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«Using the OPTION instrument OPTION Rater Manual Observing patient involvement Evaluating the extent that clinicians involve patients in decisions ...»

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Using the OPTION instrument


Rater Manual

Observing patient involvement

Evaluating the extent that clinicians involve patients in decisions

Glyn Elwyn, Adrian Edwards, Michel Wensing and Richard Grol

2005 version

In collaboration with:

Jill Bourne, Wales

Richard Byng, England

Evelyn Chan, USA

Wai Yee Cheung, Wales

Elizabeth Cox, USA

John Dowell, Scotland

Tina Eriksson, Denmark

Ellen Fischer, USA

Guido Goelen, Brussels

Claudia Goss, Verona

Wolfgang Himmel, Germany Margaret Holmes Rovner, USA Kerry Hood, Wales Amanda Howe, England Hayley Hutchings, Wales Christoph Kindler, Switzerland Alex Krist MD, USA Wolf Langewitz, Switzerland Tara Lawn, England France Légaré, Canada Cathy Lisles, Wales Young Mi Kim, USA Matthias Nuebling, Germany Charlene Pope, USA Frances Rapport, Wales Mike Robling, Wales Angela Towle, Canada Trudy van der Weijden, the Netherlands Myrra Vernooy, the Netherlands Heidi Weber, Switzerland Marjorie Weiss, England Clare Wilkinson, Wales Hub Wollersheim, the Netherlands Using the OPTION instrument Contents

1. General Issues

2. Scale design and item definitions

3. OPTION scale (Research Version)

4. OPTION scale (Educational feedback version) Using the OPTION instrument

1. General issues This scale is designed to measure the extent to which clinicians (medical, nursing or other relevant professional) involves patients in decisions within consultations. The authors recognise that these interactions are complex and involve contributions from parties, patients and clinicians. A consultation where there is clear evidence of participation in the decision will as likely have contributions from patients in equal measure to the contributions of the professional. Nevertheless, when developing the scale we recognised the difficulty of designing a scale that assessed the contribution of both agents simultaneously and decided to concentrate the OPTION scale on assessing the skills exhibited by the clinician. This approach is also justified by the differential power relationship that exists in patient-professional interactions, and that if professionals do not offer opportunities, and promote patient involvement in decision making, then the process is highly unlikely to be observed. Nevertheless, we concede that the patient contribution to the process of participation in decision needs to be evaluated in parallel and are making efforts to support the development of such as scale.

Research education etc The scale is designed so that it can be applied to all types of consultations, it is therefore intended to give an involvement score for all ‘types’ of consultations, whether the encounter is one that involves a first consultation about a problem or a review of a previously discussed problem, reassurance, or any of a range of possible categories of encounters. It is recognised however, that patient involvement in decisions is going to be dependent on the type of consultation, so it is important to record the overall consultation type and to record the index clinical condition that the rater uses as the basis for the assessment of involvement in the decision making process. These variables are added to the rating dataset so that the analysis can assess the degree of involvement achieved in differing types of consultations and with respect to the topic or conditions discussed (see Table 1). Often there is more than one problem in the consultation. A practical decision should be taken to score the process for an index problem. An index problem is the problem where the highest degree of involvement occurs within the overall consultation, as the aim is to identify the practitioner’s ability to involve patients. Where there is more than one OPTION rater, they will need to agree the index problem for the rating.

Raters should therefore use the total duration of the consultation to score the OPTION scale, recognising that involvement in decision making can be at the level of involvement in problem solving decisions (e.g. there are two possible diagnoses here, here are the options and possible ways of investigating them…), involvement in treatments (there are a range of possible treatments for this problem, let me explain a bit more about them…), or involvement in further management (there are a number of ways in which this problem could be managed, lets consider them in more detail…). If the clinician involves the patient in any of these types of decision, then the OPTION score would be used to assess the proficiency of the skills exhibited. It is recognised that often, some of the skills may have taken place in previous encounters, but this data will be correlated with the consultation type (new, review or composite).

Using the OPTION instrument Table 1. Consultation data: index problem and consultation categories

–  –  –

In addition to data about the rater identity, consultation type and condition considered, information about the patient and the practitioner is collected (age, gender and information about additional postgraduate qualification, such as Membership of a professional college. These variables are part of the OPTION dataset and are used to evaluate construct validity.

Consultations often involve more than two individuals and when obtaining consent a record should be made of the ages and gender of the individuals who are involved in the consultation. A parent presents a child for instance, or two people consult about a mutual concern (husband, wife, mother, daughter and so on). These consultations are often of a complex nature, and the interaction involves many conversations about problems and decisions. In most adult-child consultations, it will be clear that the decision making discourse will occur between the adult and the practitioner, and it is the age and gender of the person engaged in the consultation process that should be recorded on the OPTION scale, although a note of the age of the child can also be made under the index problem. Where an adult accompanies a teenager, the age of the person to engage in the consultation process should be recorded (i.e. a rater judgement). In consultations where more than one adult is present, the rater should indicate which individual takes the primary role in the consultation process and the clinician behaviour should be judged in relation to this interaction.

2. Scale design and item definitions A five-point scale is used to assess the existence of a communication behaviour (competence). The first point on the scale, namely 0, is used when the behaviour is not observed in the consultation. Details about how each scale point should be given to differing skill levels of behaviours observed are provided in this manual. In

general terms, the five levels (0-4) will correspond to the following general outline:

Using the OPTION instrument

–  –  –

Raters should use the scale points when a behaviour observed corresponds to the descriptions provided in this manual. A set of calibration audiofiles is available from the OPTION Group for those who want to become OPTION raters.

The Scale Items

–  –  –

To embark on a decision making process, there has to be clarity about a specific problem or problems. In order to involve the patient in a decision, it should be clear that a decision making process is taking place. The skill to be observed therefore is the ability to identify, emphasise, draw attention to a problem (e.g. high blood pressure, menopausal symptoms, atrial fibrillation etc), as one where a decision exists about further action, and that it needs to be considered by both clinician and patient. In other words, the patient’s attention is focused on the fact that the consultation is one where a decision making process is being considered and that the clinician is going to involve the patient, if they so wish, in considering the problem.

For this behaviour to occur there has to be a degree of agreement about the nature of the problem. The problem need not necessarily be a diagnosis where there are choices between treatments or form of management. It is also possible to share a decision about whether or not to take a test, order an investigation or send off a referral. The item therefore assess the clarity with which the clinician draws the patients attention to the ‘problem’ that needs a decision making process.

This item does not attempt to cover the issue of diagnosis as such – for example a patient with a headache may want to be reassured that this symptom is not due to a tumour (we expect that such tasks have been completed before a discussion about what to do (problem management) can occur. So in the instance of a patient with a headache where the clinician is not unduly concerned about the possibility of serious pathology, the clinician could proceed by saying, “so we agree that you have a headache, and that it is unlikely to be due to a serious problem. There are a number of ways in which we could proceed, and I will explain these to you so that you can let me know your views about what would suit you best”. This type of statement, where the agreed problem is ‘headache symptom’ could then proceed to the behaviour of drawing attention to the Using the OPTION instrument making process, and would be given a score of 4. No attempt to draw attention to a need for a decision making process should be scored as 0. Attempts to draw attention to the need to embark on a decision making process, should thereafter be scored on the degree of skill exhibited. A score of 1 should be given if the attempts is very brief or perfunctory; a score of 2 if the clinician draws attention to a problem that requires a decision making process (baseline skill level); a score of 3 should be given when the clinician puts emphasis on the decision making process required; score of 4 given when the skill is exhibited to a high standard, e.g.

supplementary explanations and evidence of patient recognising the need to engage in the process of decision making.

Often there is no clarity about problems, or at least no clarity about the decisions to be taken about the problem or problems identified. If this is the case, this item is given a score of 0. In other words, the skill of drawing attention to the need for a decision making process is not observed. Despite a score of 0 for item 1, the rest of the scale should be completed for the consultation.

Item 2 The clinician states that there is more than one way to deal with the identified problem (‘equipoise’).

0 The behaviour is not observed.

1 A minimal attempt is made to exhibit the behaviour.

2 The clinician conveys the sense that the options are valid and need to be considered in more depth.

3 The clinician explains ‘equipoise’ in more detail, that options have pros and cons that need to be considered 4 The behaviour is observed and executed to a high standard.

More than one way of managing problems exist in many (if not most) clinical situations, and there is always the choice between providing an intervention and not doing so, i.e. acting conservatively or making a conscious decision to review the need to intervene at a further consultation. Where there is a perfunctory attempt to convey the existence of more than one option then a score of 1 should be give. A score of 2 should be given when the clinician conveys the sense that the options are valid and need to be considered in more depth (baseline skill level). A score of 3 should be given when the clinician explains ‘equipoise’ in more detail and that options have pros and cons that need to be considered. Where the clinician also explains ‘why’ choices are available e.g. there is genuine professional uncertainly as to the ‘best’ way of managing the problem (clinical equipoise) the behaviour will have been executed to a high standard and a score of 4 is given.

Item 3 The clinician assesses the patient’s preferred approach to receiving information to assist decision making (e.g. discussion in consultations, read printed material, assess graphical data, use videotapes or other media).

0 The behaviour is not observed.

1 A minimal attempt is made to exhibit the behaviour.

2 The clinician asks the patient about their preferred way of receiving information to assist decision.

3 The behaviour is exhibited to a good standard.

4 The behaviour is observed and executed to a high standard.

Although it is entirely feasible for a clinician to exhibit all the behaviours outlined in this framework in one consultation, it is also recognised that the level of information exchange required to prepare patients for Using the OPTION instrument participation in decision making is time consuming and requires reflection about the implications. There are therefore many different approaches that can be used to achieve this purpose. In many instances, clinicians and patients wish to discuss the options and their characteristic in the relevant consultation so that decisions can be made and action taken. But there are also many other possible approaches, and the arrival of decisions aids that range from paper-based data to digital interactive methods are transforming the degree to which the process of information exchange, and therefore, decision making, is undertaken. Practitioners are becoming aware of these tools, and as they become more readily available to patients, clinicians will need to assess if patients wish to engage with these methods in order to participate more fully in decisions. A score of 2 (baseline skill level) would be given to the clinician who asks about the patient’s preferred method of receiving information. A score of 3 would be given for doing this behaviour well e.g. the clinician who states that there are many ways in which information can be conveyed, many of which need the patient to read outside the consultation, and who then assesses the patient’s preferred method. A score of 4 would be given for giving many examples of the types of information formats and media available for the patient, and then providing an opportunity for the patient to select their preferred method or methods.

Item 4 The clinician lists ‘options’, which can include the choice of ‘no action’.

0 The behaviour is not observed.

1 A minimal attempt is made to exhibit the behaviour.

2 The clinician lists options.

3 The behaviour is exhibited to a good standard.

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