Respect and shared decision making in the clinical encounter, A Video-Reflexive Ethnography

Abstract

Background: Shared decision making (SDM) is key for improving the quality of healthcare delivery. Respecting patients’ preferences and values is integral to SDM, so it is intuitive that respect is also important for SDM. Yet, there is room for further studies on respect. This study describes what respect means to patients and clinicians and how respect is related to SDM in primary care clinical encounters. Methods: A Video-Reflexive Ethnography (VRE) with 40 hours of video recordings from 15 primary care clinical encounters and 27 video-reflexivity sessions. Clinicians (14), patients (13) and caregivers (3) were invited to share their perspectives on respect and decision making in individual reflexivity sessions. The video-reflexivity sessions were video-recorded and transcribed. A grounded theory analysis was conducted. Results: This study extends current descriptions of respect to include respect for both ‘patients and clinicians as persons’ in the clinical encounter. It also highlights an affective and emotional aspect of respect. Respect is described as ‘valuing individuality’ (patients and clinicians as persons in a broader social context), ‘valuing agency’ (patients’ ability to influence the encounter and future care) and ‘valuing feeling comfortable’ (at-ease and open). Respect is relevant in all types of decision making in primary care clinical encounters (clinician-led, patient-led and shared). SDM in primary care should be seen as a process, carried out over time. Regardless of who makes the decision, participants described attributes of respect that enabled them to accept the process and the decision. Throughout the clinical encounter, clinicians highlighted institutional factors that influenced the extent to which respect was evident. Both patients and clinicians described respect as being co-created by them interacting in the encounter in ways that involved additional work and effort. Conclusion: Respect is valued by both patients and clinicians, but it is not always easy to practice. Training and re-structuring the institutional constraints that clinicians face may facilitate respectful encounters. Respect may influence patients wanting to see their clinician again improving continuity of care; may encourage both clinicians and patients to open up in ways that strengthen the relationship; and may lead to partnership in treatment planning affecting adherence.