Implementing Assisted Decision-making in Healthcare in Ireland: Understanding Enablers, Barriers and Context from the perspective of patients and healthcare professionals

Abstract

Introduction: Supporting the decision-making of those with capacity challenges is a relatively new area of health and social care policy and research. The Assisted Decision-Making (Capacity) Act 2015 has yet to be commenced in Ireland, however codes of practice and educational strategies are in development to support healthcare professionals to practice in accordance with the Act. The overall aim of this research is to develop an educational discussion game (PlayDecide TM) which will encourage healthcare professionals, older people (with and without a diagnosis of dementia) and family caregivers to discuss assisted decision-making (ADM). It is envisaged that this discussion game will support the implementation of the emergent codes of practice. This paper describes a pre-implementation formative evaluation informed by the perspectives of relevant stakeholders in ADM practice. This provides a diagnostic analysis of contextual issues, barriers and enablers influencing the adoption of ADM practice in acute care settings. Methods: The pre-intervention diagnostic activity involved site visits and key informant interviews from within two acute care settings and two day-hospital settings. Data were collected using qualitative interviews and follow-up validation discussion groups. In total, 18 interviews and three validation groups were conducted with family carers and older people with and without a diagnosis of dementia. A further 32 interviews and four validation groups were conducted with healthcare professionals located across the four sites (social workers n=8, SLT/PT/OTs n=8, nurses n=8 and physicians n=8). Reflections were elicited on the following: current practice in relation to decision-making; contextual determinants of current practice; and potential barriers/facilitators to enable behavioural change. Results: The qualitative data yielded nuanced descriptions of the following themes: common and accepted ways of engaging in decision-making; favoured modes of communication; areas of tension and cohesion within teams; ideas of how ADM might work; desired behaviour change; ideas on how to implement behaviour change among staff and patients and potential areas of resistance. Discussions: Identification of implementation factors related to organisational culture, interpersonal relationships and governing norms will lead to more targeted and site-specific implementation strategies. This will enhance the likelihood of successful implementation of behaviour change. Conclusions: The findings from the diagnostic analysis will provide real world context-driven narratives and participant issues that will be incorporated into the serious discussion game through a co-design process with key stakeholders, including patients and healthcare professionals. The discussions prompted by the serious game will allow the players to generate ideas about the contextual and cultural adaptations required for successful implementation of ADM policy. Lessons learned: It is essential to identify barriers as well as facilitators prior to implementing any behaviour change interventions. The developmental stage of formative evaluation is the bedrock of successful implementation of change into practice. Limitations: Ethnographic observations of staff/patient interactions were inhibited by local access barriers. Diagnostic activity relied therefore, on first person narrative accounts of decision-making processes rather than direct observations. Suggestions for Future Research: The findings from the formative evaluation will prompt the development and evaluation of targeted, site- specific behaviour change interventions supporting the adoption of ADM.

Keywords

• assisted decision-making
• capacity
• dementia
• acute care
• formative evaluation