Saturday 7 May 2016

So you want to get better at shared decision-making

If you are a teacher, evidence-based practitioner or senior leader and are looking to improve your decision-making processes, then this post is for you.  In this post we will be looking at the competences and processes associated with shared decision-making between clinicians  and patients.  We then go onto explore the implications for education professionals and their decision-making processes.  But first I will summarise both my underlying position and associated theory of action.

A summary of my argument and underpinning theory of action (amended from Fullan and Hargreaves, 2012)
  • Decisional capital - the capital that professionals acquire through structured and semi-structured, practice and reflection - is a core component of a school's professional capital
  • Decisional capital can be enhanced by school leaders working with colleagues to take advantage of their knowledge, skills and experience.
  • Decisional capital can be enhanced by teachers, heads of departments and head-teachers engaging in the deliberate practice of their decision-making skills - and this practice may require thousands of hours and a number of years to develop.
  • Research exists in medicine about how to improve the shared decision-making processes between clinicians and patients
  • These research findings can be adopted for use in schools to identify the competences and processes required by school leaders - at whatever level - to engage in shared decision-making with colleagues (and potentially pupils).
  • By using these competences as a check-list school leaders can take action to improve shared decision-making with colleagues.
  • The use of these competences will lead to an increase in decisional capital within the school and contribute to improved outcomes for both pupils and colleagues. 
The health professions and shared decision-making with patients 

One area, which might have potential to support teachers and headteachers engage in better collaborative decision decision is the work of Elwyn, Edwards and Kinnersley(1999) - cited by Greenhalgh (2014) - who were pioneers in the academic study of shared decision-making between doctors and patients.   Elywn, et al (1999) state that clinical decision-making can be seen as a spectrum – with a paternalistic model at one end of the spectrum and an informed choice model at the other.  As such, shared decision-making sits in the middle.  Elywn et al represent the model in figure 1 and which I have amended for a school-setting

Figure 1 

Shared decision-making
Informed choice/individual teacher professional autonomy
In the context of schools, this could be likened to a range of decision-making processes, which had a command and control model at one end of the spectrum and teacher autonomy at the other.  In this context, informed choice involves a teacher receiving information about possible changes in practice which may impact upon their classroom practice, but they are professionally autonomous enough to make and informed decision and choice on how to proceed.  As such, shared decision-making is an attempt to stake out a middle-ground in the decision-making process.  If school leaders were to share decision-making with colleagues when addressing problems, then the characteristics are likely to be as follows (amended from Elwyn et al 1999 p 478)
  • Shared decision-making involves at least two participants - maybe the headteacher and the teachers and often others
  • Both parties - be it leaders and teachers - take steps to participate in the decision-making process
  • Information sharing is a prerequisite to shared decision-making
  • The decision - which may be to do nothing - is made, and both parties agrees to the decision.
Given the relational nature of the process, I will now turn the leadership competences necessary to engage in shared decision-making.  The competences required for teachers to engage in shared decision-making will be explored in a subsequent post.  

The competences necessary to engage in shared decision-making

Edwards et al (2004) identify a number of competencies that clinicians need to demonstrate in order to engage in shared decision-making with their patients, and these are illustrated in Table 1.

Table 1 Competences required for shared decision-making

Define the problem
Clear specification of the problem that requires a decision
Portray equipoise
That professionals may not have a clear preference about which treatment option is best in the context
Portray options
One or more treatment options and the option of no treatment if relevant  identified – alongside the option of no change
Provide information in preferred format
Identify patients preferences is they are to be useful in the decision-making process
Check understanding
Of the range of options and information provided about them
Explore ideas, concerns and expectations
About the clinical condition, possible treatment options and outcomes
Checking role preference
That patients accept the process and identify their decision-making role preference
Involving the patient to the extent to which they desire to be involved
Deferment if necessary
Reviewing treatment needs and preferences after time for further consideration, including with friends or family member, if the patient requires
Review arrangements
A specified time to review the decision

Inevitably, there is a not straight ‘read-across’ between competences required for health professional to engage in shared-decision making with a patient and those which an educational leader needs to engage in a shared decision-making with colleagues.  That said, there are four aspects of the competences which are worthy of further consideration by the evidence-based practitioner, and which if practiced may lead to an increase in the school's decisional capital.

First, the competences provide an easily amended check-list for decision-makers wishing to engage colleagues in shared decision-making.  In particular, the competences make explicit the need to: define the problem; identify options; explore the implications of the decision;  check shared understanding of the situation; involve colleagues in decision-making process; and, then making follow-up arrangements.  In doing so, it provides decision-makers and their colleagues with a tool with which they can use to reflect upon the decision-making process and identify areas for development within a shared decision-making process.  As such, it has the potential to provide a mechanism for decision-makers to engage in deliberate practice.

Second, the notion of equipoise is central to the process – i.e. maintaining a sense of balance, if not neutrality, when outlining the different options available and their respective advantages and disadvantages.  By displaying authentic equipoise, this should lead to greater engagement by the colleagues in shared decision-making, resulting  increased levels of decisional capital emerging, as colleagues feel they have a authentic part to play in the decision-making process.

Third, these competences should help those colleagues who are leading the decision-making process, to really think through how they want their colleagues to engage in the process.  One of the most misused word in the management lexicon is consultation, which is often used to mean so many different things – be it the testing of ideas, genuine consultation where opinions are being sort or on other occasions if can be conflated with collaboration and co-creation.  By using the competences outlined in the shared decision-making, it should help decision-leaders to be explicit about the decision-making process, and also allow colleagues to participating in the process to be clear about their expectations about their involvement in the decision-making process.  If expectations are aligned this is likely to lead to an increase in the stock of decisional capital, rather than a decrease.

Fourth, given the increased emphasis on pupil voice and engaging with pupils, understanding the nature of shared decision-making and the associated processes may be an essential first-step in helping a school develop opportunities for 'genuine' pupil voice.  Indeed, this notion of accessing pupil voice is an essential component of processes that need to be undertaken by evidence-based practitioner.

And some final words

This post has drawn heavily from practices associated with evidence-based medicine and which may be anathema to some headteachers and teachers.  Nevertheless, if we can get past the notion that all evidence-based medicine is nothing more than using RCTS to tell health professional what to do, then will be able to develop the skills, knowledge and understanding necessary for effective evidence-based education, at a rate that is faster than would otherwise be case.  And in doing, so we will hopefully bring about better outcomes pupils, colleagues and the communities that schools serve


Elwyn, G., Edwards, A., & Kinnersley, P. 1999. Shared decision-making in primary care: the neglected second half of the consultation. The British Journal of General Practice, 49(443), 477–482.

Edwards, A., Elwyn, G., Hood, K., Atwell, C., Robling, M., Houston, H., Kinnersley, P., Russell, I. and Study Steering Group, 2004. Patient-based outcome results from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice. Family practice, 21(4), pp.347-354.

Greenhalgh, T., 2014. How to read a paper: The basics of evidence-based medicine. John Wiley & Sons

Hargreaves, A and Fullan, M. 2012. Professional Capital: Transforming, teaching in every school. Routledge, Abingdon


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