Shared Decision Making in Mental Health In-patient Settings: Implications for Practice
Shared Decision Making in Mental Health In-patient Settings: Implications for Practice
Project summary: This research explored the concept of shared decision making (SDM) in mental health in-patient settings. It was achieved through the facilitation of focus groups with service users, carers, OTs, social workers, peer support worker, psychiatrists and nurses. The focus groups aimed to gain insight into the experiences of each party within the decision making process. This included the degree to which they felt involved in the process and influential in the outcome. The data arising from the focus group was analysed collaboratively using a framework known as critical narrative analysis. This framework facilitates an analytical process which focuses on issues of power and subject positioning. The summary below provides an indication of the way in which the different groups regarded themselves within the decision making process.
Service users demonstrated their awareness of the changing level of inclusion that was preferred at different phases of their contact with mental health services. They also recognised the need to appear to conform to the outcomes of decisions that they did not agree with, in order to achieve the end result they desired.
Carers positioned themselves as outside of the decision making process and felt that their knowledge of their family member was often disregarded. Professional standards or structures, such as confidentiality, were seen to be used by professionals to exclude them from decision making forums and from being informed about the outcome of those decisions.
Occupational Therapists strongly aligned themselves with the service user which they felt gave other professionals the permission to side line them and reduced their level of influence within the decision making process. Whilst they were clear about their unique area of expertise being focused on occupational assessment and promoting recovery, they did not feel this was valued by others.
Social Workers viewed their role as Approved Mental Health Practitioners as giving them a legitimised and outwardly respected position within the decision making processes relating to Mental Health Act assessments. In routine decision making within the ward setting however, they viewed themselves as outsiders who were, at best, informed about the outcomes of decision but were rarely consulted in the process.
Peer Support Workers described having no voice within decision making forums and dealing with the often conflicting role of being employed by the organisation whilst also attempting to advocate for service users. They were clear that their expertise lie with sharing the experience of mental distress. However, they did not feel that the structures were in place to utilise or respect this within the decision making process.
Psychiatrists positioned themselves as in the exasperated paternal role within the decision making process who were attempting to involve other professionals, but were continuously relied upon to make the definitive decision. They recognised that their education and social position influenced this and acknowledged that their salary was often regarded by other professional as the justification for their lack of willingness to take responsibility for the outcome of decisions.
Nurses viewed themselves as the enforcers of the decisions which were made by other professional groups, most significantly psychiatrists. They reiterated the expertise they held as a result of being the professional group who spent the most time with the service user. They also discussed their lack of willingness to make decisions which were perceived to be the responsibility of the psychiatrists, due to the level of accountability they associated with this role.
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.
Dissemination:
Stacey, G., Felton, A., Morgan, A., Stickley, T., Willis, M., Diamond, B., Houghton, P., (In press) A critical narrative analysis of shared decision-making in acute, in-patient mental health care. Journal of Interprofessional Care
Houton, P. (2014) Power and decision making on acute wards. Clinical Psychology Bite-Size
Resources:
PDF Presentation
Power and Decision Making on Acute Wards
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