Shared Decision-Making Processes in In-patient Mental Health Services: A discourse analysis

Project Duration

January 2011 - December 2013

Funder

Nottinghamshire Healthcare Trust

Aims

The Essential Shared Capabilities (DH 2004) identified the need for "Values Based Practice" which acknowledges that decisions taken in mental health care are based on values as well as evidence. Thus incorporating the different, and sometimes conflicting, principles of those involved in planning, delivering and receiving services (Cleary, 2003). 

Woodbridge and Fulford (2005) advocate a "democratic" approach to decision-making whereby the values of all involved are respected and considered. However this notion of decision-making is not without its problems due to its failure to adequately address issues of power and vested interest (Houghton and Diamond, 2010; Moncrieff, 2007; Pilgrim, 2007). This paper will report on a qualitative research project which explored these issues amongst groups of stake-holders. 

Methods

Separate focus groups were conducted amongst the following groups: service users, carers, peer support workers, occupational therapists, social workers, consultant psychiatrists and mental health nurses in order to analyse the various discourses. 

Outcomes and Findings

Key Findings 

• The goal of shared decision making in acute inpatient settings is a long way from being met. All focus groups felt that decisions were not shared and that the service user voice is marginalised.
• The concept of shared decision making should be broken down into its component parts. Borrowing a phrase from communication theory, we need to specify the "core conditions" for a shared decision to take place. We suggest that in order for shared decision making to take place all participants must be Informed, Involved and have Influence (the three I's) in the decision-making process. 
• The three "I"s of shared decision making are fluid. Shared decision making is a three stage process, that moves between information, involvement and influence over the decision.
• The ward round is the main forum for SDM in inpatient settings and it is not fit for purpose. Every focus group from psychiatrists through to service users felt that the ward round as a structure did not facilitate SDM, and particularly SDM with the service user voice at its heart.
• The discourse of VBP and SDM need to take account of how differentials of power and the positioning of speakers affect the context in which decisions take place.

Conclusion

This study has explored an analysis of multiple perspectives of how decisions are made about patient care in adult mental health inpatient environments. There is recognition amongst all parties that the system does not facilitate decision-making that is genuinely shared. Each of the groups has their respective values but they each position themselves relatively powerless to entirely change the system to make shared decision-making authentic. However, very real power hierarchies exist and have powerful effects on actors within the hierarchy. 

The "No decision about me without me" framework (DH, 2012) requires the acknowledgement of power when service users are not involved in shared decision-making and a fair rationale given. The question remains however how forces of power can be made explicit when it is needed to be exposed for the person’s benefit? In this study, none of the groups were able to offer an alternative model that would underpin shared decision making. This suggests that the current structures may blind those participating within them to see new ways of working.