急诊医师识别的共享决策障碍和促进因素：探索性分析。
Physician-identified barriers to and facilitators of shared decision-making in the Emergency Department: an exploratory analysis.
机构信息
Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA.
Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, Massachusetts, USA.
出版信息
Emerg Med J. 2019 Jun;36(6):346-354. doi: 10.1136/emermed-2018-208242. Epub 2019 May 16.
OBJECTIVES
Shared decision-making (SDM) is receiving increasing attention in emergency medicine because of its potential to increase patient engagement and decrease unnecessary healthcare utilisation. This study sought to explore physician-identified barriers to and facilitators of SDM in the ED.
METHODS
We conducted semistructured interviews with practising emergency physicians (EP) with the aim of understanding when and why EPs engage in SDM, and when and why they feel unable to engage in SDM. Interviews were transcribed verbatim and a three-member team coded all transcripts in an iterative fashion using a directed approach to qualitative content analysis. We identified emergent themes, and organised themes based on an integrative theoretical model that combined the theory of planned behaviour and social cognitive theory.
RESULTS
Fifteen EPs practising in the New England region of the USA were interviewed. Physicians described the following barriers: time constraints, clinical uncertainty, fear of a bad outcome, certain patient characteristics, lack of follow-up and other emotional and logistical stressors. They noted that risk stratification methods, the perception that SDM decreased liability and their own improving clinical skills facilitated their use of SDM. They also noted that the culture of the institution could play a role in discouraging or promoting SDM, and that patients could encourage SDM by specifically asking about alternatives.
CONCLUSIONS
EPs face many barriers to using SDM. Some, such as lack of follow-up, are unique to the ED; others, such as the challenges of communicating uncertainty, may affect other providers. Many of the barriers to SDM are amenable to intervention, but may be of variable importance in different EDs. Further research should attempt to identify which barriers are most prevalent and most amenable to intervention, as well as capitalise on the facilitators noted.
目的
由于共享决策（SDM）有可能提高患者的参与度并减少不必要的医疗保健利用，因此在急诊医学中越来越受到关注。本研究旨在探讨医生在 ED 中识别 SDM 的障碍和促进因素。
方法
我们对有执业经验的急诊医师（EP）进行了半结构化访谈，旨在了解 EP 何时以及为何进行 SDM，以及何时以及为何感到无法进行 SDM。访谈记录逐字转录，一个由三人组成的团队使用一种定向的定性内容分析方法，以迭代的方式对所有记录进行编码。我们确定了新出现的主题，并根据一种综合理论模型组织主题，该模型结合了计划行为理论和社会认知理论。
结果
对美国新英格兰地区的 15 名 EP 进行了访谈。医生描述了以下障碍：时间限制、临床不确定性、对不良结果的恐惧、某些患者特征、缺乏随访以及其他情绪和后勤压力源。他们指出，风险分层方法、认为 SDM 降低责任的感知以及自己不断提高的临床技能有助于他们使用 SDM。他们还指出，机构文化可能会在鼓励或阻碍 SDM 方面发挥作用，患者可以通过特别询问替代方案来鼓励 SDM。
结论
EP 在使用 SDM 时面临许多障碍。其中一些障碍，例如缺乏随访，是 ED 特有的；其他障碍，如沟通不确定性的挑战，可能会影响其他提供者。SDM 的许多障碍都可以通过干预来解决，但在不同的 ED 中可能具有不同的重要性。进一步的研究应该试图确定哪些障碍最为普遍，哪些障碍最容易干预，并利用所注意到的促进因素。
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