|Year : 2018 | Volume
| Issue : 4 | Page : 377-381
Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making: An exploratory study
Rana F Obeidat1, Robin M Lally2
1 Adult Health Nursing, Faculty of Nursing, Zarqa University, Zarqa, Jordan
2 College of Nursing, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Nebraska Medical Center, Nebraska, USA
|Date of Web Publication||28-Feb-2019|
Rana F Obeidat
Adult Health Nursing, Faculty of Nursing, Zarqa University, Zarqa
Source of Support: None, Conflict of Interest: None
BACKGROUND: Successful implementation of shared decision-making in clinical encounters is influenced by system, patient, and clinician factors that both facilitate and present barriers to patient-centered care. Little is known about which factors Jordanian physicians believe influence their ability to implement shared decision-making with cancer patients. AIMS: To determine Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making. SETTINGS AND DESIGN: A cross-sectional exploratory survey design was used in the study. A convenience sample of 86 Jordanian medical and radiation oncologists and surgeons was recruited. MATERIALS AND METHODS: A valid measure of physicians' views of shared decision-making was slightly modified from its original English and used to collect data. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) for windows version 19.0 (SPSS, Inc., Chicago, IL, USA). Descriptive and inferential statistics were carried as appropriate. RESULTS: Insufficient time to spend with the patient, patient expecting a certain treatment rather than a consultation, and the patient's family overriding the decision-making process were the most frequently reported barriers to patient participation in treatment decision-making. Physicians believed that patients trust in physicians and patient being accompanied at the consultation were important facilitators of patient participation in treatment decision-making. CONCLUSIONS: Jordanian physicians perceive multiple barriers to patient participation in treatment decision-making. Patient-related difficulties (e.g., indecision), and system-related difficulties, in particular, patient's family influence on the decision-making process are more prevalent among Jordanian physicians compared to Western physicians.
Keywords: Barriers, cancer, Jordanian, participation, shared decision-making
|How to cite this article:|
Obeidat RF, Lally RM. Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making: An exploratory study. Indian J Cancer 2018;55:377-81
|How to cite this URL:|
Obeidat RF, Lally RM. Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making: An exploratory study. Indian J Cancer [serial online] 2018 [cited 2019 Aug 25];55:377-81. Available from: http://www.indianjcancer.com/text.asp?2018/55/4/377/253279
| » Introduction|| |
Shared decision-making has gained much support as the most suitable patient-centered medical decision-making approach especially for preference sensitive decisions (e.g., decisions for surgical treatment of early stage breast cancer)., Informed decision-making is a decision-making approach in which patients make their own decisions after being informed of the available options, and the risks, and benefits. In contrast, patients engaged in the shared decision approach make decisions jointly with their health-care provider after a discussion of available options, and the risks and benefits, and finally reaching an agreement with their health-care provider on the decision that best fits their own personal values and preferences. Research has shown the benefits of shared medical decision-making for the patient (e.g., increased satisfaction and improved health-related quality of life) and benefits related to the clinical encounter (e.g., reduced cost and improved quality of care)., Successful implementation of shared decision-making, as part of patient-centered care approach in the clinical encounter, may be influenced by multidimensional factors including those related to patients and families (e.g., patient decision-making preferences), health-care providers (e.g., provider motivation for the shared decision-making approach), and the health-care system (e.g., time, availability of decision support interventions).,,, One of the most influential facilitators for shared decision-making among Western health-care providers has been shown to be provider motivation., Time constraints and lack of opportunity to engage in shared decision-making due to patient characteristics, and the clinical situation have been reported as barriers to the successful implementation of shared decision-making.,,
In Jordan, as in other Middle Eastern countries, shared medical decision-making is not widely used. However, in the last few years, the shared decision-making approach has started to make its way into the Jordanian health-care system albeit slowly. King Hussein Cancer Center was the pioneer in introducing shared decision-making to health-care decisions in Jordan especially for surgical treatment of early stage breast cancer. A recent study of Jordanian physicians' comfort with and use of various decision-making approaches  showed that while the majority of the physicians were comfortable with the shared decision-making approach less than half of them reported using this approach as their usual approach to treatment decision-making with their cancer patients. Thus, the purpose of this study was to determine Jordanian physicians' perceived barriers and facilitators to patient participation in treatment decision-making.
| » Materials and Methods|| |
A cross-sectional exploratory survey design was used in this study. Jordanian medical and radiation oncologists and cancer surgeons practicing in three teaching hospitals, three hospitals affiliated with the Jordan Ministry of Health, King Hussein Cancer Center, and private clinics in the Capital of Amman were invited to participate in the study. Inclusion criteria and detail of recruitment and data collection are provided elsewhere, however, in brief, surveys were distributed to the 91 physicians whose contact details were provided by the Jordan Oncology Society and 30 more Jordanian physicians who were not members of Jordan Oncology Society but were mainly practicing in oncology through their own private clinics in the capital of Amman (i.e., a total of 121 surveys were distributed). The principal investigator (PI) and/or a research assistant (RA) explained the study and its purpose during face-to-face encounters with each physician. Physicians who agreed to participate in the study were provided with the surveys to complete at their own convenience and were asked to return these to the PI/RA in a sealed envelope bearing no identifying information.
Power analysis for a one-way ANOVA with five groups was conducted using an alpha of 0.05, a power of 0.80, and a medium effect size (f = 0.25). The analysis revealed that the desired sample size is 200. However, due to the small number of oncology physicians in Jordan and feasibility issues (i.e., time constraints, lack of funds) this sample size could not be recruited. Recruitment was stopped after 1 year of data collection (i.e., June 2014–June 2015).
After permission was obtained from its original author (Dr. Cathy Charles), a structured questionnaire on medical decision-making was used for data collection with some modifications (i.e., questions on physicians' attitudes toward disclosure of cancer diagnosis and prognosis were added to the questionnaire). The questionnaire is a comprehensive measure of physicians' perceptions of the meaning of shared decision-making, their attitudes toward and use of different medical decision-making approaches (i.e., paternalistic, informed, information exchange, and shared decision-making), their perceptions of barriers and facilitators of shared decision-making use in the clinical encounter, and their support of different interventions aimed at promoting patient participation in medical decision-making. The questionnaire was used in several previous studies of shared medical decision-making among Western physicians.,, The questionnaire was used in its original language of English, as most physicians in Jordan are fluent in English. The questionnaire presented physicians with two lists of items that may act as barriers or facilitators to treatment decision-making and asked physicians to indicate on a 4-point Likert scale (i.e., never, sometimes, often, and almost always) the degree to which they actually experienced these items with their newly diagnosed or newly referred cancer patients. The list of barriers is comprised of 15 items that cover four categories of barriers to treatment decision-making: system-related difficulties (e.g., time constraints), patient-related difficulties (e.g., anxiety, denial), patient preference for a non-recommended treatment (e.g., patient requesting a treatment not known to be beneficial or refusing a physician recommended treatment that may benefit him/her), and an agenda-setting patient (e.g., a patient who in the physician's opinion wants to be more involved in treatment decision-making than the physician wants).
The list of facilitators is composed of six items that cover patient emotional readiness, information readiness, willingness to participate in treatment decision-making, patient trust in the physician, and patient support (i.e., emotional and information support). Both the barriers and the facilitators scales showed a satisfactory internal consistency reliability in the current study (Cronbach alpha of 0.88 and 0.73, respectively). The study was approved by the Institutional Review Board at each of the clinical settings involved. The return of completed questionnaires was considered physicians' consent to participate.
Characteristics of the sample were analyzed using descriptive statistics (e.g., frequencies, mean,…, etc.). The perceived barriers were grouped into the four categories as previously defined by Shepherd et al. Variables relating to each category were summed and a total score was computed for each category; the higher the score the greater the reporting of the category as a barrier to treatment decision-making. Univariate analysis (e.g., one way ANOVA) was performed to examine the association of physician characteristics with the category of perceived barriers to patient participation in treatment decision-making.
| » Results|| |
A total of 121 eligible physicians were approached for participation and a total of 86 physicians (i.e., 74 physicians from the list provided by Jordan Oncology Society and 12 from private clinics in the capital of Amman) agreed to participate and completed the study survey for a response rate of 71%. Time constraint was the main reason reported by physicians who declined to complete the survey. No statistically significant differences were found in the demographic characteristics of the participating physicians and the eligible, non-participating physicians. Participating physicians had a mean age of 44 years and a mean time qualified as a physician of 19 years. Surgeons (47%) and medical oncologists (36.5%) were the dominant specialists; 16.5% were radiation oncologists [Table 1].
Barriers to patient participation in treatment decision-making
Insufficient time to spend with the patient (65.9%), the patient comes expecting a certain treatment rather than a consultation (65.8%), and the patient's family overriding the decision-making process (65.5%) were the most common barriers to patient participation in treatment decision-making reported “often” or “almost always” by participating physicians [Table 2]. Barriers in the category of patient-related difficulties (mean = 16.01 ± 3.06) followed by system-related difficulties (mean = 13.25 ± 2.25) were most often reported by the physicians. Physicians practicing in public hospitals more commonly reported system-related barriers (P = 0.03). Physicians practicing in private settings more commonly reported barriers in the category of agenda-setting patient (P = 0.00) [Table 3].
|Table 2: Items perceived by Jordanian physicians as barriers to patient participation in treatment decision-making (n=86)|
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|Table 3: Univariate analysis of variables associated with perceived barriers (n=86)|
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Reported facilitators to patient participation in treatment decision-making
The majority of participating physicians reported that patients trusting the physician (94.2%), having someone with them at the consultation (77.9%), and patient emotional readiness for decision-making (73.3%) were helpful (i.e., response categories “often” and “always”) to patient participation in treatment decision-making [Table 4].
|Table 4: Items perceived by Jordanian physicians as facilitators to patient participation in treatment decision-making (n=86)|
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| » Discussion|| |
In this study, most of the 19 listed barriers on the study survey were endorsed by Jordanian physicians as barriers they perceived to patient participation in treatment decision-making, albeit with significant varying degrees. Consistent with studies conducted among Western physicians , insufficient time to spend with the patient was ranked as a primary barrier to patient participation in treatment decision-making by Jordanian physicians. In our study, physicians practicing in public hospitals reported more system-related barriers including time constraints than physicians practicing in other settings. This finding is expected because of the increased patient load, and the lack of organization, evidence based care, and coordination of care in Jordanian public health-care settings  compared to other settings. A reform of the public health system in Jordan is thus needed to improve the quality of care not only for cancer patients but also for all Jordanian patients.
Patient-related difficulties (e.g., indecision) were more frequently reported as barriers to patient participation by Jordanian physicians than barriers in the other categories. It has been reported in many studies that patients may not be involved in medical decision-making to the degree they prefer even when they are well informed about the available treatment options. Therefore, it is understandable that the adoption of shared decision-making may be even slower in countries like Jordan where patient autonomy has not always been emphasized and when patient-related difficulties are involved.
One of the most cited explanations for the slow adoption of shared decision-making into clinical practice is the power imbalance between patients and their health-care providers in particularly physicians., Power imbalance is prominent in the Jordanian health-care system. Jordanian patients in general are not accustomed to being autonomous in medical decision-making; rather, Jordanians usually depend solely on their physicians for medical decision-making. For instance, a recent study of the preferences for participation in treatment decision-making among Jordanian women diagnosed with breast cancer has reported that the vast majority of patients preferred to play a passive role in treatment decision-making. Lacking information about cancer, cancer treatment, and patients' legitimate rights (e.g., right to information and participation in decision-making) among Jordanian cancer patients heightens the power imbalance for them , and further hinders their meaningful participation in treatment decision-making. Though Jordanian physicians are usually authoritarian in their communication with patients, recent research has shown that the majority of Although Jordanian physicians working with cancer patients prefer shared decision-making over other decision-making approaches they less frequently reported using this approach in their clinical practice with cancer patients. Barriers cited in this current study, especially patients' unwillingness to participate in treatment decision-making, could explain the discrepancy found in earlier research  between reported comfort and reported use of the shared decision-making approach among Jordanian physicians treating cancer patients. Thus, for shared decision-making to be successfully implemented in the Jordanian health-care system, Jordanian patients have to be empowered by providing them knowledge about cancer, cancer treatment, the availability of treatment options, and their legitimate rights as patients. An attitudinal change is essential for both patients and health-care providers in order to affect system-related barriers. For example, in contrast to studies conducted among Western physicians,,, in this study the patient's family overriding the decision-making process was a commonly reported barrier to patient participation by Jordanian physicians. The influential impact of the patients' families on the decision-making process is mostly attributed to the family-centered nature of the Jordanian society. A Jordanian family is protective of its members to the degree of making decisions on behalf of them including making medical decisions. Hence, any intervention aimed at promoting patients' participation in treatment decision-making has to consider the family role in the decision-making process.
Patient factors perceived by Jordanian physicians as helpful in facilitating patient participation in treatment decision-making are similar to those perceived by Western physicians , including patient trusting the physician, patient being accompanied at the consultation, and patient emotional readiness for decision-making. Patient trusting the physician was ranked first of all listed facilitators among participating physicians. Patient trust in the physician may facilitate communication and information exchange and thus enhance the decision-making process. However, when trust is not accompanied by sufficient knowledge about the disease and treatment from the patient it acts as a hindrance to patient participation as it may reflect patients' lack of self-efficacy for active involvement in the decision-making process. Thus, future research should explore the relationship between knowledge about cancer and cancer treatment, trust in physicians, and patient self-efficacy for participation in treatment decision-making among Jordanian cancer patients.
This study has potential limitations. The convenience sampling used in the study as well as the small sample size limits the generalizability of the study results. However, generalizability is supported by obtaining data from physicians in all sectors of the Jordanian health-care system. In addition, this study presents results of self reported data and thus, recall bias might have affected its results. Physicians who participated in this study might have underreported or overreported experienced barriers and/or facilitators to patient participation in treatment decision-making.
This work was supported by Deanship of Scientific Research, Zarqa University, Jordan.
Financial support and sponsorship
This study was funded by Deanship of Scientific Research, Zarqa University, Jordan.
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Fried TR. Shared decision making—finding the sweet spot. N Engl J Med 2016;374:104-6.
Levit LA, Balogh E, Nass SJ, Ganz P. Delivering high-quality cancer care: Charting a new course for a system in crisis. Washington, DC: The National Academies Press; 2013.
Charles CA, Whelan T, Gafni A, Willan A, Farrell S. Shared treatment decision making: What does it mean to physicians? J Clin Oncol 2003;21:932-6.
Kane HL, Halpern MT, Squiers LB, Treiman KA, McCormack LA. Implementing and evaluating shared decision making in oncology practice. CA Cancer J Clin 2014;64:377-88.
Kehl KL, Landrum MB, Arora NK, Ganz PA, van Ryn M, Mack JW, et al
. Association of actual and preferred decision roles with patient-reported quality of care: Shared decision making in cancer care. JAMA Oncol 2015;1:50-8.
O'Brien MA, Ellis PM, Whelan TJ, Charles C, Gafni A, Lovrics P, et al
. Physician-related facilitators and barriers to patient involvement in treatment decision making in early stage breast cancer: Perspectives of physicians and patients. Health Expect 2013;16:373-84.
Friedberg MW, Van Busum K, Wexler R, Bowen M, Schneider EC. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Aff 2013;32:268-75.
Joseph-Williams N, Elwyn G, Edwards A. Knowledge is not power for patients: A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Educ Couns 2014;94:291-309.
Pollard S, Bansback N, Bryan S. Physician attitudes toward shared decision making: A systematic review. Patient Educ Couns 2015;98:1046-57.
Zeuner R, Frosch DL, Kuzemchak MD, Politi MC. Physicians' perceptions of shared decision-making behaviours: A qualitative study demonstrating the continued chasm between aspirations and clinical practice. Health Expect 2015;18:2465-76.
Frosch DL, May SG, Rendle KA, Tietbohl C, Elwyn G. Authoritarian physicians and patients' fear of being labeled 'difficult'among key obstacles to shared decision making. Health Aff 2012;31:1030-8.
Obeidat R, Khrais HI. Jordanian physicians' attitudes toward disclosure of cancer information and patient participation in treatment decision-making. Asia Pac J Oncol Nurs 2016;3:281-8. [Full text]
Charles C, Gafni A, Whelan T. Self-reported use of shared decision-making among breast cancer specialists and perceived barriers and facilitators to implementing this approach. Health Expect 2004;7:338-48.
Shepherd HL, Tattersall MH, Butow PN. Physician-identified factors affecting patient participation in reaching treatment decisions. J Clin Oncol 2008;26:1724-31.
World Health Organization (WHO). Country cooperation strategy for WHO and Jordan 2008-2013. Cairo: World Health Organization; 2010. WHO-EM/ARD/034/E.
Ters A, Yima T. Power imbalance prevents shared decision making. BMJ 2014;348:17-8.
Obeidat R. Decision-making preferences of Jordanian women diagnosed with breast cancer. Support Care Cancer 2015;23:2281-5.
Othman A, Ahram M, Al-Tarawneh MR, Shahrouri M. Knowledge, attitudes and practices of breast cancer screening among women in Jordan. Health Care Women Int 2015;36:578-92.
Obeidat RF, Dickerson SS, Homish GG, Alqaissi NM, Lally RM. Controlling fear: Jordanian women's perceptions of the diagnosis and surgical treatment of early-stage breast cancer. Cancer Nurs 2013;36:484-92.
Cohen E, Botti M. Cancer patients'; perceptions of the barriers and facilitators to patient participation in symptom management during an episode of admission. Cancer Nurs 2015;38:458-65.
[Table 1], [Table 2], [Table 3], [Table 4]