Key issues in the process of implementing shared decision making (DM) in mental health practice
| DOI | https://doi.org/10.1108/MHRJ-01-2017-0006 |
| Pages | 257-274 |
| Date | 11 September 2017 |
| Published date | 11 September 2017 |
| Author | Shulamit Ramon,Helen Brooks,Sarah Rae,Mary-Jane O’Sullivan |
| Subject Matter | Health & social care,Mental health |
Key issues in the process of implementing
shared decision making (DM) in mental
health practice
Shulamit Ramon, Helen Brooks, Sarah Rae and Mary-Jane O’Sullivan
Abstract
Purpose –This review paper will look at internationally existing publications in the English language on mental
health shared decision making (SDM) implementation of a variety of interventions, including different
methodologies and research methods, age groups and countries. The purpose of this paper is to provide an
overview of: process, degree and outcomes of implementation; barriers and facilitators; perspectives on
implementation by different stakeholders; analysis of the process of implementation in mental health services
through the lenses of the normalisation process theory (NPT).
Design/methodology/approach –Following a targeted literature search the data were analysed in order to
provide an overview of methodologies and methods applied in the articles, as well as of the variables listed
above. Three different types of information were included: a content analysis of key issues, reflective
understanding coming out of participating in implementation of an SDM project in the form of two narratives
written by two key participants in an SDM pilot project and an NPT analysis of the process of implementation.
Findings –Only a minority of mental health SDM research focuses on implementation in everyday practice.
It is possible and often desirable to achieve SDM in mental health services; it requires a low level of
technology, it can save time once routinized, and it is based on enhancing therapeutic alliance, as well as
service users’motivation. Implementation requires an explicit policy decision, a clear procedure, and
regular adherence to the aims and methods of implem entation by all partici pants. These necessary a nd
sufficient conditions are rarely met, due to the different levels of commitment to SDM and its process by the
different key stakeholders, as well as due to competing providers’objectives and the time allocated to
achieving them.
Originality/value –The review indicates both the need to take into account the complexity of SDM, as well
as future strategies for enhancing its implementation in everyday mental health practice. Perhaps because
applying SDM reflects a major cultural change in mental health practice, current value attached to SDM
among clinicians and service managers would need to be more positive, prominent and enduring to enable a
greater degree of implementation.
Keywords Implementation, Mental health, Review, Shared decision making
Paper type General review
Introduction
This review paper focuses on the implementation of shared decision making (SDM) in mental
health, an issue that has arisen only recently at the stage in which some of the pilot projects on
SDM have led to this strategy becoming accepted policy in some mental health services, while
the majority of such projects have not moved to the implementation stage. Implementation is
defined here as the routinisation of SDM as a process applied in everyday practice by
multidisciplinary p roviders across the rang e of key interventions, to include medical,
psychological and social interventions.
SDM is defined as the process by which intervention options are looked at in a two-way
exchange of information and knowledge ( formal and experiential) by a patient and a clinician,
who together decide on a course of action (Charles et al., 1999). This collaborative process is
Received 18 January 2017
Revised 12 April 2017
17 June 2017
Accepted 17 June 2017
Shulamit Ramon is a Professor
at the School of Health and
Social Work, University of
Hertfordshire, Hatfield, UK.
Helen Brooks is a Research
Fellow at the Division of
Nursing, Midwifery and Social
Work, University of
Manchester, Manchester, UK.
Sarah Rae is an Expert by
Experience at Cambridge, UK.
Mary-Jane O’Sullivan is an
Advanced Clinical Lead at
Crisis Resolution Home
Treatment Team,
Cambridgeshire and
Peterborough NHS Foundation
Trust, Fulbourn, UK.
DOI 10.1108/MHRJ-01-2017-0006 VOL. 22 NO. 3 2017, pp. 257-274, © Emerald Publishing Limited, ISSN 1361-9322
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MENTALHEALTH REVIEW JOURNAL
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based on mutual respect, open communication and consideration of individual preferences and
values, usually entailing:
1. the inclusion of at least two people, patient and clinician;
2. who share information;
3. take steps to build a consensus about preferred intervention; and
4. reach agreement on the intervention to be implemented.
Based on a systematic literature review of journals that centre on implementation of SDM, this
paper looks at key themes highlighted in the relevant articles thus identified, followed by a
reflective section, leading to an overall analysis from the perspective of normalisation process
theory (NPT) (normalisation theory process). NPT is a sociological theory developed to support
the work of implementing and embedding complex interventions in healthcare and other
institutional settings (May et al., 2007). NPT constructs were used as sensitising concepts whilst
designing and undertaking the review, and as a heuristic framework for analysing and
synthesising the literature.
Two reflective narratives based on experiencing implementation work are included, as ways of
illuminating issues raised in the key content section, and of highlighting the experiential reflective
perspectivealongside a scientific one.Such a perspective is all too often missingin formal research,
while it is a key element in enabling SDM, which is based on understanding coming from both
scientificand experiential knowledge.The first narrative was writtenby a senior nurse who hasbeen
involved in a UK SDM project introducing a SDM intervention during its experimental phase
(see Stead et al., 2017),as well as during the first two years of its implementation, playing an even
more central role in the latter phase. The second narrative was provided by a service user trainer
and researcher, who has been involved in the project since its inception.
SDM in mental health is perceived as a necessary and useful process especially in the promotion
of the new meaning of recovery in mental health (Davidson, 2003; Ramon et al., 2007;
Slade, 2009) which is defined as leading a meaningful life, even if symptoms of mental ill
health have not disappeared.
The analysis of the articles, the key themes and the reflective narratives fromthe NPT perspective
provides an in-depth overview of what is meant by the process of implementation and its
components. This connects the text to an emerging conceptual framework focussed on both
outcomes and processes of change in mentalhealth services which impacts on allstakeholders of
these services, be they service users, clinicians, peer support workers, managers or researchers.
Methods
Literature search strategy
The aim of the search was to identify articles on the implementation of SDM within mental health
services. Given the relatively recent interest in the topic under consideration, and our own
knowledge of the mental health SDM literature, we did not anticipate that traditional database
searches would yield relevant articles. We therefore opted for a targeted search, using articles
known to the authors on SDM and searching further on the basis of the identified themes and
authors within these articles. The authors compiled a list of journals related to implementation and
SDM, which were searched for relevant papers (Appendix 1). Reference lists of included papers
were also searched to identify further papers of relevance.
Inclusion criteria were: studies published between 2000 and 2016 and those pertaining to
mental health services on the subject of the implementation of SDM written in English.
Exclusion criteria were: studies focusing on SDM in mental health but not on implementation,
studies not published in English.
In total, 73 articles were thus identified, of which 46 were looked at in full, ending up with
28 articles for a more detailed analysis. SR and HB reviewed search results to agree on whether
articles should be included or excluded based on this agreed criteria.
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