Decision making is a continual process and essential for quality patient care. Every day, the plan of care is reviewed and realigned with the current needs of the client. The nurse is central in this assessment, modification, and integration of the plan of care. Although the patient is the ultimate decision-maker, the nurse and the healthcare team often provide the needed information and support to the client. This phenomenon has become known as the term and action of shared decision making (SDM). According to Truglio-Landrigan (2016) [2], the outcomes expected through the use of SDM include enhanced knowledge, improved satisfaction of treatment, improved cost savings, quality of life, and client confidence and autonomy. As part of patient-centered care, SDM is critical when a patient faces multiple healthcare options with varied benefits and risks [3]

SDM stems from the 1978 International Conference on Primary Health Care Declaration of Alma-Ata that recognized the importance of patients actively participating in all aspects of their care, including planning, organizing, and implementing care decisions [4]. Building on this foundation, The Agency for Healthcare Research and Quality (AHRQ) stresses the importance of providing patients and their families with evidence-based care options in accessible formats that consider individual learning and cultural needs. Also, the Quality and Safety Education for Nurses competencies include preparing nurses to foster and support SDM.

Nurses can help Support patients by practicing shared decision making (SDM), which engages patients in making active choices about their care. Implementing a decision-making model that includes patients can improve care quality. As SDM becomes standard in healthcare organizations, various decision- making models are being developed. The AHRQ SHARE Approach decision-making model is an excellent example providing the nurse with a step-by-step approach to facilitate decision making with patients and families. It is designed to guide SDM by examining and analyzing healthcare option advantages, disadvantages, and potential risks. According to AHRQ, the SHARE Approach’s benefits include increased patient satisfaction resulting from improved care quality and a good care experience. The model comprises the five-step SHARE process and includes:

Seek your patient’s participation.

Help your patient explore and compare treatment options. Assess your patient’s values and preferences.

Reach a decision with your patient. Evaluate your patient’s decision.

The following provides an example of how the nurse can use the SHARE model when working with patients and families facing difficult decisions related to care options.

Teresa is a 32-year-old, African American female, nulligravida, who is married and desires children. She was planning on having a baby next year once her job became a permanent position at that time. Her husband, Carl, works as an accountant for a local hardware company. Four weeks ago, Teresa found a 4 cm mass in her right breast, upper outer quadrant. Her axillary lymph nodes are enlarged on the affected side. Teresa was immediately sent for a mammogram and ultrasound by her gynecological provider. She was then referred to an oncologist. It took a couple of weeks to get an appointment with an oncologist. While she was waiting for her appointment with the oncologist, she frantically researched her new diagnosis on the internet. Teresa also remembered that her grandmother had breast cancer many years ago, which ultimately led to her death.

During Teresa’s visit with the oncologist, she received the diagnosis of stage two breast cancer. Her lymph node biopsy results indicate that she has two nodes positive for cancer. The regional cancer is human epidermal growth factor receptor 2 positive (HER positive). Her oncologist reviewed her surgical and medical options, and after a discussion, Teresa and her oncologist decided that surgery and chemotherapy was the best treatment plan for her. Teresa will be scheduled for a modified radical mastectomy followed by a chemotherapy treatment plan with Doxorubicin. She is informed that the HER positive type of cancer and diagnosis stage has a 93% survival rate with treatment.

Just days later, Teresa is meeting with her nurse case manager. At this appointment, the nurse will begin establishing the nurse-patient relationship and developing a plan of care with the new client. There are complex factors that will need to be assessed to establish a client-centered plan of care. The nurse will offer the information that the patient needs to make informed choices. There is no one correct course of action. Each case is different, and each patient has individual needs and preferences. The nurse and the patient will evaluate these intricacies and work together to establish the plan. These actions are shared decision making in action. The Agency for Healthcare Research and Quality (AHRQ) has established a shared decision-making model called the SHARE Approach (AHRQ, 2016) [5]. This decision-making approach includes five steps that guide the healthcare provider and the patient. These steps include: Seek, Help, Assess, Reach, and Evaluate.

SEEK-Step One

The Seek step occurs as the healthcare provider seeks to gain the participation of the patient. In this case exemplar, the nurse has quickly reached out to the patient, Teresa, and they are meeting for an appointment. The patient acceptance of the appointment is supportive of the fact that this patient is recruited into action. During this first meeting, the nurse will conduct a thorough assessment. Since the client has a new diagnosis, the nurse will want to assess how the patient is coping with the new diagnosis. As previously stated, the nurse will need to assess the amount of support and resources that the patient has, and it is also vital to get to know the patient’s desires and beliefs. The plan of care is developed to complement the patient’s life and culture. Seeking participation will vary in task intensity in different situations.

Clients may not desire to accept or participate further in some decisions of care. Without dual-sided participation, the shared-decision making approach will fail. Therefore, careful and clear communication is essential. The nurse should listen carefully to the patient’s spoken and unspoken responses. It is also key to creating an open environment in which the patient feels comfortable to share. The nurse should also demonstrate confidence and knowledge as appropriate for the situation. After the initial assessments, the nurse should ask the patient if they would like assistance with designing the plan of care utilizing the shared-decision making style. When this patient-tailored invitation is sent to the patient, it is most likely to be effective at gaining the patient’s participation and accomplishing the task of step one of the SHARE approach.

HELP-Step Two

The second step, the Help stage, is where the work occurs. The exploration of treatment options is critical. The nurse and Teresa met for the initial appointment. The nurse first allowed the patient to share and disclose the experience of the diagnosis. Teresa shares that she is very fearful. She has since read much about breast cancer online. While she is now informed and has been able to digest and understand most of what she is reading, she does not understand the pharmaceutical agents very much. She is also fearful because of her family history and wants to get this surgery done as soon as possible. Teresa’s husband has come to the appointment with her today and is very worried and supportive. During this encounter, the nurse has uncovered that her client and her spouse are very eager to develop this plan of care and welcome the assistance. Thus, the Share approach is appropriate for this client. The nurse should help the patient to continue to explore all options. If there is new evidence related to the diagnosis, this should also be shared with the patient. After exploring all options, the nurse and patient should evaluate the plan of care and make any desired changes.

ASSESS-Step Three

Step three, the Assess stage, includes a discussion about the client’s health needs. It is essential for this step of shared decision making that consideration is given to the patient’s personal preferences. Teresa is a young, 32-year-old African American female whose diagnosis develops when she is looking forward to her life and planning to begin a family in a year. ANA confirms that a culturally competent caregiver is best suited for this patient’s care needs. Cultural competence confirms that the nurse can understand the patient’s cultural preferences and is respectful of the patient’s beliefs, values, and desires. Before the start of chemotherapy, the subject of childbearing should be included in the discussion, as the medication of choice to treat Teresa; Doxorubicin, has a high risk of causing infertility. Major side effects of this drug that should be discussed with the patient and family include hair loss, diarrhea, vomiting, and anorexia. Options such as egg freezing for future use should be discussed with Teresa and her partner. Breastfeeding after breast surgery should be addressed in the discussion, as, according to Huiyan et al. (2017) [6], it may reduce re-occurrence risk.

The caregiver should be mindful that Teresa’s grandmother died from breast cancer. Genetic counseling and testing for cancer susceptibility should be offered to this client. A great topic to start a discussion with Teresa about genetics is BRCA 1 and 2 genetic testings in women with a family history of breast cancer. According to Ricks-Santi and colleagues (2017) [7], BRCA 1 and 2 mutations are linked to a high incidence of pre-menopausal breast cancer. Teresa is considered at high risk for breast cancer, given her grandmother’s history of breast cancer death. This evidence also has shown that African American women are at a higher risk of gene mutation. Because of these findings, Teresa’s BRCA 1 and 2 risk assessment and genetic test results analysis may be relatively complex. The advantages of genetic counseling and testing results in Teresa’s case could be meaningful in decision-making related to prophylactic surgical interventions and chemoprevention. Educational pamphlets that Teresa can use to read more about genetic testing will be useful in this shared decision-making process.

REACH-Step Four

The fourth step is Reach. At this stage in our case exemplar, all of the options discussed in step four are presented to Teresa. With her nurse's support, Teresa can carefully weigh the options and make a decision that is supported by her beliefs and health needs. Teresa chooses to harvest her follicles before beginning her chemotherapy regimen.

However, this decision also presents a delay in treatment that may result in a poorer prognosis for her breast cancer treatment. Again, she must carefully weigh this choice and determine the best path, given her values and preferences. In addition, Teresa opts to have further genetic testing completed. She states that she believes this is the best way to proceed with her care decisions after reading the information.

EVALUATE-Step Five

The final step in the SHARE Model, to support informed patient decision making, is evaluation. This step provides an opportunity for the nurse and client to adjust the client’s plan as needed. During this step, the nurse and client re-evaluate the decision(s) made and determine if any changes are needed moving forward. Some decisions may not allow for the evaluation stage, given the nature of the situation. In these cases, the nurse must assist the patient in considering all options carefully. Many client decisions offer the opportunity for plans to be re-evaluated after a trial period. Re-evaluation allows the clients to modify, refine, or change previous decisions to fit their current situation better. Evaluation should be a planned process that is formally scheduled early in the nurse-client relationship. During the evaluation step, the nurse and patient determine how the plan was implemented and the patient’s overall satisfaction with the current plan. During this meeting, the nurse can also work with the client in identifying any barriers experienced. Clients may benefit from community-based resources or programs. For example, Teresa may have decided to forgo follicle harvesting before treatment, given her family history of breast cancer-associated death. She may now identify her need for additional support as she comes to terms with her loss of fertility and the possibility of giving birth to a child.

Given the many complex health care choices patients face today, nurses and health care workers need a systematic process to assist patients in decision making. AHRQ’s SHARE Approach (2016) is an easy to follow five-step guide designed to facilitate shared decision making. As exemplified in this case exemplar, this model offers nurses guidance as we implement shared decision making in patient care.

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