Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Core Process of Client Centered Care - Making Decisions

a) Make the client the key decision-maker in planning care and services. Spend time with clients in order to understand the situation from their perspective. Follow the client’s lead regarding his/her desire for participation in decision-making.

b) Identify priorities for change or action. Nurses may ask:

  • What’s most important to you now?

c) Identify options from client’s/community’s perspective. Nurses may ask:

  • What do you think your options are?
  • How do you see that happening?
  • Can you picture that?

d) Act as a resource for clients in deciding care strategies. Clarify and provide information or teaching that clients want and say they need, with respect to their health/illness situation or possible health strategies. Nurses may ask:

  • What do you need in order to (…)?
  • What would help you (….)?

e) Act as advocate for the client’s/community’s values and decisions.

  • Invite clients to participate in all care conferences/program-planning meetings.
  • Present the client’s/community’s perspective in care conferences/program planning meetings when the client is unable to participate or wishes not to participate.
  • Document collaboration in care plan/reports.

f) Provide Decision Support
Nurses have a unique role to play in partnering with clients facing health decisions. A client centred partnership means that nurses respect and advocate for clients – as experts in their own lives – to lead the healthcare team; while nurses – as professional experts – have a central role in providing/sharing clinical expertise to facilitate clients’ decision making on areas where they need or want more information.

This partnership aims at strengthening clients’ ability to reach decisions that are well-informed and best for them (Grinspun, 2004).

  • Involve clients in decision making in ways they prefer. The majority of Canadians want to be involved in health decisions (Magee, 2003; Martin, 2002; O’Connor et al., 2003). Participation to preferred level, rather than participation itself, results in improved outcomes (Gaston & Mitchell, 2005).
  • Provide structured decision support to clients using patient decision aids and decision coaching. The following process is based on the Ottawa Decision Support Framework and has been evaluated in multiple studies (Murray, Miller, Fiset, O’Connor & Jacobsen, 2004; O’Connor et al., 1999; O’Connor et al., 2002; Stacey, O’Connor, Graham & Pomey, in press).
  • Assess decision and decisional conflict:
    1. Decision: Tell me about the decision you are facing.
    2. Stage: How far along are you with making a choice?
    3. Certainty: Do you feel sure about the best choice for you?
    4. Knowledge: Do you know which options are available to you? Do you know both the benefits and risks of each option?
    5. Values: Are you clear about which benefits and risks matter most to you?
    6. Support: What role do you prefer in making your choice? Do you have enough support and advice to make a choice? Are you choosing without pressure from others? Who else is involved?
  • Tailor decision support to needs:
    1. Uninformed: reinforce accurate knowledge; clarify misconceptions; provide facts; re-align expectations.
    2. Unclear values: clarify what matters most to the client and facilitate the client sharing their values with others involved in the decision making.
    3. Unsupported: Build skills/confidence in: decision making, management, communicating needs, accessing support/resources, handling pressure, implementing change.
  • Evaluate:
    1. decision quality (informed, realistic expectation, choice matches values/priorities) (O’Connor & Stacey, 2005; Ratliff et al., 1999; Sepucha et al., 2004).
    2. actions (progresses in stage of decision making/change).

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