Fitzgerald Ita, Sahm Laura J, Maidment Ian, Wallace Emma, Zisman-Ilani Yaara, Højlund Mikkel, O'Dwyer Sarah, Ní Dhubhlaing Ciara, Crowley Erin K, Howe Jo
Pharmacy Department, St Patrick's Mental Health Services, Dublin, Ireland.
Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Ireland.
Schizophr Bull. 2025 Jul 7;51(4):916-932. doi: 10.1093/schbul/sbaf058.
Shared decision-making (SDM) implementation remains limited in psychosis management, particularly within antipsychotic prescribing. When and why prescribers engage in SDM within these contexts is largely unknown. Part 1 of this two-part realist review aimed to understand the impact of structural and contextual factors on prescriber engagement in SDM within antipsychotic prescribing.
CINAHL Plus, Cochrane Library, Embase, PsycINFO, PubMed, Scopus, Sociological Abstracts, Web of Science, and Google Scholar were searched for evidence to develop realist program theories outlining the relationship between macro-level contexts and their impact on prescriber behaviors.
From 106 included documents, five program theories explaining relationships between (i) leadership and governance, (ii) workforce development, and (iii) service delivery contexts and their impact on reducing prescriber engagement with behaviors required of SDM application were developed. No facilitative macro-level contexts were identified. Key mechanisms reducing prescriber engagement in desired behaviors include fear of individual blame for adverse outcomes and exposure to liability, pressure from service environments to prioritize decreasing risk of harm, devaluing of experiential knowledge, and beliefs that SDM conflicts with duties of beneficence and non-maleficence.
Even empirically efficacious interventions will be difficult to implement at scale within real-world settings due to misalignment with complex cultural, legal, and professional realities prominent therein. Mechanisms responsible for reducing prescriber engagement in SDM should be the target of structural interventions necessary to support contextual integration into psychosis management. Part 2 outlines features of service delivery contexts, workforce development, and technology that can increase prescriber engagement in SDM.
在精神病管理中，共享决策（SDM）的实施仍然有限，尤其是在抗精神病药物处方方面。在这些情况下，开处方者何时以及为何参与共享决策在很大程度上尚不清楚。这个两部分的现实主义综述的第一部分旨在了解结构和背景因素对抗精神病药物处方中开处方者参与共享决策的影响。
检索了CINAHL Plus、Cochrane图书馆、Embase、PsycINFO、PubMed、Scopus、社会学文摘、科学网和谷歌学术，以寻找证据来发展现实主义项目理论，概述宏观层面背景及其对开处方者行为影响之间的关系。
从106篇纳入文献中，开发了五个项目理论，解释了（i）领导与治理、（ii）劳动力发展以及（iii）服务提供背景之间的关系，以及它们对减少开处方者参与共享决策应用所需行为的影响。未发现促进性的宏观层面背景。减少开处方者参与期望行为的关键机制包括担心因不良后果而受到个人指责和面临责任风险、服务环境要求优先降低伤害风险的压力、对经验知识的贬低，以及认为共享决策与行善和不伤害的职责相冲突的信念。
由于与其中突出的复杂文化、法律和专业现实不一致，即使是经验证有效的干预措施在现实世界环境中也难以大规模实施。减少开处方者参与共享决策的机制应成为支持将背景因素融入精神病管理所需结构干预的目标。第二部分概述了服务提供背景、劳动力发展和技术的特征，这些特征可以增加开处方者参与共享决策的程度。
