Introduction
Aims of the present study
Methods
Participants
Procedure
Data analysis
Ethical considerations
Results
COM-B | TDF | Barriers and facilitators |
---|---|---|
Capability | Knowledge | An awareness of the philosophy of SDM but not always the term |
A lack of knowledge regarding care and treatment options | ||
Cognitive and interpersonal skills | The overlap between core therapeutic skills and skills needed for SDM | |
Negotiation and containment as ‘new’ skills needed for SDM | ||
Memory, attention, and decision making processes | The availability of options may affect what is presented to the young person and family | |
Behavioural regulation | A lack of clarity around whether there are guidelines and protocols for SDM | |
Reviews of treatment and goals, whilst considered important, are conducted sporadically | ||
Opportunity | Environmental context and resources | Facilities not conducive to SDM |
Limited or a lack of psychological interventions for SDM | ||
Administration and time constraints that inhibit SDM | ||
Procedural influences stop SDM | ||
Social influences | Team members positively and negatively influencing decisions | |
Dominating parents | ||
Motivation | Professional role and identity | Shared decision making is something CAMHS clinicians ‘do’ |
Overruling a young person’s wishes due to professional standards | ||
Beliefs about consequences | Shared decision making empowers young people and families | |
Shared decision making takes too much time | ||
Shared decision making can make psychological problems worse | ||
Beliefs about capabilities | Feeling confident engaging in SDM | |
Feeling less confident due to a lack of knowledge around options | ||
Emotion | Feeling overwhelmed which inhibits SDM |
Capability
Knowledge
An awareness of the philosophy of SDM but not always the term
It’s about us not being the expert all the time, it’s about being very explicit about what we can offer, what we’ve got… asking them what helps, what’s been helpful, as well as what we automatically think we may be able to offer them…and not us always sitting in that medical expert model…to keep the parents and families as the experts in their own lives really (Mental Health Nurse 4).
It’s been only recently that I have been told about this shared decision-making, the term specifically…. I know what the meaning is. I think we have used the shared decision issues [for] a very long time… I mean, when we see patients in our clinic, when we think about treatments, when we offer treatments … asking their opinions and taking that into consideration (Psychiatrist 2).
A lack of knowledge regarding care and treatment options
Five years ago, there were a lot more resources out there, you felt comfortable signposting outside, you had better links, and I think over the years, as things have dwindled, I find myself struggling to see what’s out there as well (Clinical Psychologist 5).
I am just thinking of us trainees for example, moving from placement to placement, how are you aware of all the options available? Or if you are aware of the three options rather than the five, you’re only going to present the three that you know about (Trainee Psychologist 2).
Skills
The overlap between core therapeutic skills and the skills needed for SDM
I think the basics, just to be listening well, to be a little bit more involved—to be actually listening properly and using what is being said rather than make your own points around it. I think it’s just the ability to connect with the people they work with really; I think that’s the main thing. It’s just about rapport-building and being quite transparent in what you’re doing (Therapist 1).
Negotiation and containment as ‘new’ skills needed for SDM
Containment and negotiation…the dance of reciprocity, two steps forward and four steps back, and onto the side, a little jiggy then move forward again…you need to be careful not to alienate one individual (Mental Health Nurse 4).
Memory, attention and decision-making processes
The availability of options may affect what is presented to the young person and family
Something [treatment option] that we didn’t offer? I don’t think I would necessarily point that out (Clinical Psychologist 4).
I think information’s key, I think the whole thing that…families need to be given the information and they can make the decisions for themselves about where they go and what supports they might get, so I think they should [have all options] (Mental Health Nurse 2).
Behavioural regulation
A lack of clarity around whether there are guidelines and protocols for SDM
Well I don’t know [if there are protocols/guidelines], I would assume there might be (Mental Health Nurse 1).
Reviews of treatment and goals, whilst considered important, are conducted sporadically
Reviewing progress is really important, that you review what is happening with that young person, because if you don’t review, you don’t know what has helped, how much progress has been made, and where you next need to go, your next step, so reviewing progress is very important, and making changes if needed (Mental Health Nurse 1).
I will ask about the next one, and the review as such, is usually every 6 sessions, sometimes that happens, sometimes that doesn’t, and sometimes its partial follow up, so it’s not very concrete at the moment (Psychiatrist 1).
Opportunity
Environmental context and resources
Facilities not conducive to SDM
Our offices are grim. Especially for young people, it’s just horrible. I think because it looks office-y and it looks clinical and it looks really official, that wouldn’t exactly give you—it’s like going into your doctor’s office and being told that you’re an equal partner really; it doesn’t feel particularly believable (Therapist 1).
…You instinctively want to cut down on conversation to get out of there, out of the room, so its basic things like that (Clinical Psychologist 3).
Limited or a lack of psychological interventions for SDM
For example, the family therapist within the community, there’s been a move to the eating disorder team…so for self-harm it is CBT or nothing (Clinical Psychologist 4).
We’re quite often having to have the conversation even if we do have something. Sometimes there’s a wait, which can be difficult for families if they’re wanting something, for example like play therapy, because it’s quite an intensive therapy, there’s always a waiting list (Clinical Psychologist 1).
Administration and time constraints that inhibit SDM
If you have a time constraint around assessment and you’ve got five bits of paper to fill out, you’re going to try your best to get the information from the client; you’re not necessarily going to be thinking about the client in the longer term, if that makes sense…so it might be that rash decisions get made or it’s a short-term decision rather than thinking about the child’s needs as a whole and how they would engage in that longer term (Clinical Psychologist 1).
I try to do [SDM] without overrunning, but it becomes difficult to manage the rest of the cases, because one has taken over more than an hour, then you begin to feel your own anxiety gets in the way…you become more dominant in a way, to say this is what you should do, this is what will help you, and you become more directive I suppose (Psychiatrist 1).
Procedural influences stopping decision-making
So for anxiety and depression… we’ve had quite a few people going for training—so, the anxiety and depression pathway. So within that is CBT, because we know that’s what evidence—because that’s what we’ve been trained in—… the evidence shows CBT is effective… now we’d say CBT [to young people and families for treatment] (Clinical Psychologist 2).
Social influences
Team members positively and negatively influencing decisions
As a team, we often feedback cases to the team, or talk about a client that you know is struggling, or we’d like to get more ideas, can we talk about it as a whole team, then we’ll come back as a team and present that and talk about that and get a lot more ideas coming through about what we can do (Mental Health Nurse 2).
So yes, certainly dynamics, relationship….I suppose, between other professionals and that can be within the team or outside the team as well. It’s sometimes hard to hold the young person in mind if you’ve got too many voices kind of going over them, really (Clinical Psychologist 2).
Dominating parents
She’s pretty much dragged him to an appointment. So the care plan with my patient, I’m saying “What do you want to do?” and [the young person’s] like, “This is actually quite manageable really. I don’t really want to do anything about it,” whereas Mum’s really clear that it’s causing tension in the home and it can’t carry on; that she wants zero habits all the time (Therapist 1).
Motivation
Professional role and identity
Shared decision making is something CAMHS clinicians already ‘do’
That’s always been my approach. And, to be honest, I try to do that with everything else, so for example, if I’m using CBT, I try to do so in a collaborative way, asking for their views and opinions (Trainee Psychologist 3).
Overruling a young person’s wishes due to professional standards
Someone’s decision making may be impaired due to a psychotic episode, low BMI [Body Mass Index] due to an eating disorder, or suicidal… and the decision of the child or young person may that they don’t want to go into hospital, or talk to the professional, but again it is about keeping the young person safe (Trainee Psychologist 2).
Beliefs about consequences
Shared decision making empowers young people and families
They are empowered, it helps therapy so much and in so many ways, that it moves the process that they are engaged in things that you are doing and the throughput happens (Clinical Psychologist 5).
Shared decision making takes too much time
[SDM] could slow down the pace or slow down the work because you’ve got to work at their pace, when they’re ready to access and take in that information (Mental Health Nurse 3).
Initially it is more time consuming, I don’t think that would bear out over time as it helps with motivation, but initially I think yeah (Clinical Psychologist 3).
Shared decision making can make psychological problems worse
When someone is behaving in a way which in the short-term might alleviate their anxiety, so, for example, ‘I don’t want to go outside because it’s scary’. Okay, in the short term that’s going to make the anxiety go away but then the behaviour reinforces and they stay in the house for six months. So the disadvantage of being person-centred and going along with their decision there is actually that sometimes they can remain stuck if they’re unwilling to engage in a therapeutic technique for which there is pretty good evidence works really well (Trainee Psychologist 3).
Beliefs about capabilities
Feeling confident in engaging in SDM
…I feel comfortable and confident [in engaging in SDM], yes… (Psychiatrist 1).
Feeling less confident due to a lack of knowledge around options
There’s something in our service called cognitive analytic therapy and when I explain it to families I don’t really feel that confident because I’ve never really worked within that model or understand it that much. But I guess, that’s just about my learning that I need to go and speak with somebody and get more information and get people to help me understand it a bit more (Clinical Psychologist 4).
Emotions
Feeling overwhelmed which inhibits SDM
Everyone’s really, really overstretched, overwhelmed. So maybe for some staff, what might happen is that they maybe think actually there could be this other treatment option that we could consider with the family, but then they might forget (Clinical Psychologist 4).