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PubMed2004

What makes women feel powerful? An exploratory study of relationship power and sexual decision-making with African Americans at risk for HIV/STDs.

Because of the importance of relationship power and cultural norms on women's ability to protect themselves from HIV/STDs, effective interventions must address power differentials among men and women. These programs need to be informed by and adapted to the cultural values of the target population. Accordingly, we conducted exploratory interviews with 22 young African American women at risk of HIV/ STDs and unintended pregnancy and their male partners regarding the meaning of power in heterosexual relationships, what makes a woman feel powerful in a relationship with a man, and who makes sexual and reproductive decisions in their relationships. Content analyses suggested that relationship power was linked to control and decision-making for most participants; yet, others appeared to associate power with positive relationship qualities such as respect and security. In addition, most participants reported that they shared decision-making about sexual and reproductive matters with their partners. Subsequently, interviews were conducted with another 40 women to explore and identify cultural beliefs regarding what makes women feel powerful in their relationships with their husbands or partners. Cultural consensus analysis was performed and results indicated that the participants comprise a cultural group with shared beliefs about what makes women feel powerful in their relationships. Participants believed that women's sense of power in their relationships came from (1) knowing what they want and having autonomy and control; (2) the quality of their relationships; (3) having resources to provide for their families; and (4) physical attractiveness and sexual factors.

Adult↗

PubMed2004

Shared decision making in patients with newly diagnosed prostate cancer: a model for treatment education and support.

Screening for prostate cancer is controversial. Treatment choices for verified cases of prostate cancer provide another level of controversy as to which treatment, if any, is best. This controversy and uncertainty create a dilemma for the newly diagnosed patient. A great deal of information must be assimilated if the patient is to make an informed decision to pursue any treatment A metropolitan Veterans Affairs hospital has created a model to assist the newly diagnosed prostate cancer patient in acquiring this information, while helping him through the decision tree. This model, which utilizes the skills of the advanced practice nurse, strives toward maintaining the patient's autonomy while clarifying these uncertainties, introduces the concept of shared decision making, and provides a potential support group.

Algorithms↗

PubMed2006

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction.

OBJECTIVE: This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction. BACKGROUND: Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking. DESIGN: Questionnaire survey distributed through GPs. SETTING AND PARTICIPANTS: The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP. RESULTS AND CONCLUSIONS: The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.

Adult↗

PubMed2001

Health literacy and shared decision making for prostate cancer patients with low socioeconomic status.

Quality of life (QOL) considerations are important in the treatment decision making process for prostate cancer patients. Although patient involvement in the treatment decision process has been encouraged, low health literacy can limit patient understanding of the complex information about treatments and their probable QOL outcomes and is a barrier to patient participation in the decision-making process. The objectives of the study were to evaluate (i) knowledge, level of satisfaction, and treatment preferences and intentions of men newly diagnosed with prostate cancer after participation in a CD-ROM shared decision making program; and (ii) the relationship between prostate cancer knowledge and health literacy. Thirty newly diagnosed prostate cancer patients from two Veteran's Administration (VA) hospitals in Chicago completed a demographic questionnaire and participated in an interactive CD-ROM shared decision making program. Subsequently, knowledge of prostate cancer, satisfaction with the information in the computer CD-ROM program, treatment preferences, and likelihood of following treatment preferences were assessed using interviewer-administered questionnaires. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM). The Pearson correlation test was used to assess the relationship between health literacy and prostate cancer knowledge. The chi2 test and the Fischer exact test were used to evaluate relationships between patient demographics and other variables. More than three-quarters of the patients rated the information in the CD-ROM as "very satisfactory" (highest possible rating). Two-thirds of the patients (21 of 30) selected a treatment after participation in the CD-ROM program and 90.5% of these patients stated that they were very or somewhat likely to adhere to their selection. However, prostate cancer knowledge was variable, with one-third of the patients scoring 69.9% or lower. Participants' health literacy was equivalent to a 7th-8th grade reading level (mean = 57.1+/-10.9), and more than one-third of participants (36.7%) had lower than 9th grade literacy levels. Participants' prostate cancer knowledge was correlated with health literacy (Pearson correlation rhor = 0.65, rhop = 0.0001). Patients were satisfied with the interactive shared decision making CD-ROM program, and two-thirds of patients were able to select a preferred treatment based on the information presented in the program that they intended to follow. However, prostate cancer knowledge scores varied among participants after participation in the CD-ROM program, raising doubts that patients were adequately informed to make appropriate choices regarding their treatment. Lower prostate cancer knowledge scores corresponded to lower literacy scores, indicating that low literacy may have hindered patient understanding of the shared decision making program. The development of shared decision making tools should include collaborative efforts with the target population to improve the success of shared decision making programs among patients with low health literacy.

Aged↗

PubMed1979

Bioethical decision making: an approach to improve the process.

Current problems with the decision-making process for bioethical dilemmas are described, with emphasis on the social roles taken in this process by medical experts and laypersons. An approach is presented to improve bioethical decision making. Two consecutive steps are required. First, branching logic is used to separate the bioethical dilemmas into a series of independent, sequential decision points along a decision-making tree. This allows complex dilemmas to be dealt with more easily by resolving the individual component issues in a logical, stepwise fashion. Secondly, explicit criteria are used to decide whether each individual component is ethical or technical in nature. Using these two steps increases the likelihood that the professional and the layperson will assume their appropriate social roles and improve the overall decision-making process. How this approach can be applied to policy-making decisions, in addition to case-by-case deciding, is discussed, as are some of the settings in which the approach might be particularly helpful.

Amniocentesis↗

PubMed2006

Decision-making in community-based paediatric physiotherapy: a qualitative study of children, parents and practitioners.

Approaches to practice based on partnership and shared decision-making with patients are now widely recommended in health and social care settings, but less attention has been given to these recommendations in children's services, and to the decision-making experiences of non-medical practitioners and their patients or clients. This study explored children's, parents' and practitioners' accounts of shared decision-making in the context of community-based physiotherapy services for children with cerebral palsy. Semi-structured interviews were conducted with 11 children with cerebral palsy living in an inner city area of northern England, and with 12 of their parents. Two focus groups were conducted with 10 physiotherapy practitioners. Data were analysed using the constant comparative method. When asked explicitly about decision-making, parents, children and practitioners reported little or no involvement, and each party saw the other as having responsibility for decisions. However, when talking in more concrete terms about their experiences, each party did report some involvement in decision-making. Practitioners' accounts focused on their responsibility for making decisions about resource allocation, and thereby, about the usefulness and intensity of interventions. Parents indicated that these practitioner-led decisions were sometimes in conflict with their aspirations for their child. Parents and children appeared to have most involvement in decisions about the acceptability and implementation of interventions. Children's involvement was more limited than parents'. While parents could legitimately curtail unacceptable interventions, children were mostly restricted to negotiating about how interventions were implemented. In these accounts the involvement of each party varied with the type of issue being decided and decision-making appeared more unilateral than shared. In advocating shared decision-making, greater understanding of its weaknesses as well as its strengths, and greater clarity about the domains that are suitable for a shared decision-making approach and the roles of different parties, would seem a helpful step.

Cerebral Palsy↗

PubMed1989

Clinical decision making and health care policy: what is the link?

The relationship between clinical decision making and health care policy is here considered in different ways. First, it is suggested at the most simple level that a key link between the two is that both are concerned with health. Second, the need for accepting the presence of uncertainty at both levels is highlighted: uncertainty related to inputs and outputs; to assessing weights for various outcomes; to attitudes to risk; etc. Third, the paper emphasises the desirability of looking beyond only the output 'health' at the two levels of decision making. Not that the relationship between clinical and health service decision making is taken to be constant across all health care systems in all countries. The paper suggests rather that just how clinical decision making is affected by the health care environment in which it finds itself needs more investigation than it has received to date. The authors indicate that the recent growth in the formal analysis of medical decision making is to be welcomed but stress the need to extend such analysis to consider the impact on clinical decision making of health care policy making.

Cross-Cultural Comparison↗

PubMed2006

Decision-making deficits in alcohol-dependent patients with and without comorbid personality disorder.

BACKGROUND: Impairments in decision making are a consistent finding in substance use disorder (SUD) populations. However, decision-making deficits are not specific for SUDs and are also reported in the context of other psychiatric disorders such as antisocial and borderline personality disorders (PDs). Given the frequent comorbidity between SUD and cluster B PD, it might be questioned whether the decision-making impairments typically reported in SUD populations reflect the addictive disorder, the cluster B PD, or a combination of the 2. METHODS: In the current study, we compare the decision-making performance of non-substance-abusing controls (n=53) on the Iowa Gambling Task (IGT) with the decision-making performance of 3 abstinent alcohol-dependent samples, i.e., alcoholic patients without any PD (n=38), alcoholic patients with a cluster A or C PD (n=19), and alcoholic patients with a cluster B PD (n=23). RESULTS: Overall, all 3 alcohol-dependent subsamples performed inferior compared with controls. Between alcoholic subsamples, the alcoholic patients with a cluster A or C PD had the highest IGT score, followed by the alcoholic patients without a PD, while the cluster B alcoholic patients were the most impaired. CONCLUSION: These findings suggest that impairments in decision making underlie both alcohol dependence and cluster B PD, and alcoholic patients with a comorbid cluster B PD are particularly impaired in their decision making. These deficits may underlie the severe problems that characterize cluster B alcoholic patients specifically in inappropriate behaviors (e.g., poly substance abuse, legal, and professional dysfunction).

Adult↗

PubMed2004

The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage.

Most theories of choice assume that decisions derive from an assessment of the future outcomes of various options and alternatives through some type of cost-benefit analyses. The influence of emotions on decision-making is largely ignored. The studies of decision-making in neurological patients who can no longer process emotional information normally suggest that people make judgments not only by evaluating the consequences and their probability of occurring, but also and even sometimes primarily at a gut or emotional level. Lesions of the ventromedial (which includes the orbitofrontal) sector of the prefrontal cortex interfere with the normal processing of "somatic" or emotional signals, while sparing most basic cognitive functions. Such damage leads to impairments in the decision-making process, which seriously compromise the quality of decisions in daily life. The aim of this paper is to review evidence in support of "The Somatic Marker Hypothesis," which provides a systems-level neuroanatomical and cognitive framework for decision-making and suggests that the process of decision-making depends in many important ways on neural substrates that regulate homeostasis, emotion, and feeling. The implications of this theoretical framework for the normal and abnormal development of the orbitofrontal cortex are also discussed.

Adolescent↗

PubMed1988

Sexual decision making and object relations theory.

The Sexual Decision-Making Inventory (SDMI) was developed to measure levels of sexual decision making based on the developmental concepts of Object Relations Theory. The inventory asks subjects to report on their thoughts and feelings at the time they decided to have sex in their most recent sexual relationship. The inventory was tested in a pilot study involving 45 male and 49 female undergraduates. A factor analysis was performed on the SDMI and six levels of sexual decision making were defined: Object Constancy, Ambivalence, Need for Merger, Need Gratification, Low Self-esteem, and Narcissistic Gratification. Endorsement of items on these subscales was related to perceptions of the relationship. In a second study involving 79 male and 135 female undergraduates, subjects completed the SDMI, the Bell Object Relations Self-report Inventory, and a questionnaire concerning perceptions of the relationship in which the sexual decision was made. Object Constancy was positively correlated to object relations, satisfaction with the relationship, and durability of the relationship; Ambivalence, Need Gratification, and Low Self-esteem were negatively correlated with object relations, satisfaction with the relationship, and durability of the relationship; Narcissistic Gratification was negatively correlated with object relations and most aspects of the relationship with interesting exceptions such as sexual satisfaction. Sex differences demonstrated that females were more likely to endorse items on the Object Constancy subscale; whereas males were more likely to endorse items on the Ambivalence, Need Gratification, and Narcissistic Gratification subscales. There were no sex differences, however, in quality of general object relations.

Adult↗

PubMed2001

Criminal decision making: the development of adolescent judgment, criminal responsibility, and culpability.

Theories of judgment in decision making hypothesize that throughout adolescence, judgment is impaired because the development of several psychosocial factors that are presumed to influence decision making lags behind the development of the cognitive capacities that are required to make mature decisions. This study uses an innovative video technique to examine the role of several psychosocial factors--temporal perspective, peer influence, and risk perception--in adolescent criminal decision making. Results based on data collected from 56 adolescents between the ages of 13 and 18 years revealed that detained youth were more likely to think of future-oriented consequences of engaging in the depicted delinquent act and less likely to anticipate pressure from their friends than nondetained youth. Examination of the developmental functions of the psychosocial factors indicates age-based differences on standardized measures of temporal perspective and resistance to peer influence and on measures of the role of risk perception in criminal decision making. Assessments of criminal responsibility and culpability were predicted by age and ethnicity. Implications for punishment in the juvenile justice system are discussed.

Adolescent↗

PubMedDate not supplied

Rochester Participatory Decision-Making Scale (RPAD): reliability and validity.

PURPOSE: We wanted develop a reliable and valid objective measure of patient-physician collaborative decision making, the Rochester Participatory Decision-Making Scale (RPAD). METHODS: Based on an informed decision-making model, the RPAD assesses physician behavior that encourages patient participation in decision making. Data were from a study of physician-patient communication of 100 primary care physicians. Physician encounters with 2 standardized patients each were audio recorded, resulting in 193 useable recordings. Transcribed recordings were coded both with RPAD and the Measure of Patient-Centered Communication (MPCC), which includes a related construct, Finding Common Ground. Two sets of dependent variables were derived from (1) surveys of the standardized patients and (2) surveys of 50 patients of each physician, who assessed their perceptions of the physician-patient relationship. RESULTS: The RPAD was coded reliably (intraclass correlation coefficient [ICC] = 0.72). RPAD correlated with Finding Common Ground (r = 0.19, P < .01) and with the survey measures of standardized patient's perceptions of the physician-patient relationship (r = 0.32 - 0.36 [P < .005]) but less with the patient survey measures (r = 0.06 to 0.07 [P < .005]). Multivariate, hierarchical analyses suggested that the RPAD made a more robust contribution to explaining variance in standardized patient perceptions than did the MPCC Finding Common Ground. CONCLUSIONS: The RPAD shows promise as a reliable, valid, and easy-to-code objective measure of participatory decision making.

Decision Making↗

PubMed2000

Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices.

BACKGROUND: Involving patients in healthcare decisions makes a potentially significant and enduring difference to healthcare outcomes. One difficulty (among many) is that the 'involvement' of patients in decisions has been left undefined. It is usually conceptualised as 'patient centredness', which is a broad and variably interpreted concept that is difficult to assess using current tools. This paper attempts to gauge general practitioners' (GPs') attitudes to patient involvement in decision making and their views about the contextual factors, competences, and stages required to achieve shared decisions within consultations. AIM: To explore and understand what constitutes the appropriate involvement of patients in decision making within consultations, to consider previous theory in this field, and to propose a set of competences (skills) and steps that would enable clinical practitioners (generalists) to undertake 'shared decision making' in their clinical environment. METHOD: Qualitative study using focus group interviews of key informants. RESULTS: Experienced GPs with educational roles have positive attitudes to the involvement of patients in decisions, provided the process matches the role individuals wish to play. They perceive some clinical problems as being more suited to a cooperative approach to decision making and conceptualised the existence of professional equipoise towards the existence of legitimate treatment options as an important facilitative factor. A sequence of skills was proposed as follows: 1) implicit or explicit involvement of patients in the decision-making process; 2) explore ideas, fears, and expectations of the problem and possible treatments; 3) portrayal of equipoise and options; 4) identify preferred data format and provide tailor-made information; 5) checking process: understanding of information and reactions (e.g. ideas, fears, and expectations of possible options); 6) acceptance of process and decision making role preference; 7) make, discuss or defer decisions; 8) arrange follow-up. CONCLUSIONS: These clinicians viewed involvement as an implicit ethos that should permeate medical practice, provided that clinicians respect and remain alert to patients' individual preferred roles in decision making. The interpersonal skills and the information requirements needed to successfully share decisions are major challenges to the clinical consultation process in medical practice. The benefits of patient involvement and the skills required to achieve this approach need to be given much higher priority at all levels: at policy, education, and within further professional development strategies.

Attitude of Health Personnel↗

PubMed2004

Stochastic dominance and medical decision making.

Stochastic Dominance (SD) criteria are decision making tools which allow us to choose among various strategies with only partial information on the decision makers' preferences. The notion of Stochastic Dominance has been extensively employed and developed in the area of economics, finance, agriculture, statistics, marketing and operation research since the late 1960s. For example, it may tell us which of two medical treatments with uncertain outcomes is preferred in the absence of full information on the patients' preferences. This paper presents a short review of the SD paradigm and demonstrates how the SD criteria may be employed in medical decision making, using the case of small abdominal aortic aneurysms as an illustration. Thus, for instance by assuming risk aversion one can employ second-degree stochastic dominance to divide the set of all possible treatments into the efficient set, from which the decision makers should always choose, and the inefficient (inferior) set. By employing Prospect Stochastic Dominance (PSD) a similar division can be conducted corresponding to all S-shaped utility functions.

Aortic Dissection↗

PubMed1999

Women's approaches to decision making about mammography.

Health professionals have an obligation to understand women's decision making about mammography and to advocate for their active participation in health care decision making. Although mammography is a major screening measure for the second largest cancer killer of women, only approximately half of women older than age 50 years, and fewer older than age 70 years, undergo mammography in accordance with American Cancer Society (ACS) guidelines. Therefore, the purpose of this study was to identify women's overall decision-making approaches when considering mammography. Subjects were a purposive, convenience sample of 50 women in the community who had made a decision about mammography; they included those who chose to have mammograms and those who decided not to have mammograms according to the pre-1997 ACS guidelines. Subjects participated in audiotaped interviews. Results indicated that women approached the mammography decision differently, regardless of the decision they made. Three overall decision-making approaches to addressing risk factors, issues about mammography, or other factors before their decision were evident. The approaches were (1) thoughtful consideration; (2) cursory consideration; and (3) little or no consideration. Each approach has implications for nurses who assist women in making decisions about mammography.

Adult↗

PubMed1995

Decision making in the treatment of acute illness in nursing homes: framing the decision problem, treatment plan, and outcome.

This article investigates the social-cultural factors and other circumstances that influence decision making in the treatment of acute illness in three West Coast nursing homes. Participant observation, in-depth interviews with physicians, nursing staff, nursing home residents, and family members, and event analysis were used to gather data. Using decision-making theory as the theoretical framework, analysis focuses on how internal and external factors influence the decision-making process. Two case studies are used to illustrate how in real-life acute clinical situations, physicians frame decision problems, treatment plans, and expected outcomes in order to persuade residents and their families to comply with their preferred treatment plans.

Acute Disease↗

PubMedDate not supplied

Ethical decision making in oncology: a case study approach.

Every day healthcare professionals are involved in making difficult clinical decisions. This has become more apparent as society changes, in part due to technologic growth and diminishing resources. This article identifies basic principles of bioethics, applies those principles to situations that occur in the process of providing care to oncology patients, and identifies concerns expressed by nurses attending an oncology conference that are related to those patient situations. Bioethical principles are described and include autonomy, beneficence, nonmaleficence, and justice. A decision-making model is provided as a tool to resolve ethical dilemmas.

Adult↗

PubMed1990

Decision-making abilities of mothers with mental retardation.

The decision-making abilities of mothers with mental retardation and contrast mothers were examined. Both groups received two high- and two low-risk vignettes in full and partial formats. Although there were no significant differences between the two groups on the appropriateness of their decisions, as expected, the mothers with mental retardation scored lower both on the recall and elicited measures. Both groups scored lower on the partial formats than on the full formats, and on the high-risk vignettes than on the low-risk ones. These results suggest that familiarity with the parenting situation as well as the degree of risk inherent in that situation is of importance when one is examining decision making for either group. The results also suggest that although mothers with mental retardation can make in vitro decisions that are similar to those of nonhandicapped mothers of the same socioeconomic background, additional research must examine in vivo decision making for both groups.

Adult↗