1. Title of the Change Project
Student ID.
MSc in Healthcare Management,
Institute of Leadership, Royal College of Surgeons in Ireland
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Partners in Care
Introducing the LEARNS-DECIDER Shared Decision Making Framework to Optimise Patient-Practitioner Concordance
Yvonne Delaney, MSc in Healthcare Management.
Abstract
This organisational change project relates to the development and pilot of a shared decision-making framework to assist Public Health Nursing teams to optimise concordance. The initial rationale for choosing this project was the requirement for a standardised approach to the management of patient non compliance. As the change progressed incrementally, framed by the HSE change model and informed by the literature review, an interesting shift occurred which altered the direction of the project to one which would aim to optimise concordance. Concordance appears to offer an alternative method consistent with person-centred approaches as opposed to focusing on labelling patients as non compliant when in fact they are simply exercising choice. This places the onus on the practitioner to facilitate informed decision-making through patient centred learning with the desired effect of informed patients exercising choice through shared decision-making conversations.
Public Health Nurses, Community Registered General Nurses, Clinical Nurse Specialists and management voluntarily participated in a focus group (n=7) and an optional questionnaire which explored their experience of the promotion of concordance and the management of non concordance. The focus group and questionnaire yielded some insightful, qualitative and quantitative findings. The qualitative findings are representative of the real experience of the practitioner and were found to be in congruence with the literature. The overarching message that arose was that patients’ needs, choice, values & desires must be respected, recognised and acknowledged once we have established that they have the ability to make sound decisions.
Following the focus group, the project aim and objectives were refined and what resulted was the development and pilot of a shared decision-making framework underpinned by patient centred learning. A pilot evaluation questionnaire based on the use of the draft shared decision-making framework provided the author with incremental guidance which will inform the final draft of this framework. The resultant shared decision-making framework will reside within a practice guideline which will be developed in phase two of this collaborative project. The CIPP evaluation model informed the main conclusion from the process to date which is the need for structured training to enhance the competency of the practitioner around the facilitation of client centred learning and shared decision-making conversations with the effect of mainstreaming the change within the culture, processes and structures of the Public Health Nursing service.

2. Methodology continued Organisational Impact
Partners in Care
Introducing the LEARNS-DECIDER Shared Decision Making Framework to Optimise Patient-Practitioner Concordance
Yvonne Delaney, MSc in Healthcare Management.
Introduction
Methodology continued
Evaluation
B) Planning - Culture & Force field analysis, business case for staff self care sessions to build resilience, focus group & questionnaire with stakeholders, aim & objectives refined, staff monthly newsletter compiled and circulated.
C) Implementation development & pilot of the LEARNS-DECIDER Framework –figure 1.
D) Mainstreaming: Review of pilot evaluations of the LEARNS-DECIDER framework, newsletter celebrating outcomes, planning for supporting guideline.
The LEARNS-DECIDER framework navigates a process of information sharing & negotiation which enables transparency of decision making. In using the framework both patient and practitioner explicitly determine the desired plan of care based on the best practice recommendations presented by the practitioner alongside the subjective health priorities of the patient.
A concordant approach in healthcare combines the expertise of the professional in the form of best practice evidence with the expertise of the patient regarding the subjective insight into their lived experience, their needs & preferences which all underpin patient choice 1. In attempting to achieve better outcomes for patients, the PHN * service set out to explore approaches that would eliminate unwarranted perceptions of patient non compliance which only serves only to disregard patient autonomy & choice. The use of concordant approaches such as shared decision making in clinical practice facilitates patients’ participation as informed partners in their healthcare journey 2.
The CIPP model 6 was employed to guide appraisal of this change project. Pre & post pilot findings indicate the value of the framework as presented in Figure 2: Staff Confidence In shared decision making
Organisational Impact
Figure 1: LEARNS 4 – DECIDER 5
Integrating the LEARNS- DECIDER Framework into practice has enhanced decision making between patients & practitioners & honours patients’ values & preferences in making choices based on evidence based options. Recommendations are to enhance this work further through staff training, patient reported evaluation & the use of validated decision-making tools.
This report illuminates the way practically & conceptually & calls for professional & organisational leadership in meaningful areas in order to mainstream this change within the culture, processes & structures of the PHN service.
Aims & Objectives
AIM: The development of a shared decision-making framework to optimise concordance.
Objectives: 1. To facilitate shared decision making conversations underpinned conceptually by the evidenced base.
2. To pilot the decision making framework with the steering group.
3. That nurses will report more confidence in their ability to document shared decision-making & enhance concordance.
The Health Service Executive (HSE) Change model 3 framed this project from inception to evaluation and the strategies employed are presented A-D as follows:
A) Initiation
-Change ideas invite circulated
-S.W.O.T of self & organisation
-Project impact statement
-Communication strategy
* Public Health Nursing
Conclusion
Methodology
References
Fraser, S. (2010) Concordance, compliance, preference or adherence. Patient preference and adherence, 4, National Heart Foundation of Australia, (2011). Improving Adherence in Cardiovascular Care. A Toolkit for Health Professionals. National Heart Foundation of Australia. 3. HSE (2008). Improving Our Services: A Users’ Guide to Managing Change in the HSE. HSE. 4. Registered Nurses’ Association of Ontario (2012). Facilitating Client Centred Learning. Registered Nurses’ Association of Ontario, Canada. 5. Delaney, Y. (2015) –unpublished, underpinned by HSE (2013) National Consent Policy. Quality and Patient Safety Directorate, HSE. 6. Stufflebeam, D. & Shinkfield, A. (2007). Evaluation theory, models and applications, San Francisco: Jossey Bass/John Wiley & Sons, Inc.