COVID-19 的教训：护理实践中共同决策的时机

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The COVID-19 pandemic revealed limitations in current approaches to educating the public and individual patients about their health, particularly in the context of misinformation on social media and other venues. Patients' existing belief systems influenced their perceptions about the validity of COVID-19 information and their subsequent decisions to receive a vaccine. In response, clinicians and researchers have reiterated the value of shared decision making to navigate patient preferences and ambiguity (Durand et al., 2022). Shared decision making is “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences” (Elwyn et al., 2012). The evidence supporting shared decision making has grown since the term was introduced in the medical literature 40 years ago, but clinicians have not broadly translated it into practice. This period of reflection after rapid COVID-related changes to the structure and process of health care delivery presents an opportunity for nurses to lead shared decision making implementation to better align their professional role with the public health needs of society. In this commentary, we argue for an evolution of one of nursing's key functions—expanding the construct of patient education to include shared decision making—and suggest system-level changes that could enable the broad translation of shared decision making methods. We offer our perspectives as practising nurses, researchers, educators, and administrators across the health care continuum.

Nurses can leverage patient education as part of a broader effort to establish therapeutic relationships, assess structural barriers to care and increase patients' self-efficacy. However, nurses are often taught that the goal of patient education is to improve patient adherence to evidence-based treatment; and in practice, patient education may be a simple knowledge transfer. For example, a nurse caring for an older patient or a patient with diabetes may educate them on the increased risk of severe COVID-19 outcomes and how to prevent infection. Despite best intentions, this approach does not align with the science of behaviour change or incorporate patients' expertise and may reinforce harmful power structures. Empirically valid behaviour change theory demonstrates that knowledge is necessary but not sufficient for improved health outcomes. A myriad of factors influences the pathway from knowledge to behaviour, including structural barriers, illness perception, goals, social relationships and self-efficacy (Bandura, 2004). Patient education alone rarely addresses them.

In contrast to current practice, shared decision making would align patient education methods with both the evidence base for behaviour change and nursing's humanist values. Different shared decision making models exist, but key components across models include rapport-building and learning about the patient, their values and goals; creating or affirming the patient's awareness of choice; and describing treatment options (Bomhof-Roordink et al., 2019). By centring the person and their goals in the conversation, shared decision making allows for meaningful action planning that is context specific and builds authentic therapeutic relationships. Conceptual models and growing evidence link shared decision making and patient outcomes through a reduction in patients' anxiety and symptom burden and improvements in patient satisfaction and treatment adherence (Shay & Lafata, 2015).

This reconceptualization of the nurse's role in patients' decision making would change the way nurses communicate with patients about COVID-19. They would invite patients to have a conversation about COVID-19 and build trust and rapport by being relatable—even vulnerable and sharing personal experiences. Nurses would engage in therapeutic listening, checking personal biases. This reduces the likelihood of prejudices, stereotypes, and discrimination introduced by personal beliefs, ignorance, or group memberships. They would offer information (e.g., about vaccines or masking) in the context of patients' goals. In so doing, nurses can help someone who is opposed to vaccines consider other public health measures like masking or social distancing. They can invite someone who is resistant to any measures to have another conversation in the future. Acceptance of health-promoting behaviours might not take place during the first conversation, but through relationship building and shared decision making nurses can help regain the trust that many patients have lost in the health care system. The message during COVID: Talk to a nurse about what you believe. Nurses care and can help you decide the best way to keep you and your loved ones healthy.

Moreover, a person-centred approach to patient education and decision making will only become more needed as populations age and increase multimorbidity. As healthcare is currently structured, providers and specialists operate in silos. They possess technical expertise but may lack comfort or role clarity regarding behaviour change. Additionally, patients have access to an overwhelming amount of health information—both credible and misleading. Often they are left alone or with family members to interpret multiple or complex care plans, prioritize components of them and coordinate care. Nurses can practise shared decision making to transcend the noise and influence patients' health and behaviour using processes that centre patients' contexts, beliefs, values and preferences in individualized care planning. Once elicited, nurses can reiterate patient perspectives with specialists and other care team members to facilitate care plan integration.

Nurses are well-positioned to engage in these simple but powerful conversations, yet broad shared decision making implementation requires system-level change. The current approach to patient education is reinforced in nursing curricula, electronic health records and healthcare regulations. The time pressures of real-world clinical practice limit opportunities for trust-building and deliberation. COVID-19 has only exacerbated them, and many nurses are disillusioned and weary. So how should nurses leverage professional strengths to move forward?

Nursing faculty can integrate existing shared decision making competencies into nursing curricula and guide nursing students to practice shared decision making with time pressures during clinical rotations and via simulation. Chief nursing officers and other nursing leaders can identify champions at different organizational levels to implement shared decision making models and methods appropriate to their setting and patient populations. Health care organizations can pilot changes to the electronic health record that facilitate shared decision making. Rather than presenting checkboxes for patients' preferred learning style or barriers to learning, the electronic health record could encourage clinicians to ascertain patients' beliefs about their illness and goals for life at home. Other health information technology tools such as interactive decision aids, patient portals, personal health records and secure electronic messaging can help with shared decision making. For example, patients can access decision aids and relevant patient education materials via a patient portal and communicate with their health care team about the decision via secure messaging. Additionally, health care organizations will be incented to invest in technology infrastructure and human relationships as payment policy continues to shift from fee-for-service to fee-for-health and other population health approaches. Rather than using precious time to quickly skim multiple educational points, nurses can be encouraged through shared decision making to focus on what matters most to patients whilst developing connection with patients that brings meaning to work and improves patient ownership and outcomes.

COVID-19 has demonstrated that individuals and communities who feel their autonomy and decision making power have been undermined may respond in a way that is detrimental to their well-being and the well-being of others. Historically, nurses have been at the forefront of efforts to promote patients' dignity, rights and autonomy. With practical system-level changes, nurses can continue to do this through shared decision making.

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COVID-19 大流行揭示了当前对公众和个体患者进行健康教育的方法存在局限性，特别是在社交媒体和其他场所存在错误信息的情况下。患者现有的信念系统影响了他们对 COVID-19 信息有效性的看法以及他们随后接受疫苗的决定。作为回应，临床医生和研究人员重申了共同决策在引导患者偏好和模糊性方面的价值（Durand 等人，  2022 年）。共享决策是“一种临床医生和患者在面临决策任务时共享最佳可用证据的方法，并且支持患者考虑选项，以实现知情偏好”（Elwyn 等，  2012）。自 40 年前医学文献中引入该术语以来，支持共同决策制定的证据越来越多，但临床医生并未将其广泛地转化为实践。在与 COVID 相关的医疗保健服务结构和流程发生快速变化之后的这段反思期为护士提供了一个机会来领导共同决策的实施，以更好地使他们的专业角色与社会的公共卫生需求保持一致。在这篇评论中，我们主张对护理的一项关键职能进行演变——扩大患者教育的结构以包括共享决策——并提出系统级的改变，以实现共享决策方法的广泛转化。我们提供我们作为执业护士、研究人员、教育工作者的观点，

护士可以利用患者教育作为更广泛努力的一部分，以建立治疗关系、评估护理的结构性障碍并提高患者的自我效能。然而，护士经常被告知，患者教育的目标是提高患者对循证治疗的依从性；在实践中，患者教育可能是一种简单的知识转移。例如，护理老年患者或糖尿病患者的护士可能会对他们进行有关 COVID-19 严重后果风险增加以及如何预防感染的教育。尽管有最好的意图，但这种方法不符合行为改变的科学或结合患者的专业知识，并且可能会加强有害的权力结构。经验上有效的行为改变理论表明，知识对于改善健康结果是必要的，但还不够。无数因素影响从知识到行为的途径，包括结构性障碍、疾病认知、目标、社会关系和自我效能（Bandura， 2004 年）。仅靠患者教育很少能解决这些问题。

与目前的做法相比，共同决策将使患者教育方法与行为改变的证据基础和护理的人文主义价值观保持一致。存在不同的共享决策模型，但模型中的关键组成部分包括建立融洽关系和了解患者、他们的价值观和目标；创造或肯定患者的选择意识；并描述治疗方案（Bomhof-Roordink 等人，  2019）。通过在对话中以人和他们的目标为中心，共同决策允许进行有意义的行动计划，该计划是针对特定环境的，并建立真正的治疗关系。概念模型和越来越多的证据通过减少患者的焦虑和症状负担以及提高患者满意度和治疗依从性，将共同决策制定和患者结果联系起来（Shay & Lafata，  2015 年）。

这种对护士在患者决策中角色的重新概念化将改变护士与患者就 COVID-19 进行沟通的方式。他们会邀请患者就 COVID-19 进行对话，并通过建立信任和融洽关系——甚至是脆弱和分享个人经历。护士会参与治疗性倾听，检查个人偏见。这减少了由个人信仰、无知或群体成员身份引入的偏见、刻板印象和歧视的可能性。他们将在患者目标的背景下提供信息（例如，关于疫苗或掩蔽）。通过这样做，护士可以帮助反对疫苗的人考虑其他公共卫生措施，例如戴口罩或保持社交距离。他们可以邀请对任何措施有抵抗力的人将来进行另一次对话。在第一次谈话中可能不会接受促进健康的行为，但通过建立关系和共同决策，护士可以帮助重新获得许多患者在医疗保健系统中失去的信任。COVID 期间的信息：与护士谈谈您的信念。护士关心并可以帮助您决定让您和您所爱的人保持健康的最佳方式。

此外，随着人口老龄化和多发病率的增加，以人为本的患者教育和决策方法只会变得更加需要。由于医疗保健目前是结构化的，提供者和专家在孤岛中运作。他们拥有技术专长，但在行为改变方面可能缺乏舒适感或角色清晰性。此外，患者可以获得大量的健康信息——可信的和误导的。通常他们独自一人或与家人一起解释多个或复杂的护理计划，优先考虑其中的组成部分并协调护理。护士可以通过在个性化护理计划中以患者的背景、信念、价值观和偏好为中心的过程来练习共同决策，以超越噪音并影响患者的健康和行为。一经引出，

护士可以很好地参与这些简单但有力的对话，但广泛的共享决策实施需要系统级的改变。当前的患者教育方法在护理课程、电子健康记录和医疗保健法规中得到了加强。现实世界临床实践的时间压力限制了建立信任和深思熟虑的机会。COVID-19 只会加剧这种情况，许多护士幻灭和疲倦。那么护士应该如何利用专业优势向前发展呢？

护理教师可以将现有的共享决策能力整合到护理课程中，并指导护理学生在临床轮换期间和通过模拟练习具有时间压力的共享决策。首席护理官和其他护理领导者可以确定不同组织级别的拥护者，以实施适合其环境和患者群体的共享决策模型和方法。医疗保健组织可以对电子健康记录进行试点更改，以促进共同决策。电子健康记录可以鼓励临床医生确定患者对自己的疾病和家庭生活目标的信念，而不是为患者首选的学习方式或学习障碍提供复选框。其他健康信息技术工具，例如交互式决策辅助工具、患者门户、个人健康记录和安全电子信息，有助于共同决策。例如，患者可以通过患者门户访问决策辅助工具和相关的患者教育材料，并通过安全消息与他们的医疗团队就决策进行沟通。此外，随着支付政策继续从按服务收费转向按健康收费和其他人口健康方法，医疗保健组织将被激励投资于技术基础设施和人际关系。与其利用宝贵的时间快速浏览多个教育点，

COVID-19 表明，感觉自己的自主权和决策权受到损害的个人和社区可能会做出不利于他们和他人福祉的反应。从历史上看，护士一直站在促进患者尊严、权利和自主权的最前沿。通过实际的系统级更改，护士可以通过共同决策继续做到这一点。

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