CHAPTER 14 Talking with clients about evidence

After reading this chapter, you should be able to:

• Describe why it is important that health professionals communicate effectively with their clients

• Understand what is meant by the term client-centred care

• Explain what is meant by shared decision making and discuss some of the challenges associated with it and the strategies that can be used to facilitate it

• List the key communication skills needed by health professionals when talking with clients about evidence

• Describe the various methods that can be used for communicating information to clients, the main considerations associated with each method and the major factors that should be considered when deciding which communication tool(s) to use with a client

• Explain how to effectively communicate statistical information to clients

At the heart of the definition of evidence-based practice that was provided in Chapter 1 lies the involvement of clients and the consideration of their values and preferences when making decisions regarding their health care. As part of the health care that they are receiving, clients often need to make decisions about aspects of their health care such as whether to proceed with a particular intervention. A health professional’s ability to communicate effectively with clients and, often, also their family members is crucial to the successful involvement of clients in these decisions. For these decisions to be fully informed and ones with which the client is involved, clients need to know about the benefits, harms and risks associated with the various intervention options. Even when a decision about intervention is not needed, there are often many other aspects of their health care that clients can benefit from being knowledgeable about. Individualised education that is specific to the disease and the client is able to improve a client’s self-efficacy to manage chronic conditions, assist with short-term behaviour change, improve quality of life and reduce morbidity and healthcare utilisation.¹ Effective communication can also help to build trust between clients and health professionals, make clinical practice more effective and reduce clinical mishaps and errors.²

Despite its importance, many health professionals are not specifically trained in how to effectively communicate with clients, and many clients do not know how to communicate with health professionals. Therefore, we have devoted a chapter of this book to this topic so that, when you are interacting with clients, you are aware of the importance of talking with your clients about evidence and are knowledgeable about the skills and resources that can assist you to do this successfully. In this chapter, we will discuss why effective communication is important, outline the steps to communicating effectively with clients and discuss some of the key communication skills that health professionals need, including sections on how to decide which communication method and tool(s) to use and how to communicate statistical information to clients. We will also outline the concept of client-centred care and one of the skills that is often central to achieving this, namely shared decision making.

Why is effective communication so important?

You may not think of communication as a particularly important or specialised skill for health professionals to have and often health professionals do not give it the emphasis that it needs. Health professionals often think of communication as secondary to their ‘real’ job of caring for clients. However, the success of an intervention is frequently dependent upon the health professional successfully providing the client with appropriate information. In addition, health professionals often do not realise that, as with many of the other interventions that they provide to clients, there are theories and principles that should be used to guide communication with clients.

Effective communication is central to a ‘client-centred’ approach by health professionals. The evolution and benefits of client-centred care are discussed in the following section.

Client-centred care

Client-centred care (also commonly referred to as patient-centred care or client-centred practice) is a broad umbrella term reflecting a particular approach to the health professional–client relationship that implies communication, partnerships and a focus beyond the specific clinical condition.³ Client-centred practice by health professionals reflects their commitment to quality care by the way they respect clients’ needs, goals, values, expectations and preferences and involve clients in the decision-making process.⁴

Central to client-centred care is treating clients with dignity, responding quickly and effectively to clients’ needs and concerns ⁵ and providing clients with enough information to enable them to make informed choices about their health care.⁶ Client-centred care has become the model that is advocated by health professionals and health professional associations. This model of care sits between the ‘paternalistic’ and ‘informed patient or independent choice’ models of care.^7,⁸ In the traditional ‘paternalistic’ model of care, the health professional is in control, discloses information as and when suitable and makes the decisions for the client who is expected to be passive, unquestioning and compliant. At the other end of the spectrum is the ‘informed patient or independent choice’ model in which health professionals present the facts and leave the decision making solely up to the client.⁷

There is emerging evidence of the benefits of client-centred care to health professionals and clients. Client-centred practice can increase client satisfaction and quality of life, reduce client anxiety and improve adherence to long-term medication use.^3,⁹ For health professionals, client-centred practice can contribute to more appropriate and cost-effective use of health services, such as reducing the number of diagnostic tests and unnecessary referrals.^3,^9,¹⁰ Features of client-centred practice include shared decision making and tailoring communication and education to the needs, abilities and preferences of the client, each of which will be discussed in the following sections of this chapter.

Shared decision making

Shared decision making refers to clinical decision making as a partnership between the client and health professional, with communication focussed on achieving shared understanding of treatment goals and plans.¹¹ Shared decision making allows clients the opportunity to express their values. Client involvement in the decision-making process often extends beyond just choosing treatment options and can also involve:⁷

• recognition and clarification of the health issue

• identification of possible solutions

• appraisal of possible solutions

• implementation of the chosen solution

• evaluation of the solution.

Many leading health organisations now advocate client participation in clinical decision making. These include the National Health and Medical Research Council of Australia,² the USA Preventive Services Taskforce⁷ and the General Medical Council of the UK.¹²

Shared decision making between clients and health professionals has been linked with improved client outcomes, for example improved control of hypertension,¹³ better compliance,¹⁴ greater family satisfaction with communication,¹⁵ improved emotional status¹⁶ and reduced visits to emergency departments and use of medications.¹⁷ However, shared decision making is not possible in all clinical encounters, nor is it welcomed or desired by all clients. The next section presents some of the challenges that can be associated with shared decision making.

Shared decision making: the challenges

Challenges related to the availability of evidence

Sometimes shared decision making can be relatively straightforward, for example in common health problems where there is only one course of action or where the evidence is clear and most informed health professionals and clients would agree that the benefits outweigh the harms.¹⁸ In other situations, shared decision making can be more difficult. For example, with some chronic conditions the research evidence that is provided by randomised controlled trials and systematic reviews often fails to endorse one intervention and instead highlights the benefits and harms of a number of interventions. While difficult, shared decision making can be particularly valuable in these situations, with health professionals helping clients to understand the risks, benefits and trade-offs of the various interventions.¹⁴ Finally, for some medical conditions there may not be sufficient evidence about the benefits and harms of intervention options, in which case the health professional needs to assist the client to assess this uncertainty against the client’s values and preferences.¹⁸

Clients’ involvement in shared decision making

Shared decision making is not always possible, for example in medical emergencies or with clients who do not have the cognitive capacity to participate. Further, shared decision making is also not always welcomed or desired by clients. In a nationally representative sample of 2750 adults in the USA it was found that, while 96% of the participants wanted to be asked for their opinions and offered choices, half preferred to rely on their doctors for information and half wanted to leave the final decisions up to their doctors.¹⁹ Clients’ preferences for involvement in decision making were found to differ by health status and socio-demographic characteristics. For example, clients who were in poorer health, male, older than 45 years of age and with fewer years of education were less likely to want to participate in shared decision making.

Individual clients may also vary in the degree to which they want to participate in shared decision making depending upon the specific clinical situation.² This illustrates the need for you, as a health professional, to determine the role that each of your clients wishes to take in the management of their health. A simple question that you can ask to help establish this is ‘How do you feel about being involved in making decisions about your treatment?’²⁰

It is worth pointing out that shared decision making may also have unwanted effects. For example, once clients are fully informed about benefits, harms and risks, they may still decide not to undertake treatment for a health condition or to have a screening test because they are at low risk of developing future problems.³ It has been suggested that this expression of ‘fully informed choice may sometimes frustrate the health professional’³ as it can lead to some clients choosing a path that results in harm or death. A clear example of this is when clients reject the need for blood transfusions due to religious beliefs.

Shared decision making also has legal implications, in particular concerning informed consent. Health professionals have been found legally liable for damages in instances where inadequate information has been provided to clients and harm has arisen following intervention.²¹ In recent court cases, the High Court of Australia has referred to the importance of shared decision making, defining it as ‘a shared exercise in which healthcare practitioners are obliged to take active steps to ensure that patients are empowered to make their own decisions about important procedures to be undertaken on their bodies’.²¹

The complexities of client and health professional involvement in shared decision making

Shared decision making is a complex process, which involves not only the client’s values and preferences, but also their feelings and views about their relationship with the health professional and the degree of effort that both parties put into the decision making process and the communication between them.⁷ Box 14.1 provides some examples of the complexities in health professional–client relationships that can influence shared decision making.⁷

BOX 14.1 EXAMPLES OF THE COMPLEXITIES IN THE HEALTH PROFESSIONAL–CLIENT RELATIONSHIP ⁷

• Clients who believe that the health professional cares about them and is collaborating with them and making an effort on their behalf may be more likely to be encouraged to do their own bit in relation to their health care.

• Clients who doubt that their health professional likes them or doubt that their health professional is focussed on their best interests may be less confident about the recommended intervention options.

• Health professionals who have positive views of their clients as partners who are capable and able to be trusted are more likely to facilitate the involvement of clients in the decision-making process.

• Health professionals who are mentally disengaged from clients or the decision-making process may be less likely to facilitate other aspects of client involvement in the decision-making process.

Strategies to assist shared decision making

As a health professional, there are various strategies that you can use to facilitate effective shared decision making and these are presented in Box 14.2.^{14–16,22–24} Central to successful shared decision making is effective communication, which involves communicating the evidence to clients and is informed by how clients prefer to receive information and their ability to understand it. These issues are described in more detail later in this chapter.

BOX 14.2 STRATEGIES TO FACILITATE SHARED DECISION MAKING

• Attend to the whole of clients’ problems and take account of their expectations, feelings and ideas.

• Value clients’ contributions, for example, the life experiences and values that clients bring to the decision-making process.

• Provide clear, honest and unbiased information.

• Assess the degree to which your clients understand the information that you have provided to them.

• Assess the degree to which your clients want to be involved in decision making.

• Provide a caring, respectful and empowering context in which clients can be enabled to participate in decision making.

• Be well informed about the most current evidence, particularly regarding issues such as diagnosis and intervention.

• Do not assume that your clients will make the same decisions as you just because the evidence has been provided to them in a manner that they can understand.

Assessment tools for health professionals to use in shared decision making

A number of scales have been developed to assess the involvement of clients and health professionals in shared decision making. The scales in these two areas will be discussed separately and one example of each will be described in detail. These scales can also assist you by providing examples of questions that you can ask and competencies you can aim for in your own clinical practice.

Scales to measure health professionals’ involvement in shared decision making

In a 2001 systematic review, eight instruments that assess various aspects of clinical decision making were described, but the authors of the review concluded that none of the eight instruments sufficiently captured the concept of whether the health professional encouraged client ‘involvement’ in the decision-making process.²⁴ The authors of the review subsequently developed and revised the 12-item OPTION (Observing Patient Involvement in Decision Making) scale to measure the extent that a health professional engages in shared decision making during client consultations.^25,²⁶ Examples of the 12 ‘competencies’ that are assessed in OPTION are:

• Item 1: The health professional draws attention to an identified problem as one that requires a decision-making process.

• Item 3: The health professional assesses the client’s preferred approach to receiving information to assist decision making.

• Item 5: The health professional explains the pros and cons of options to the client (taking ‘no action’ is an option).

• Item 10: The health professional elicits the client’s preferred level of involvement in decision making.

Each ‘competency’ is rated by observers on a scale that measures the order of magnitude to which the health professional demonstrates the skill. The scale is as follows:

• 0— ‘The behaviour is not observed’

• 1— ‘A minimal attempt is made to exhibit the behaviour’

• 2— ‘The health professional 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’

Scales to measure clients’ involvement in shared decision making

Questionnaires have been developed to assess clients’ satisfaction with decision making,²⁷ degree of decisional conflict,²⁸ perceived involvement in care,²⁹ risk communication and confidence in decision making²⁰ and the extent of shared decision making.³⁰ One of these will now be further described.

The COMRADE (Combined Outcome Measure for Risk Communication and Treatment Decision Making Effectiveness) was developed by combining items from some existing shared decision-making scales and constructs identified by clients during focus groups.²⁰ It consists of 20 statements that represent two broad aspects of decision making—risk communication and confidence in the decision.

Each statement is scored on a five-point Likert scale from 1 (strongly agree) to 5 (strongly disagree). While the original scale statements use the term ‘doctor’, the COMRADE can be used by all health professionals. Examples of the 20 statements are as follows.

Statements about risk communication:

• The health professional gave me enough information about the treatment choices available.

• The health professional gave me the chance to express my opinions about the different treatments available.

• The health professional gave me the chance to decide which treatment I thought was best for me.

Statements about confidence in decision making:

• I am satisfied that I am adequately informed about the issues important to the decision.

• I am satisfied with the way the decision was made in the consultation.

• I am sure that the decision is the right one for me personally.

The COMRADE is intended to be used in conjunction with three other relevant instruments, the SF-12 measure of quality of life, the short-form anxiety instrument and the patient enablement instrument (see the reference that describes the COMRADE ²⁰ for more details).

Key steps to communicating evidence to clients effectively

A five-step model for communicating evidence to clients in a way that facilitates shared decision making has been proposed ³¹ and is presented below. Although the model was developed as a guide for medical practitioners who are consulting with clients and helping them to make healthcare decisions, the key principles of the model can be used as a guide for any health professional who is communicating evidence to a client.

1. Understand the client’s (and family members’) experiences and expectations.

You need to take the time and make the effort to understand the needs, fears, experiences, expectations and values of your client.

2. Build partnerships.

Rather than just providing information to your client in an old-style paternalistic manner, you should try and gain your client’s trust and build a partnership with them. Activities that may assist with this include: encouraging partnership (for example, ‘This is a decision that we need to make together’), acknowledging the difficulty of the situation/decision that is being discussed, expressing empathy and expressing mutual understanding (for example, ‘I think I understand …’).³¹

3. Discuss the evidence, including a balanced discussion about uncertainties.

In addition to answering your client’s questions, you should also discuss issues that they may not have thought to ask or are reluctant to bring up. A discussion of the evidence needs to include a simple explanation of the uncertainties surrounding the evidence, but be aware that overemphasising the uncertainty can cause some clients to lose confidence.³¹ Using an appropriate method to communicate statistical information can be beneficial at this stage and a discussion of the various methods for doing this are explained in a later section of this chapter.

4. Present recommendations.

Obviously a healthcare decision does not need to be made every time that you communicate evidence to a client, particularly if it is evidence related to a prognostic or qualitative information need that you or your client had. However, when the clinical question is about the effect of an intervention, a decision may need to be made. This step should only occur after you have integrated the best quality clinical evidence that is available for the issue with your client’s values and preferences. You should explain how your recommendation has been generated from both the evidence and your client’s values.³¹ In situations where the evidence is uncertain or contradictory and you do not have a specific recommendation, you should present each of the options neutrally.

5. Check for understanding and agreement.

It is important to confirm that your client has understood the information that you have presented to them. You may wish to ask your client to briefly summarise their understanding of the information for you. You may need to repeat the information, explain it in a different way or provide more detailed information. There are various communication tools that can be used to share information with clients and, in some cases, help them to make decisions. These tools are discussed in a later section of this chapter.

Key communication skills needed by health professionals

In addition to the general communication and relationship-building skills that you should have as a health professional, some of the key skills that you need when talking with your clients about evidence are listed in Box 14.3.

BOX 14.3 KEY SKILLS NEEDED BY HEALTH PROFESSIONALS WHEN TALKING WITH THEIR CLIENTS ABOUT EVIDENCE

• Ability to communicate complex information using non-technical language

• Tailoring the amount and pace of information to the client’s needs and preferences

• Drawing diagrams to aid comprehension

• Understanding the principles of shared decision making and how and when to implement this with clients

• Ability to determine how much involvement in decision making clients desire

• Considering the client’s preferences and values and integrating this with the clinical evidence for the various treatment options

• Understanding the factors that can impede information exchange and shared decision making

• When a healthcare decision needs to be made, the ability to clearly explain the probability and risk for each option

• Facilitative skills to encourage client involvement

• Evaluation of internet information that clients might bring with them

• Creating an environment in which clients feel comfortable asking questions

• Giving clients time to take in the information

• Declaration of ‘equipoise’ when present—equipoise exists when there is uncertainty about which treatment option, including the option of no further treatment, will benefit a client the most

• Checking client understanding

• Negotiation skills

Adapted with permission from Ford S, Schofield T, Hope T. What are the ingredients for a successful evidence-based patient choice consultation? A qualitative study; published by Social Science and Medicine 2003.