DNP Use of SDMs in Clinical Settings

Decision Making in Clinical Settings

Introductory Information about Interprofessional Engagement in Shared Decision-Making

• Definition of interprofessional engagement. Although no universal definition exists, interprofessional engagement can be regarded as the collaboration that occurs between professionals from different disciplines who work together to identify and solve problems as well as formulating treatment strategies. The engagement process is based on a teamwork approach that draws on the knowledge and experience of various fields to develop comprehensive solutions to frequently complex problems (Fang, 2023).

• History of interprofessional engagement. It is reasonable to suggest that humankind has relied on interprofessional engagement in some form since time immemorial when different people were recognized as possessing prized skills that were not shared by many others. In a modern context, however, the history of interprofessional engagement can be traced to the late 1960s when “teamwork became the cornerstone for effective collaboration as primary care centers” (Barr, 2019).

• Impact of interprofessional engagement on delivery of healthcare. Interprofessional collaboration in healthcare settings allows professionals from diverse backgrounds to cooperate as a coordinated unit. This team-based approach draws on the unique talents and viewpoints of various disciplines to enhance patient care. Working together fosters mutual understanding and respect between team members. Likewise, it also provides opportunities to learn best practices from one another which facilitates the detection and prevention of medical errors, while speeding intervention when risks emerge (The Importance of Interprofessional Collaboration in Healthcare, 2023).

• Identify innovative practice changes. Contributions from administrators, physicians, IT staff, and nurses facilitate the development of documentation tools, communication platforms, and data infrastructure to capture real-time patient insights at the bedside. By working within an interprofessional framework, nurses can help shape future best practices rather than simply adopting new policy guidelines (Clark et al., 2023).

• Introduce the six steps for implementing interprofessional SDM within clinical. Implementing interprofessional shared decision making (SDM) within clinical setting is a step-wise process that is intended to maximize the value of the contributions of each team members by drawing on their respective areas of expertise, including doctors of nursing practice (DNPs). In this context, the DNP essentials outline core competencies for nursing\\\'s highest practice degree in order to equip nurses to be effective leaders and clinicians. Several of these essential areas specifically relate to DNP competencies for facilitating shared decision-making as discussed further below.

Six Steps for Implementing Interprofessional Shared Decision Making

Step1: Engage clinical team should include:

• Identify the team (key players) used in the innovative practice change. Although a “core clinical team” comprised of healthcare professionals from relevant specialty areas, such as physicians, nurses, social workers, rehabilitation specialists and case managers is routinely used, every decision-making scenario – and patient -- is unique. Therefore, this step requires a careful assessment concerning which disciplines should be represented to achieve optimal clinical outcomes.

• How will you propose the practice change to the key players? Persuading professionals of any ilk to leave their respective “comfort zones” by implementing changes to establish policy and practice protocols can be a daunting enterprise. Therefore, prior to any proposal for practice change, policy proposers should ensure that the evidence supports suggested changes through data analysis and literature reviews. In addition, careful assessment concerning the readiness for change among key players and the identification of any knowledge gaps should be performed, followed by targeted messaging concerning the expected benefits of the proposal for patients, providers and the organization to help “buy-in” among the key players.

Because clinicians are busy professionals, extra efforts should be made to minimize any disruption to current protocols and ongoing feedback from representative interprofessional team members should be solicited. Likewise, recruiting champions from the represented disciplines who can act as change advocates to their peers and demonstrating management buy-in through allocation of resources and funding for the practice change will also be important elements in the proposal for any practice change. Finally, it is essential to develop clear implementation protocols and schedule regular meetings pre- and post-launch to identify problem areas and opportunities for improvement.

Step 2: Identify the decision(s)

• Evaluate the common decisions for your target patient population and where they occur within the process of care.

• Discuss an ethical issue that may impact your decision to proceed with your quality improvement project. While this step is fairly straightforward, it is also iterative and there are, therefore, multiple ethical issues that can arise which may impact the decision to proceed with a quality improvement project, including most especially the revelation of new evidence that may adversely affect that intended outcome of any quality improvement initiative. This evidence can be related to newly released information concerning the potential harms to patients, providers and/or organizations that might result from the implementation of a given DNP initiative or even empirical observations from team members.

• What would be your approach if critical players lead to unwarranted practice variation of your practice change. The approach used in these situations depends on the severity and scope of the unwarranted practice variation. If the severity and scope are minimal, collaborations between the DNP and responsible provider concerning the need for a standardized approach based on the evidence supporting the change initiative may suffice. Conversely, if variations are identified that pose serious threats to patient or provider safety, the approach used would require a full team meeting as well as notice to any appropriate management level, including the top leadership team.

Step 3: Find quality patient decision aids

• Discuss what SDM you would use in your quality improvement project to enhance patients’ knowledge of options and expectations and improve patient-clinician communication.

Implementing any DNP quality improvement initiative to enhance patients’ knowledge and expectations in ways that will also improve patient-clinician communication demands open lines of communication between healthcare providers and patients. The process would start by nurses asking patients open-ended questions to elicit their preferences, cultural and individual beliefs, and values about their treatment regimen, including their prescribed medications. In this type of situation, patients could be provided with simple explanations concerning how their medications work, any potential side effects, risks/benefits analysis, and alternatives.

In addition, nurses should use teach-back methods to confirm patient understanding and document their priorities and preferences related to symptom management. Pre- and post-intervention data on patient activation levels, perceived involvement in decisions, medication adherence rates, and patient satisfaction would serve to identify opportunities for improvement. This SDM-focused intervention channels essential nursing communication techniques to enhance patient autonomy through the provision of timely and relevant knowledge and the formation of a therapeutic rapport with their healthcare providers (Marks et al., 2022).

• Discuss the international Patient Decision Aid Standards that you can use to appraise patient decision aids their quality (Elwyn et al., 2006).

The development of patient decision aids has expanded rapidly over recent years, with over 500 currently in existence after initial origins in academic settings. These tools are designed to supplement patient-provider discussions and help patients better understand treatment options while clarifying personal preferences. Research shows decision aids can improve patient knowledge and realistic expectations regarding procedures and empower involvement in choices; however, there is a lack of consensus around concepts, appropriate methodology, and quality control criteria for patient decision aids (Elwyn et al., 2006).

This limitation presents issues since variabilities and potential biases in these tools can significantly impact what options patients select. Recognizing this need, the International Patient Decision Aids Standards (IPDAS) Collaboration formed to develop an internationally accepted framework of quality indicators that patient decision aids should meet. They reviewed existing quality assessment checklists but determined a tailored tool was required given how decision aids function as interventions providing probability estimates to guide deliberation in preference-sensitive decisions. The IPDAS initiative represents an important effort to standardize development and evaluation measures for patient decision aids to assist practitioners and properly inform end-users (Elwyn et al., 2006).

• Evaluate the A-to-Z inventory that provides decision aids appraised under the International Standards (http://decisionaid.ohri.ca). Select and discuss a tool that correlates with your project

The alphabetic inventory of international standards for decision aids provides a useful (but not exhaustive) “one-stop” venue for locating relevant SDM aids and strategies for a wide array of healthcare purposes. One tool in particular that closely correlates with my DNP project is the decision aid for patients provided by the Mayo Clinic entitled, “Alzheimer\\\'s disease: Should I take medicines?” available at https://decisionaid.ohri.ca/Azsumm.php?ID=1131.

Step 4: Provide interprofessional SDM training

• Discuss a common barrier to implementing interprofessional SDM.

In virtually any setting, a common barrier to the implementation of interprofessional SDM is a fundamental lack of relevant knowledge and skills on the part of the decision coach and individual team members that are required for resolving a given problem (Legare et al., 2011).

• Discuss an inventory of training programs to handle the barriers.

Here again, while every implementation situation and the corresponding barriers are unique in some ways, organizations such as the Sustainable Health Research Center (SHRC) provide an inventor of training programs that can handle such barriers. For example, the training program offered by the SHRC, “When a decision is not easy to make,” outlines a 1-1/2 hour, step-by-step workshop that underscores the importance of sharing relevant information with patients to help them make informed decisions about their preferred healthcare interventions.

Step 5: Define responsibilities of team members

• Discuss the role each team member will play. The penultimate step in implementing an interprofessional SDM approach in a clinical setting involves identifying and discussing the respective roles of each team member to ensure clarity in their responsibilities. Outlining specific roles avoids duplication or confusion of efforts, thereby facilitating coordination. Likewise, explicitly delineating team member responsibilities also avoids ambiguity in task completion and promotes efficiency. For instance, typical team member responsibilities in clinical settings include issues such as physicians communicating evidence, nurses checking patient understanding, case managers providing requisite resources, and patients communicating their individual preferences to establish accountability.

Step 6: Monitoring use and outcomes

• Discuss the use of interprofessional SDM that you can use to monitor patient reports or observations. A useful SDM process leverages an integrated platform to capture real-time patient health data, experience, and observed disease impacts in between clinical encounters. As part of the SDM, patients would complete short surveys on medication side effects, treatment plan challenges, quality of life changes, and other relevant metrics through a user-friendly dashboard. This feedback would generate data flowing into their electronic records for the interprofessional team to review together during weekly care coordination huddles. The primary care provider, specialists, pharmacist, social worker, care manager and nurses would assess emerging issues and determine any care plan adjustments needed collaboratively with the patient’s goals in mind. By monitoring patient reported outcomes through a technology-enabled feedback loop along with open communication channels, the team can remain responsive to the patient’s evolving condition, needs and preferences to guide shared decision making.

• There are several instruments for measuring observations of SDM, discuss one. Properly implemented and administered, a flowsheet can be a valuable SDM tool for measuring observations. For instance, a flowsheet for patients with heart failure to track key indicators of worsening condition that should prompt early intervention. The monitoring parameters could include daily weight, blood pressure, edema, and shortness of breath. The flowsheet would have clear thresholds established through shared decision making between cardiology, primary care, nursing, pharmacy and the patient/caregiver. For example, weight gain of 2 pounds overnight or more, systolic blood pressure over 140, pitting edema past shin, or shortness of breath at rest could flag the need to adjust diuretics. Patients and family members would record their observations on paper or electronically. The interprofessional team would review submitted flowsheets weekly and intervene if any concerning trends are identified to arrange follow up care through collaborative discussion involving the patient to address their preferences and needs.

Accreditation in Healthcare

1. Select one accreditation agency for a hospital: The Joint Commission

• What is the purpose of accreditation in healthcare? The overarching purpose of Joint Commission accreditation is to signal to the public an organization’s delivery of trusted, reliable, evidence-based care that meets modern benchmarks for quality (Our Mission and Vision, 2024).

• How long is the accreditation cycle with this agency? Accreditation by the Joint Commission also drives ongoing enhancements through periodic assessment and re-evaluation about every 3 years.

DNP Leaders Addressing Deficiencies

Elaborate on three standards deficiencies found in the 2020 HFAP Quality Review by answering the following questions for each deficiency:

Deficiency No. 1:

• What was the deficiency? 01.01.23 Contractor Quality Monitoring: The hospital’s governing body holds ultimate responsibility for all services provided whether by employees, formal contract, joint venture, informal agreement, shared services, or lease arrangement. Deficiencies identified specific contracts that were neither reviewed by the Quality Committee nor advanced to the governing body for review

• Example of surveyor citation? No performance measures were established for governing body review.

• How can a DNP leader make a clinical change to help improve a similar deficiency in a hospital setting? A DNP leader can collaborate with quality improvement personnel and analytics teams to identify key clinical, operational, and patient experience metrics that should be routinely monitored and reported through dashboards and scorecards. The DNP leader can then present the recommended performance measures framework to the governing body for endorsement, implementation and timely review.

• Provide one example of utilizing a shared decision-making approach to resolve this deficiency. The DNP could convene an interprofessional workgroup with membership across nursing, medicine, quality improvement, analytics, administration, and patient advocacy. Each member would analyze organization priorities, safety reports, patient satisfaction surveys and evidence-based guidelines to propose meaningful metrics for governance oversight in their domain.

Deficiency No. 2: 07.00.00 Condition of Participation: Infection Control

• What was the deficiency? As the overall assessment of infection control practice for the organization, this condition is most often cited as a result of aggregate infection control deficiencies identified across units and/or buildings.