Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 294–297
DOI: 10.1111/ajo.12343
Short Communication
INFORMed choices: Facilitating shared decision-making in health care Michael BECKMANN,1,2,3 Catherine COOPER4 and Daniel POCOCK5 1
Department of Obstetrics and Gynaecology, Mater Health Services, 2Mater Research Institute, University of Queensland, 3School of Medicine, University of Queensland, 4Mater Education Centre, Mater Health Services, and 5Clinical Safety and Quality Unit, Mater Health Services, Brisbane, Queensland, Australia
A clinical audit was undertaken before and after the introduction of a five-minute video presentation as an adjunct to the clinical consultation in the setting of ruptured membranes at term. The video framed clinical information using an INFORM structure: providing Information, Facts, Options, Reasons, Meaning. Subsequently, women were more likely to report that information was unbiased, based on facts and evidence that they were involved in the decision-making and overall satisfied with the information provided. Key words: audiovisual aids, decision support techniques, fetal membrane premature rupture, patient participation, patient-centred care.
Introduction
Materials and Methods
Almost one in ten women will present to hospital at term with ruptured membranes prior to onset of labour.1 The woman’s decision of whether to request induction of labour versus awaiting events is often not a simple one, and there are many factors she may consider. However, the quality and quantity of information given to women about options for care can be variable and may be subject to individual clinician bias.2 There is evidence that the information exchange is sometimes undermined by the provision of inconsistent evidence3 the bias of some clinicians towards intervention,4 clinician’s tendency to over-emphasise the potential for harm when women choose not to accept intervention, and women’s tendency to comply with clinician’s suggestions. Evidence supports the use of written information,5 computer-based information,6 video-recordings,7 scales and pictographs,8 and graphics and explanations9 to enhance a sense of shared decision-making in clinician– patient interactions. We report the experiences and outcomes of introducing a video presentation as an adjunct to the consultation when women present to hospital at term with ruptured membranes prior to the onset of labour.
A pre- and postintervention clinical audit was prospectively undertaken of women presenting to Mater Health Services, Brisbane, Australia, with prelabour rupture of membranes at term, between September 2012 and June 2013. From September 2012 to February 2013 (Group 1), women who presented to the hospital’s pregnancy assessment unit with a confirmed diagnosis of prelabour rupture of membranes underwent a clinical assessment to confirm the diagnosis and then discussed their options of care with either a midwife or a doctor. The risks and benefits of induction of labour versus conservative management were conveyed, women were provided with a hospital brochure outlining these options, and women were invited to complete an anonymous written survey which was then placed in a locked survey box in the pregnancy assessment unit. Between February 2013 and June 2013 (Group 2), women with a confirmed diagnosis of ruptured membranes following clinical assessment were shown a five-minute video presentation prior to any discussion of their options of care with a midwife or doctor. Women were similarly provided with a hospital brochure outlining these options and then invited to complete an anonymous written survey. The five-minute video presentation was an enhanced voice-over PowerPointâ (Microsoft, Redmond, Washington, USA) utilising written and spoken information, clinical diagrams, pictographs to quantify risk, and an overview and summary format. The content was taken directly from the hospital’s evidence-based policy and patient information brochure and was recorded using the voices of a male obstetrician and female midwife. The framework for the
Correspondence: Dr Michael Beckmann, Mater Health Services, Ground Floor Aubigny Place, Raymond Terrace, South Brisbane, Qld 4010, Australia. Email:
[email protected] Received 28 November 2014; accepted 19 March 2015.
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© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
INFORMed choices
Table 1 INFORM – a framework for shared decision-making INFORM
For prelabour rupture of membranes at term
Information:
Providing a lay summary
Facts:
Presenting data
Options:
Outlining the choices
Reasons:
Exploring the choices
Meaning:
Explaining what will actually happen next
Of the clinical scenario when the membranes rupture prior to the onset of labour About the risks of infection for mother and baby Of induction of labour and awaiting events And assisting women to identify which factors are most important to them When women decide one option or the other
presentation was developed by the authors, in accordance with IPDAS10 criteria for patient decision-making, structuring the information around the acronym INFORM (Table 1). The anonymous feedback survey sought women’s impressions of the clinical encounter with respect to the amount of information provided, her perceived bias of information provided, the evidence base to information provided, her ability to understand the information provided, her sense of involvement in decision-making and overall satisfaction with the clinical encounter. Women provided responses using a 5-point Likert scale,11 which were subsequently collapsed into three groups for analysis (agree, neutral and disagree). A bivariate analysis was undertaken comparing the anonymous survey responses of women in Group 1 (historical control) and Group 2 (after the introduction of the video presentation). Proportional data were compared using Fisher’s exact test, and the analysis was undertaken using StataSE version 10.1 (StataCorp,
College Station, TX, USA); P < 0.05 was considered statistically significant. The survey formed part of routine quality audit measuring the impact of a change in clinical service delivery, and written consent was not sought. The Mater Health Services Human Research Ethics Committee (HREC) assessed the project as not requiring full HREC review, being an audit of practice in accordance with the definition of research in the National Statement on Ethical Conduct in Human Research, 2007 (Reference: HREC/13/MHS/75).
Results Between September 2012 and June 2013, 192 women presented to the pregnancy assessment unit of Mater Health Services, Brisbane, Australia, and were diagnosed with prelabour rupture of membranes at term. Of these, 79 women presented between September 2012 and February 2013 (Group 1) and 113 presented between February 2013 and June 2013 (Group 2). In each group, 38 women completed the feedback survey. Given the anonymous nature of the survey, it is not possible to report the baseline characteristics or maternal/neonatal outcomes of women in these groups. Compared with those women surveyed in Group 1, women in Group 2 exposed to the video presentation as part of their consultation were more likely to agree that the information was presented to them in an unbiased way (95 vs 71%) and based on facts and evidence (95 vs 68%) that they were involved in the decision-making (95 vs 74%) and overall satisfied with the information provided (97 vs 84%) (Table 2).
Discussion This study provides some objective measures of how clinician’s discussions about options of care are perceived by patients. Women reported receiving
Table 2 Survey responses from women before (Group 1) and after (Group 2) the introduction of the INFORM video presentation Agree n (%)
Neutral n (%)
Disagree n (%)
Survey question
Group 1
Group 2
Group 1
Group 2
Group 1
Group 2
P value
Spearman’s correlation
I was given enough information to make an informed choice. I felt that the information was presented to me in an unbiased way. I felt that the information provided was based on facts and evidence. I felt that the information was presented to me in a way that was easy to understand. I felt involved in the decision-making. Overall, I was satisfied with the information given
32 (84)
37 (97)
3 (8)
1 (3)
3 (8)
0 (0)
0.113
0.023*
27 (71)
36 (95)
3 (8)
1 (3)
8 (21)
1 (3)
0.021*
0.003*
26 (68)
36 (95)
6 (16)
2 (5)
6 (16)
0 (0)
0.001*
0.001*
37 (97)
37 (97)
1 (3)
1 (3)
0 (0)
0 (0)
0.999
0.469
28 (74) 32 (84)
36 (95) 37 (97)
1 (3) 1 (3)
1 (3) 1 (3)
9 (24) 5 (13)
0 (0) 0 (0)
0.007* 0.069
0.002* 0.022*
*P < 0.05. © 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
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M. Beckmann et al.
adequate information that was able to be understood, but as many as one in four women felt uninvolved in the discussion about options following prelabour rupture of membranes at term, and reflected that their conversation with a doctor or midwife was biased and not based on facts or evidence. The relatively simple addition of a fiveminute video tutorial to the clinical encounter, prior to discussion with a clinician, was associated with almost no women reporting a negative perception of the clinical encounter. There is an increasing emphasis placed on engaging patients in their care decisions through shared decisionmaking.12–14 Decision aids are one example of how shared decision-making can be facilitated.10 The INFORM video presentation functions like a decision aid, by presenting written, spoken and graphical information, and by outlining and exploring the choices to prepare the woman for participation in care decisions. Compared to usual care interventions, decision aids are more effective at improving people’s knowledge regarding options, reducing their decisional conflict and stimulating a more active role in decision-making.15 There are currently no decision aids to support the choices following prelabour rupture of membranes at term. To date, the small number of decision aids in maternity care have involved complex clinical decisions (eg prenatal testing,16 VBAC,17 ECV18) and have been shown to be both time consuming and resource heavy. By contrast, the five-minute INFORM video presentation is simple to produce and use, does not require any specific training or expensive hardware, and appears to be associated with similar increases in satisfaction and sense of involvement in decision-making. This study has a number of limitations. Not all women seen in Group 1 and Group 2 completed the survey, only English-speaking women were shown the INFORM video presentation and invited to provide feedback via survey, the study utilised a nonvalidated survey of patients as the outcome measure, and the overall numbers are small. Women were not randomised to receive or not receive the video presentation, and clinicians were not blinded to the ‘intervention’. It is therefore plausible that the observed differences between survey responses in Group 1 and Group 2 reflect differences in the baseline characteristics of the women in the two groups (data which are unavailable for analysis), and/or differences in the counselling techniques used by clinicians. However, as a very large clinical unit with many rotating midwifery and medical staff, it remains a reasonable assumption that the video presentation was the only significant change between the groups. Patients are frequently required to make complicated decisions about their healthcare options with their only source of information being the clinicians who may have their own bias, not be fully aware of the evidence, or provide inconsistent advice and information.3,4 We have demonstrated that an evidence-based INFORM video presentation for prelabour rupture of membranes at term 296
is a valuable tool in improving patient satisfaction and involvement in decision-making and is easily incorporated into clinical practice. Future research priorities include validation of the INFORM methodology, as well as measuring its effectiveness to support women considering their next birth after caesarean section, water birth, analgesic options in labour or induction of labour. The INFORM structure is likely to be relevant to clinicians across a broad spectrum of health care.
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