但也经常导致消费者的偏好占主导地位。咨询通常表现出比 SDM 更高程度的以患者为中心。
虽然我们观察到了高度的以患者为中心，但 SDM 并不普遍。帮助消费者在与服务提供者合作时采取更大主动的干预措施可能会有所帮助。例如，使用同伴指导、基于互联网的软件和个人案例经理指导等工具的计划都已显示出在增强精神卫生治疗中的 SDM 方面的潜力。需要进一步研究以确定其他环境（例如，与个案经理）中的 SDM 程度以及 SDM 对消费者康复的影响。
