Development of a program theory for shared decision-making: a realist synthesis

Area of Science:

• Health Services Research
• Decision Science
• Patient Engagement

Background:

• Shared Decision-making (SDM) emerged to counter paternalistic healthcare models, aiming to better align medical choices with patient needs.
• Despite extensive research on SDM benefits, a comprehensive theory explaining its underlying mechanisms, contextual factors, and target populations remains limited.
• Understanding the nuances of SDM is crucial for optimizing patient-centered care and improving health outcomes.

Purpose of the Study:

• To address the gap in theoretical understanding of Shared Decision-making (SDM).
• To investigate the specific situations, mechanisms, and individual factors that influence effective SDM between patients and healthcare providers.
• To develop a program theory that explains how SDM contributes to improved engagement in the decision-making process.

Main Methods:

• A seven-step realist synthesis methodology was employed, adhering to RAMESES guidelines.
• The process involved preliminary program theory development, comprehensive literature searches, rigorous selection and appraisal of studies, data extraction, and formal theory identification.
• Expert consultations and stakeholder input were integrated to refine the program theory.

Main Results:

• A program theory for SDM was developed, encompassing three key contexts: pre-existing patient-provider relationships, decision complexity, and healthcare system support.
• Eight sets of mechanisms were identified, including patient and provider trust, self-efficacy, perception of capacity, anxiety, world view, and recognition of the decision.
• The primary outcome identified was enhanced engagement in the Shared Decision-making process.

Conclusions:

• This research presents the first program theory to explicate the 'how,' 'for whom,' 'in which circumstances,' and 'why' of Shared Decision-making (SDM).
• The identified contexts and mechanisms provide a framework for understanding factors that facilitate or hinder SDM, aiding healthcare professionals, policymakers, and patients.
• While further research is recommended, this theory offers a foundational understanding of SDM's operational principles.