Exploring SDM in HIV nursing care
Discussion
ThetwopartsofthisresearchstudyshowthatHIVnursesarehighlysupportiveofSDMandstrive
toimplementitintheirday-to-dayactivities.Forexample,inthequestionnaire(Q.6),92%agreed
withthestatementthatSDMis`a collaborative process that allows patients and providers to make
healthcare decisions together'.Treatmentadherence,HIVtesting,psychologicalcareandsexual
riskwerethemainareaswhereSDMwasundertaken.Theselinkcloselytothemaindecision
areasreportedbypatientsinthereviewofpatientdecisionmakingbyBravoet al.[1].However,
Bravoet al.alsohighlighted`decisionsaboutdisclosuretoothers'and`decisionsaboutstarting
afamily'asakeyissuesforpatients[1].SDMintheseareaswasreportedmuchlessfrequently
inoursample(Q.10)indicatingthatitmaybeusefultocomparepatientperspectivesofSDMwith
thatofprofessionals.
In spite of the apparent agreement in definition of SDM found in the quantitative data, the
qualitativefindingsinthisstudyhighlightseveralnuancesaroundhowSDMisunderstoodand
practised.Formanynursesinthegroupdiscussions,SDMwasperceivedasabroadissueof
`involvingthepatientincare',ratherthanasaveryspecificprocessaroundspecificdecisionsas
recommendedintheliterature/guidanceinthisarea.Reflectingtheholisticperspectiveofnursing,
formanyparticipants,SDMwasaboutadecision`incontext'andadecision`withinarelationship'
andmuchlessaboutthemechanicsandstepsoftheactualdecision-makingprocess,which
weremorevaguelydescribed.Indeed,themostcommonlydescribedstrategiesforSDMwere
`generaldiscussion'ratherthanfol owinganyspecificframework,forexample,theOttawaDecision
Framework[22].Hence,whilsttheliteratureonSDMdefinesitasquiteanarrowandspecific
phenomenon[6],nursesappearedtohaveamoreinclusivebut,arguably,hazyviewofit.However,
thismayalsoreflectthefactthatthemajorityofparticipantscompletingthequestionnaire(86%)
reportedhavingreceivedverylittleformaltrainingonSDM(Q.14).
Anotherissuethatemergedfromthequalitativedatawasthatnursesarticulatedacollaborative,
inclusive and team-based understanding of SDM. Much of the discussion referred to nurses'
relationshipswithotherhealthprofessionalsandtheirroleinrepresentingthepatientindiscussions
withotherhealthprofessionalsandwithinMDTmeetings.Inthisway,nursesseemedtobeacting
indirectlyasfacilitatorsofSDM,aswel asdirectlyengaginginSDMwithpatientsthemselves.This
facilitationrolewasalsoevidentwhennursesdescribedthemselvesas`translating'betweendoctors
andpatientstoensurethateachunderstoodtheother'sperspective.Therolethatnursesplayin
facilitatingSDMhasnotbeenexplicitlyrecognisedintheliteraturearoundSDM,whichhastended
tofocusverymuchontherelationshipandcommunicationbetweenaparticularprofessional­
patientdyad[4].Incontrast,ourstudysuggeststhatsharedmodelsofcareandMDTmeetings
representkeysitesfordecisionmakingandthatnursesplayanimportantroleinadvocatingwithin
theseforgreaterpatientinvolvement.
Final y,thestudyhasalsorevealedthatSDMcanbechal engingfornurses.Someofthese
chal engesarerelatedtopatients.NursesexperiencedatensioninadoptinganSDMapproach
withpatientsperceivedtobecomplex,chaoticorwhoweremakingchoicescontrarytocurrent
guidelines.Similarly,thequestionnairedatashowedthatnursesperceivedsomepatientsasnot
wantingtoengageinSDMatal ,preferringthenursestoadvisethemonwhattodo(Q.12andQ.13).
Themostsignificantchallengeofallwasposedbypatientswhowishedtooptoutoftreatment
altogether.Thequestionnairedatashowedthatnurseswouldappreciategreatertrainingaround
SDM,withaspecificfocusonhowtosupportthesemorecomplexpatientscenarios(Q.15).Other
chal engesaroundSDMweremorestructural.Theyrelatedtothechangesthatwereoccurring
2016
withinthediseasearea,whichrequiredparticipantstoadheretonationaltargets,guidelinesand
protocols,allofwhichservedtoinhibitpatientchoiceandthereforelimittheopportunitytoengage
inSDMinameaningfulway.Lastly,therewereorganisationalchallenges.NursesnotedthatSDM
requiredmoretime,whichwasofteninshortsupply,andmoreresources.Withregardtothelatter,
thequestionnaireindicatedthat72%oftherespondentswantedgreateraccesstoresourcesto
facilitateSDM(Q.17)and52%saidthattreatmentdecisionaidswouldhelpthemtoimplement
www.nhivna.org
page 25 of33

---