Medical EducationInterprofessional SDM train-the-trainer program “Fit for SDM”: Provider satisfaction and impact on participation
Introduction
According to the current environmental scan by Légaré et al. [1], 54 training programs were developed for implementing SDM in medical care between 1996 and 2011. Most of these are for physicians and medical-related decisions [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], with only a few approaches geared to other professional groups, e.g. nurses [11], occupational therapists [1] or more than one professional group [12], [13], [14]. Légaré et al. [1] identified six training schemes designed for more than one health care professional field, but which do not explicitly concentrate on interprofessional aspects, e.g. participation or decision-making in the team. For those six there are no evaluation results available. This lack is also reflected in the fact that evaluation results were reported for only 17 of the 54 identified training programs [1].
Available evaluation of SDM interventions has shown that training is an effective way to facilitate the SDM approach in medical care [5], [6], [10], [15], [16], [17], [18]. Lewin et al. [19] could detect strong evidence in favor of interventions which aimed to enhance patient-centered communication in patient–provider interaction, with frequent improvement in patient-centered communication and patient satisfaction. Fewer studies indicated an improvement in health status [6], [19], [20], [21], while studies concentrating on training of allied health professionals showed positive patient satisfaction as well as positive effects on quality of health care [11], [22].
For chronic diseases requiring interprofessional treatment, it is essential to link interprofessionalism (internal participation) and SDM (external participation) in a new model of interprofessional SDM. In the original model the decisions focus on medical aspects, whereas in the adapted version the field of decision is extended to treatment decisions, organizational and team decisions. While the setting of the initial model is for patient–physician dyad, in the adapted model the interactions are interprofessional. The original SDM model only considers the interaction between patient and provider (micro-level of the health care system). In contrast, the adapted model concentrates on the meso (team) and macro (organization) level in the health care system. Participation in the first model is purely external, and in the adaption both external and internal. External participation is the sharing of treatment planning and decision-making with the patient in the sense of shared decision-making, whereas internal participation means the involvement of health care professionals within the interprofessional team in treatment planning for patients (teamwork and team decision-making). Table 1 compares the original SDM model with the adapted SDM model.
Based on this adapted SDM model, our research group developed a training program consisting of two training modules. Module 1 focuses on external participation (shared decision-making in patient-provider interaction) and mainly follows the existing German SDM training from Bieber et al. [2]. Priorities arising from the results of the pilot study are investigation and establishment of the patient's understanding and expectations, empathy and respect [23]. The main focus of Module 1 is to instruct the future trainers in SDM on a step-by-step basis. The trainers begin by explaining the interaction model of SDM in contrast to the paternalistic and informative model, and present the process, characteristics and effects of SDM. Participants are then familiarized with the core nine steps: (1) disclosure to the patient that a decision needs to be made, (2) formulation of equality of partners, (3) presentation of treatment options, (4) informing on the options, benefits and risks, (5) investigation of understanding and expectations, (6) identification of both parties’ preferences, (7) negotiation, (8) shared decision, (9) arrangement of follow-up, with compiling phrases for each step and role play facilitation for participants to practice the skills recently learned. The participants are also given the task of applying the SDM approach with their patients in the week between Module 1 and Module 2.
Module 2 was developed from scratch. Key areas elicited through a survey of experts are: communication and cooperation in the team, moderation of team processes, feedback, talking with difficult team members, as well as tools for communication and decision-making. Module 2 was specially designed to transfer SDM to the decision-making processes in the treatment team and to prepare the executives for their role as trainer. Once the various steps of SDM had been reinforced through discussion of participants’ practical experience when applying it in medical encounters, the expanded model of SDM and the model of integrated patient-centeredness were introduced. Here the trainer function and tools for the trainer were discussed, with the main emphasis on transfer from the SDM model to the leadership style (participatory leadership), communication, cooperation and decision-making in the team and advantages for treatment, staff and organization.
The study aimed to evaluate the interprofessional shared decision-making (SDM) training program “Fit for SDM” in two steps. First, the executives were asked to appraise their satisfaction with the training and their SDM competences. Second, the providers (professionals working in the patient care team in the medical rehabilitation clinics) were questioned regarding external and internal participation.
Central questions that will be addressed in the present paper are:
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How did the executives evaluate their SDM skills, satisfaction with the training and preparation as a trainer?
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Did the training enhance internal and external participation for the providers in the rehabilitation team?
Section snippets
Study design
In step 1 the university project team trained the providers in executive positions in the clinics as trainers, who then in step 2 trained their staff in the health care team. After the training of the trainers (step 1) an evaluation sheet was completed by the participants at the end of each training session (cross-sectional study, see Section 2.1.1), and a multi-center cluster-randomized controlled study was conducted for evaluation in step 2. Here, a staff survey measured participation in the
Characteristics of training participants (step 1)
The executives (providers in leading positions) in six clinics were trained as trainers, with a total of 74 participants in Module 1 and 68 participants in Module 2. The size of the training groups in the clinics varied from 8 to 27, with an average number of 9.4 participants (excluding the outlier of 27).
Concerning Module 1, 39 (41% female, 59% male) of 74 participants filled out the evaluation sheet after training, while one whole training group (clinic) did not take part. Module 2 had 68
Discussion
The interprofessional train-the-trainer program was very positively rated by the providers in executive positions (step 1) and led to an improvement in external participation for most providers in the clinics (step 2). In comparison with the evaluation of the SDM training for physicians [3], on which Module 1 is based, and using similar items for evaluation, the training program of the present study was evaluated positively at almost the same level by the executives. The slightly less positive
Conflict of interest statement
The authors indicated no potential conflict of interest.
Acknowledgements
The study is part of the German grant program “Chronic illness and patient orientation” and is supported by the German Federal Ministry of Research and Education and the German statutory pension insurance scheme (Grant number: 01GX0720).
Thank you to all providers in the rehabilitation clinics (AOK-Klinik Korbmattfelsenhof, AOK-Klinik Stöckenhöfe, Asklepios Triberg, DAK-Haus Schwaben, Kliniken Dr. Vötisch, Klinik Bad Herrenalb, Kurpark-Klinik, Neurologisches Rehabilitationszentrum Quellenhof,
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