An expanded framework to define and measure shared decision-making in dialogue: A ‘top-down’ and ‘bottom-up’ approach

Objectives: We aimed to develop a comprehensive, descriptive framework to measure shared decision making (SDM) in clinical encounters. Methods: We combined a top-down (theoretical) approach with a bottom-up approach based on audio-recorded dialogue to identify all communication processes related to decision making. We coded 55 pediatric otolaryngology visits using the framework and report interrater reliability. Results: We identified 14 clinician behaviors and 5 patient behaviors that have not been previously described, and developed a new SDM framework that is descriptive (what does happen) rather than normative (what should happen). Through the bottom-up approach we identified three broad domains not present in other SDM frameworks: socioemotional support, understandability of clinician dialogue, and recommendation-giving. We also specify the ways in which decision-making roles are assumed implicitly rather than discussed explicitly. Interrater reliability was >75% for 92% of the coded behaviors. Conclusion/practice implications: This SDM framework allows for a more expansive understanding and analysis of how decision making takes place in clinical encounters, including new domains and behaviors not present in existing measures. We hope that this new framework will bring attention to a broader conception of SDM and allow researchers to further explore the new domains and behaviors identified.