Provider perspectives on the utility of a colorectalcancer s.docx

Provider perspectives on the utility of a colorectal
cancer screening decision aid for facilitating shared
decision making
Paul C. Schroy III MD MPH,* Shamini Mylvaganam MPH� and
Peter Davidson MD�
*Director of Clinical Research, Section of Gastroenterology,
Boston Medical Center, Boston, MA, �Study Coordinator,
Section of
Gastroenterology, Boston Medical Center, Boston, MA and
�Clinical Director, Section of General Internal Medicine,
Boston
Medical Center, Boston, MA, USA
Correspondence
Paul C. Schroy III, MD MPH
Boston Medical Center
85 E. Concord Street
Suite 7715
Boston
MA 02118
USA
E-mail: [email protected]
Accepted for publication

8 August 2011
Keywords: decision aids, informed
decision making, shared decision
making
Abstract
Background Decision aids for colorectal cancer (CRC)
screening
have been shown to enable patients to identify a preferred
screening
option, but the extent to which such tools facilitate shared
decision
making (SDM) from the perspective of the provider is less well
established.
Objective Our goal was to elicit provider feedback regarding the
impact of a CRC screening decision aid on SDM in the primary
care
setting.
Methods Cross-sectional survey.
Participants Primary care providers participating in a clinical
trial
evaluating the impact of a novel CRC screening decision aid on

SDM and adherence.
Main outcomes Perceptions of the impact of the tool on
decision-
making and implementation issues.
Results Twenty-nine of 42 (71%) eligible providers responded,
including 27 internists and two nurse practitioners. The majority
(>60%) felt that use of the tool complimented their usual
approach,
increased patient knowledge, helped patients identify a
preferred
screening option, improved the quality of decision making,
saved
time and increased patients� desire to get screened.
Respondents
were more neutral is their assessment of whether the tool
improved
the overall quality of the patient visit or patient satisfaction.
Fewer
than 50% felt that the tool would be easy to implement into
their
practices or that it would be widely used by their colleagues.
Conclusion Decision aids for CRC screening can improve the

quality and efficiency of SDM from the provider perspective but
future use is likely to depend on the extent to which barriers to
implementation can be addressed.
doi: 10.1111/j.1369-7625.2011.00730.x
� 2011 John Wiley & Sons Ltd 27
Health Expectations, 17, pp.27–35
Introduction
Engaging patients to participate in the decision-
making process when confronted with prefer-
ence-sensitive choices related to cancer screening
or treatment is fundamental to the concept of
patient-centred care endorsed by the Institute of
Medicine, US Preventive Services Task Force
and the Centers for Disease Control and Pre-
vention.
1–3
Ideally, this process should occur
within the context of shared decision making

(SDM), whereby patients and their health-care
providers form a partnership to exchange
information, clarify values and negotiate a
mutually agreeable medical decision.
4,5
SDM,
however, has been difficult to implement into
routine clinical practice in part owing to lack of
time, resources, clinician expertise and suitabil-
ity for certain patients or clinical situations.
6,7
The use of patient-oriented decision aids outside
of the context of the provider–patient interac-
tion has been proposed as a potentially effective
strategy for circumventing several of these bar-
riers.
3,8
Decision aids are distinct from patient
education programmes in that they serve as
tools to enable patients to make an informed,

value-concordant choice about a particular
course of action based on an understanding of
potential benefits, risks, probabilities and sci-
entific uncertainty.
9–11
Besides facilitating
informed decision making (IDM), decision aids
also have the potential to facilitate SDM by
improving the quality and efficiency of the
patient–provider encounter and by empowering
users to participate in the decision-making
process.
11
Studies to date have demonstrated
that while decision aids enhance knowledge,
reduce decisional conflict, increase involvement
in the decision-making process and lead to
informed value-based decisions, their impact on
the quality of the decision, satisfaction with the

decision making process and health outcomes
remains unclear.
11
Besides enabling patients to make informed
choices, decision aids also have the potential to
facilitate SDM by improving the quality and
efficiency of the patient–provider encounter.
Relatively few studies have examined the utility
of decision aids for promoting effective SDM
from the perspective of the provider. Studies to
date have largely focused on provider perspec-
tives on the quality of the decision tools
themselves or issues related to implementation
into clinical practice.
11–15
The overall objective
of this study was to elicit provider feedback
regarding the extent to which the use of a novel
colorectal cancer (CRC) screening decision aid

facilitated SDM in the primary care setting
within the context of a randomized clinical
trial.
Methods
Brief overview of decision aid and randomized
clinical trial
Details of the decision aid, recruitment process,
study design and secondary outcome results
have been previously published.
16
The overall
objective of the trial was to evaluate the impact
of a novel computer-based decision aid on SDM
and patient adherence to CRC screening rec-
ommendations. The decision aid uses video-
taped narratives and state-of-the-art graphics in
digital video disc (DVD) format to convey key
information about CRC and the importance of

screening, compare each of five recommended
screening options using both attribute- and
option-based approaches, and elicit patient
preferences. A modified version of the tool also
incorporated the web-based �Your Disease Risk
(YDR)� CRC risk assessment tool (http://
www.yourdiseaserisk.wustl.edu). To assess its
impact on SDM and screening adherence,
average-risk, English-speaking patients 50–
75 years of age due for CRC screening were
randomized to one of the two intervention arms
(decision aid plus the YDR personalized risk
assessment tool with feedback or decision aid
alone) or a control arm, each of which involved
an interactive computer session just prior to a
scheduled visit with their primary care provider
at either the Boston Medical Center or the
South Boston Community Health Center. After
completing the computer session, patients met

with their providers to discuss screening and
Colorectal cancer screening decision aid, P C Schroy, S
Mylvaganam and P Davidson
� 2011 John Wiley & Sons Ltd
28
identify a preferred screening strategy. Although
providers were blinded to their patients� ran-
domization status, they received written notifi-
cation in the form of a hand-delivered flyer from
all study patients acknowledging that they were
participating in the �CRC decision aid study� to
ensure that screening was discussed. Outcomes
of interest were assessed using pre ⁄ post-tests,
electronic medical record and administrative
databases. The study to date has found that the
tool enables users to identify a preferred
screening option based on the relative values
they place on individual test features, increases
knowledge about CRC screening, increases sat-

isfaction with the decision-making process and
increases screening intentions compared to non-
users. The study also finds that screening
intentions and test ordering are negatively
influenced in situations where patient and pro-
vider preferences differ. The tool�s impact on
patient adherence awaits more complete follow-
up data, which should be available in early
2011.
Study design
We conducted a cross-sectional survey of
primary care providers participating in the ran-
domized clinical trial in January and February
of 2009. At the time of the survey, 725 eligible
patients had been randomized to one of the three
study arms. The surveys were distributed just
prior to monthly business meetings conducted
by the Sections of General Internal Medicine

and Women�s Health at Boston Medical Center
and Adult Medicine at the South Boston Com-
munity Health Center. Respondents were asked
to sign an attestation sheet if they completed the
survey to identify providers not in attendance.
For those who were not in attendance, the sur-
vey was distributed electronically as an email
attachment; respondents were asked to return
the survey via facsimile to preserve anonymity.
Two email reminders with attached surveys were
sent 2 weeks apart after the initial email to
optimize response. The study was deemed
exempt by the Institutional Review Boards at
both participating institutions.
Subjects
The survey sample included board-certified
primary care providers (general internists and
nurse practitioners) at Boston Medical Center
and the South Boston Community Health Center

who had referred patients to the randomized
clinical trial. Of the 50 providers who had referred
patients to the study since its commencement in
2005, 42 were still practicing at the participating
sites at the time of the survey. All had exposure to
at least one patient in an intervention arm and at
least one patient in the control arm; all but two of
the targeted providers had multiple patients in
each arm. None of the participants had formally
reviewed the content of the decision aid nor
received special training in SDM.
Practice settings
The Boston Medical Center is a private, non-profit
academic medical centre affiliated with the Boston
University School of Medicine, which serves a
mostly minority patient population (only 28%
White, non-Hispanic). The South Boston Com-
munity Health Center is a community health centre

affiliated with BMC, which serves a mostly White,
non-Hispanic, low-income patient population.
Survey instrument
The survey instrument included a cover letter, 23
closed-ended questions and two open-ended
questions. Much of the content was derived from
instruments used in previously published studies
by Holmes-Rovner et al. and Graham et al.
6,15
The cover letter briefly described the purpose of
the study, a statement that participation was
completely voluntary, the approximate amount
of time required to complete the survey, and a
statement that all responses are anonymous and
confidential. The closed-ended questions include
one item related to eligibility [confirmation of
participation in the clinical trial (yes ⁄ no)], two
items related to demographics (provider degree
and year of graduation), 12 items related to

perspectives on the impact of the tool on various
patient and provider components of SDM for
29
CRC screening (see Table 1), and eight items
related to perspectives on implementation or
content modification (see Tables 2 and 3). The
framing of the questions inferred a comparison
between patients exposed to the decision aid and
those not exposed, i.e., standard care patients,
regardless of their involvement in the study. All
of the items related to SDM used a 5-point Likert
scale ranging from 1 (strongly disagree) to 5
(strongly agree). Six of the items related to
implementation or content modification also

used the same 5-point Likert scale, and two used
a single best answer format. The two open-ended
questions inquired about suggestions for
improving the decision aid and complaints. The
questionnaire took �10 min to complete.
Statistical analyses
Descriptive statistics were used to characterize
the study population and response data for all
closed-ended questions. Frequency data for the
5-point Likert scale items were collapsed into
three categories: �agreed ⁄ strongly agreed�, �neu-
tral� and �disagreed ⁄ strongly disagreed�. Mean
response scores ± standard deviations were
also calculated for the same data using Micro-
soft Excel functions. Responses to open-ended
questions were summarized according to themes.
Results
Study population

In total, 29 of the 42 (71%) possible providers,
including 27 physicians and two nurse practitio-
ners, responded to the survey and acknowledged
that they had referred patients to the randomized
clinical trial. Of the 29 respondents, 4 (14%) had
received their degrees between 2000 and 2009, 15
(52%) between 1990 and 1999, and 6 (28%)
before 1990; two declined to answer the question.
Perspectives on SDM
As shown in Table 2, the majority of providers
(>60%) agreed or strongly agreed that the
decision aid complemented their usual approach
Table 1 Provider perspectives on the utility of the decision aid
for facilitating SDM
From my clinical perspective, the decision aid
Response category, n (%)
Mean item
score (SD)*
Strongly

agree ⁄ agree Neutral
Strongly
disagree ⁄
disagree
4. Complemented my usual approach to CRC screening 24 (86)
4 (14) 0 4.3 ± 0.7
5. Improved my usual approach to CRC screening 16 (59) 8 (30)
3 (11) 3.7 ± 1.0
6. Helped me tailor my counselling about CRC
screening to my patient�s needs
12 (44) 11 (41) 4 (15) 3.5 ± 1.0
7. Saved me time 18 (64) 6 (21) 4 (14) 3.8 ± 1.0
8. Improved the quality of patient visits 14 (52) 9 (33) 4 (15)
3.6 ± 1.0
9. Increased my patients� satisfaction with my care 10 (40) 13
(52) 2 (8) 3.4 ± 0.8
10. Is an appropriate use of my patient�s clinic time 27 (93) 1
(3) 1 (3) 4.1 ± 0.6
11. Increase patient knowledge about the different
CRC screening options
26 (90) 3 (10) 0 4.3 ± 0.6
12. Helped patients understand the benefits ⁄ risks
of the recommended screening options

24 (83) 5 (17) 0 4.1 ± 0.7
13. Helped patients in identifying preferred
screening option
21 (72) 7 (24) 1 (3) 4.0 ± 0.8
14. Improved the quality of the decision making 22 (79) 6 (21)
0 4.0 ± 0.7
15. Increased patients� desire to get screened 21 (75) 5 (18) 2
(7) 3.9 ± 0.9
CRC, colorectal cancer; SD, standard deviation; SDM, shared
decision making.
*1 = strongly disagree; 5 = strongly agree.
30
to CRC screening, was an appropriate use of
their patient�s clinic time, saved them time,
increased patient knowledge about the various
CRC screening options and their risks and

benefits, helped the patients identify a preferred
screening option, improved the quality of deci-
sion making, and increased their patients� desire
to get screened. Providers were more neutral in
their assessment of the decision aid�s utility for
improving their usual approach to CRC
screening, helping them tailor their counselling
style to their patients� needs, improving the
quality of patient visits, and increasing patient
satisfaction with their care. Relatively few pro-
viders disagreed or strongly disagreed with any
of these measures.
Perspectives on clinical use and content
modification
There was less consensus when asked about
implementation of the tool into routine clinical
practice. As shown in Table 2, <50% of
respondents agreed or strongly agreed that the
decision aid would be easy to use in their prac-

tice outside of a research setting or that it would
be used by most of their colleagues. A slim
majority (58%) also believed that implementa-
tion would require reorganization of their
practice. Respondents mostly agreed or were
neutral in their assessment of whether the deci-
sion aid should be disseminated as an Internet-
or DVD-based tool. When asked to identify a
preferred time for having their patients review
the tool (Table 3), 72% chose prior to initiating
the CRC screening discussion, 21% chose after
initiating the screening discussion, and 7% chose
both. Among the 21 providers who chose the
pre-visit approach, 13 preferred that the tool be
used in the office just prior to the pre-arranged
visit, five preferred at home use and three pre-
ferred both; among the six providers who chose
the post-visit approach, five preferred in-office

use and one preferred at home use.
There was also a lack of consensus when
asked about content modification. Whereas 50%
of respondents agreed or strongly agreed that
the decision aid should include a discussion of
costs, 31% disagreed or strongly disagreed
Table 2 Provider perspectives on decision aid implementation
The decision aid
Response category, n (%)
Mean item
score (SD)*
Strongly
agree ⁄ agree Neutral
Strongly
disagree ⁄
disagree
16. Would be easy to use in my practice
outside of a research stetting
12 (48) 9 (36) 4 (16) 3.4 ± 1.0

17. Use would require reorganization of my
practice for routine clinical use
14 (58) 6 (25) 4 (17) 3.6 ± 1.1
18. Is likely to be used by most of my colleagues 11 (41) 12
(44) 4 (15) 3.4 ± 0.9
19. Should include a discussion of costs 13 (50) 5 (19) 8 (31)
3.5 ± 1.2
20. Should be disseminated as an Internet-based tool 17 (63) 8
(30) 2 (7) 3.7 ± 0.9
21. Should be disseminated as a DVD-based tool 15 (56) 8 (30)
4 (15) 3.6 ± 0.9
DVD, digital video disc; SD, standard deviation.
*1 = strongly disagree; 5 = strongly agree.
Table 3 Preferences for clinical use and content modification
Item N (%)
22. When would you want your patient to
view the decision aid:
Before initiating CRC screening discussion
(pre-visit)
21 (72)

After initiating CRC discussion (post-visit) 6 (21)
Both 2 (7)
23. Would you prefer the decision aid to
contain information about:
All of the recommended screening options 15 (52)
A more restricted list of options 12 (41)
No opinion 2 (7)
CRC, colorectal cancer.
31
(Table 2). Similarly, whereas 52% of providers
preferred that the decision aid include a discus-
sion of all of the recommended screening
options, 41% preferred a more restricted list of
options and 7% had no opinion on the issue

(Table 3).
Only seven providers made suggestions for
improving the current decision aid. These
included creating non-English versions of the
tool (n = 2), clearly distinguishing colonoscopy
as the best screening option (n = 2), enabling
patients to print out their preferred screening
option (n = 2), and taking into consideration
that patients may not have access to the Internet
at home if the decision aid was to be dissemi-
nated as a web-based tool (n = 1). There were
no complaints.
Discussion
Decision aids are evidence-based tools that
enable patients to make informed, value-con-
cordant choices, but the extent to which such
tools facilitate SDM from the perspective of the
provider is less well established. In an effort to

gain new insight into the issue, we conducted a
survey of primary care providers participating in
a clinical trial evaluating the impact of a novel,
DVD-formatted decision aid on SDM and
adherence to CRC screening. Our study finds
that a majority of providers perceived that the
tool was a useful, time-saving adjunct to their
usual approach to counselling about CRC
screening and increased the overall quality of
decision making. Moreover, providers also felt
that review of the tool just prior to a scheduled
office visit was an appropriate use of patient�s
time as it enabled the patient to make an
informed choice among the different screening
options. Together, these findings suggest that
much of the tool�s perceived utility was related
to its ability to better prepare patients for the
screening discussion outside of the clinical
encounter and, in so doing, increased both the

efficiency and quality of the interaction.
Few studies have explored provider perspec-
tives on the utility of decision aids for improving
SDM. A trial by Green et al. evaluating the
effectiveness of genetic counselling vs. counsel-
ling preceded by use of a computer-based deci-
sion aid for breast cancer susceptibility found
that although there were no significant differ-
ences in perceived effectiveness, use of the tool
saved time and shifted the focus away from basic
education towards a discussion of personal risk
and decision making.
17
A second study by Sim-
inoff et al. found that a decision aid for breast
cancer adjuvant therapy facilitated a more
interactive, informed discussion and helped
physicians understand patient preferences.
13

Similarly, Brackett et al. also found that pre-
visit use of decision aids for prostate and CRC
screening was associated with greater physician
satisfaction, as it saved time during the visit and
changed the conversation from one of the
informational exchanges to one of the values
and preferences.
18
A fourth study by Graham
et al. explored provider perceptions of three
decision aids prior to their actual use.
15
Although responses were based on perceptions
alone and not on clinical experience, their find-
ings were similar to our own. A majority agreed
or strongly agreed that the decision aids could
meet patients� informational needs about risks
and benefits and enable patients to make
informed decisions. Similarly, although many

felt that the decision aids were likely to com-
plement their usual approach, responses were
more neutral when asked about the overall
impact of the tools on the quality of the patient
encounter, patient satisfaction and issues related
to implementation. The most striking difference,
however, was that relatively few of the respon-
dents in the study by Graham et al. felt that use
of the tool saved time, which could be a reflec-
tion of either the complexity of the decisions
under consideration and ⁄ or the lack of explicit
instructions regarding how the tools were to be
used with respect to the timing of the interven-
tion and ⁄ or need for provider involvement.
Our findings also corroborate a more exten-
sive body of literature on barriers to the imple-
mentation of decision aids into clinical
practice.
14
Even though our study design cir-

cumvented many of the barriers related to
workflow, accessibility and costs, only 48% of
32
providers felt that actual implementation of the
decision aids into their practices outside of the
context of a clinical trial would be easy. Based
on their feedback, however, most preferred that
the tool be used prior to initiating the screening
discussion rather than after initiation of the
discussion. Moreover, regardless of the timing, a
majority preferred that the tool be used in the
office rather than at home. Although it is quite
possible that their preferences reflected their
personal experiences with our study protocol,

Brackett et al. also found that pre-visit use was
preferred over post-visit use.
18
One of the most commonly cited barriers to
implementation of SDM is the time requirement.
Although studies to date have provided con-
flicting data regarding the impact of decision
aids on consultation time for other condi-
tions,
17–22
we postulated that by educating
patients about the risks and benefits of the dif-
ferent screening options and facilitating IDM
prior to the provider–patient encounter, our
decision aid would have the potential of
improving the efficiency of SDM and thus save
time, as noted by Green et al. and Brackett
et al.
17,18

We found that although a majority of
providers agreed or strongly agreed that pre-visit
use of the tool saved time, 21% were neutral on
the issue and 14% disagreed or strongly dis-
agreed. It is conceivable that this diversity of
opinion might be a reflection of the extent to
which provider and patient preferences agreed or
disagreed. In instances where there was concor-
dance between preferences, as was often the case
that since colonoscopy was preferred by major-
ity of both patients and providers,
16
one would
expect that the time required for deliberation
and negotiation would be substantially shorter
than in situations where there was discordance.
Alternatively, these differences might reflect
differences in case mix with respect to patient
factors, such as literacy level or desired level of

participation in the decision-making process.
A secondary objective of our study was to
elicit provider feedback regarding content and
format preferences to gain insight into potential
modifications that might enhance future uptake.
Because of an ongoing debate in the CRC
screening literature,
23–27
we focused on content
issues related to cost information and number of
screening options to include in the decision aid.
Both questions elicited a divergence of opinions.
Whereas nearly 50% of respondents felt that
cost information should be included, the
remainder was either neutral or opposed to its
inclusion. Similarly, when asked about the
number of screening options to include, �50%
preferred the full menu of options and �40%
preferred a more limited menu. This diversity of

opinion highlights some of the key challenges in
designing tools with broad dissemination
potential. In the light of recent evidence sug-
gesting that the number of screening options
may influence test choice but not interest in
screening and that the importance of out-of-
pocket costs declines as the number of screening
options discussed increases,
26
one approach
would be to develop one tool that presents the
full menu of screening options without cost
information and a second that includes a more
limited set of options with cost information. A
more appealing approach would be to develop a
more comprehensive tool that includes both the
full menu of options and cost information in a
format that permits navigation so that patients
could tailor their use to fit their own informa-

tional needs and ⁄ or recommendations of their
provider. Internet-based tools are ideally suited
for this purpose but, as noted by several par-
ticipants in our study, access remains a potential
barrier for a sizeable, albeit declining, propor-
tion of the target population. Providers in our
study felt that both Internet- and DVD-for-
matted tools were viable options for dissemina-
tion, even though the DVD-formatted tool
offers less navigation potential.
Our study has several notable limitations.
First, the survey was conducted among primary
care providers at only two institutions, and
hence, the findings may not be generalizable to
providers in other health care settings. It is
noteworthy, however, that the study was con-
ducted among a diverse patient population with
respect to both race ⁄ ethnicity and educational
status.

16
Second, as participating providers
never formally reviewed the decision aid, we
33
were unable to assess their opinions with respect
to actual content or format. Third, the content
of our survey instrument did not allow us to
tease out the extent to which use of the decision
aid impacted on individual steps of the SDM
process.
4,5
Even though satisfaction with the
decision-making process was universally high
among patients participating in the clinical
trial,

16
especially those in the intervention
groups, only a relative minority of providers felt
that use of the tool helped them tailor their
counselling about CRC screening to their
patients� needs or increased patient satisfaction
with their care. Fourth, the anonymous nature
of our survey precluded any attempt to correlate
response data with exposure rates. It is con-
ceivable that the perceptions of providers
exposed to multiple patients in the intervention
arms might differ from those exposed to only a
few patients. Lastly, we cannot rule out the
possibility of social response bias, whereby
respondents may have felt compelled to offer
more positive responses than they actually
believed.
In conclusion, our study finds that a majority
of providers perceived that pre-clinic use of our

decision aid for CRC screening was a useful,
time-saving adjunct to their usual approach to
counselling about CRC screening and increased
the overall quality of decision making. Never-
theless, many of the providers felt that imple-
mentation of the decision aid into their practices
outside of the context of a clinical trial would be
challenging, thus highlighting the need for cost-
effective strategies for addressing provider,
practice and organizational level barriers to
routine use. We speculate that Internet-based
tools with enhanced navigation functionality
have the greatest dissemination potential, as
they offer a feasible, low-cost solution to many
of the structural barriers to implementation, as
well as a way to reconcile the diversity of opin-
ion related to content.
Acknowledgement

None.
Conflicts of interest
The authors have no conflict of interests.
Funding
This study was supported by grant RO1
HS013912 from the Agency for Healthcare
Research and Quality.
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35
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individual use.
Needs Assessments
Leslie M. Tutty and Michael A. Rothery

N
eeds assessments are a form of research conduclcd to gather
information
about the needs of a population or group in a community. One
of the
more practical types of research, needs assessments are used to
develop
new services or to evaluate the relevance of exist ing programs.
They may
also be used to establish a need to revise or create policy.
Th is chapter begins with a definition o[ needs assessment, how
we define "needs:' and
how we determine who to ask about needs. Common
methodological approaches to
needs assessments are described and evaluated using examples p
rimarily from the social
work literature. The benefits of triangulation, or using more
than one source or method
of gathering information, are presented, followed by a
discussion of who shou ld digest
and weigh inform at i.on about needs once the information is ga
thered. Finally, we consider
the importance of developing a plan to implement
recommendations so that the work of
assessing needs is used to clients' benefits, not relegated to the
shelves occupied by other
dusty and neglected reports.
What Is a Needs Assessment?
Needs assessments have not changed much over the years. In
1982, Kuh (cited in Stabb,
1995) listed five general purposes commonly served by needs
assessment research that
remain relevant today:

l. Monitoring stakeholders' perceptions of various issues, which
can guide the devel-
opment of new programs or policies
2. Justifying existing policies or programs
3. Assessing client satisfaction with services
4. Selecting the most desirable program or policy from several
alternatives
5. Determining if needs have been met, a purpose closely akin
to program evaluation
Two key questions are addressed when needs <1ssessments are
undertaken: "Who?" and
"IIow?" The "who" question requires the researcher to be dear
about the membership of
the group whose needs are to be assessed. Often, a study entails
gathering information
from a variety of respondents, from individuals who may never
have been clients to those
149
150 PART II • QUAII.TITATIVE APPROACHES: TYPES OF
STUDIES
receiving multiple services. In almost every case, however, at
least one set of respondents
will be the individuals who are most immediately affected by
gaps in services or supports,
rather than relying solely on the opinions of service providers,

academics, or funders.
The "how" question addresses the methods used to gather
informa tion from the group
whose needs are of interest. These are not unique; rather, needs
assessments borrow
familiar techniques such as surveys, interviews, and focus
groups, all of which are high-
lighted in other chapters in this book. Quantitative methods
such as surveys or standard-
ized measures may be used, as may qualitative methods such as
in-depth individual
interviews or focus groups. Combinations of both arc
increasingly popular since each
method has its advantages and limitations.
Defining Need
When we invoke the concept of needs, we may easily assume
that we share with others a
common understanding of what it is we are talking about.
However, it is worthwhile look-
ing more closely at the definition of the term since useful
characteristics and distinctions
are highlighted when we do so.
The concept of need is not new: Researchers have been defining
and redefining the
term for decades. Stabb (1995) distinguishes between met and
zmmet needs. "Met
needs are necessary or desirable conditions that already exist in
actuali ty. Unmet needs
arise when there is a discrepancy between desirable conditions
and current actuality"
(p. 52). Both met and unmet needs could conceivably become
the focus of needs assess-
ment research, although unmet needs will be the main concern

in the vast majority of
cases.
A different distinction (perhaps more useful for our purposes) is
provided by Witkin
and Altschuld (1995), who define a need as "a discrepancy or
gap between 'what is,' or the
present state of affairs and vhat should be; or a desi red state of
affairs" (p. 4). In this
analysis, needs equate with unmet needs, the most common
focus fo r needs assessment
research. Revere, Berkowitz, Carter, and Ferguson (1996) add
the suggestion that need is
defined by "community values, [and is) amenable to change" (p.
5).
From these perspectives (and with reference to considerations
introduced earlier), a
needs assessment gathers information about gaps between real
and ideal conditions, the
reasons that these gaps exist, and what can be done about them,
all within the con text of
t.he beliefs of the community and available resources for
change.
Another distinction introduces the question of degree. Some
needs are stronger or
more important than others. f undamental needs with relevance
to people's survival,
safety, or basic comforts are not the same as "wants" or less
compell ing needs. A social
work professor's desire for a week in Mexico as a break from
winter is qualitatively very
different from a homeless person's need for food and shelter in
the face of the same cold
conditions. While it is often difficult to draw the line between

relatively important needs
and less important wants, it is still important to do so. Needs
assessments are focused on
needs that affect ind ividuals' abilities to function well in
important areas of their lives.
Wants associated with perceived quality of life (but not to the
same extent with life's real
essentials) are more lhe purview of market research.
Social workers generally find Maslow's (1970) hierarchy of
needs useful when consid-
ering the needs and priorities of their clients. It is also a
framework that can inform needs
assessments. Maslow's five levels of need are physical and life-
sustaining needs (such as
air, water, food, warmth, and elimination of bodily wastes),
physical safety (e.g., protec-
tion from physical attack and disease), love and support, self-
esteem and self-worth, and
self- realization (e.g., needs to be productive and creative) .
Maslow contended that these
CH APTER 9 • N EEOS A SSESSMENTS 151
basic needs must be attended to before attempting to address
higher level needs (or
"wants"). Needs assessments can gather information relevant to
any one or more of these
five levels, but the hierarchy of priorities provides useful cr
iteria fo r deciding on what to
focus first in data collection and recorn mending changes.
Finally, some authors argue that once an "expressed need" is
verbalized, it becomes a

want or a demand (Stabb, 1995) . This is not the same as
differentiating needs from wants
on the basis of the strength of the potential impact on someone's
well -being and is prob-
ably less useful for our purposes. However, a related point is
noteworthy: Verbal demands
are not always the direct expression of need. Just because
someone expresses a want does
not mean that it represents a need. Thus, in needs assessments,
it is important to gather
information from members of a population beyond those
publicly advocating for specific
demands.
Who Do We Ask About Needs?
The term stakeholders is often used to refer to clients or
potential clients or the people who
actually n-perience the need thal is being studied. However,
Revere and colleagues (1996)
suggest broadening the definition to refer to "service providers
and management, com-
munity members, certain politicians, the funding source,
business/trade associations and
the actual research •..vorkers" (p. 7) since each of these has a
vested interest in the study and
its outcomes. Th is flex[ble use of the term is helpful,
suggesting a range of potential
sources of data and recognizing that needs assessments have
ramifications for people
beyond those normally surveyed .
Needs assessments traditionally look to three groups as sources
of data: the target group
(i.e., clients or potential clients), key informants such as
community leaders or service
providers, or a sample of aJI members of the relevant comm

unity. Each is described in more
detail below.
The target group or populatio11 comprises the very individuals
about whom we arc con-
cerned and whose needs we wish to assess. Common sense
suggests that these are the
voices we most wish to listen to in our quest to gather the best
and most current infor-
mation. However, engaging with individuals to encourage them
to share their needs and
opinions is not always easy. Highly disadvantaged, socially m
arginalized individuals and
groups, the typical focus of social workers' interventions, are
nol always accustomed to
being asked their opinions and may not easily articulate their
needs to a researcher when
invited to do so. Furthermore, they may have understandable
reasons for not trusting
members of those who have more power in society, a group to
which researchers belong.
Consider the homeless as an example, especially the
subpopulation that has been diag-
nosed with psychiatric disorders. With any such group, the
researcher cannot simply
approach and invite them to enumerate Lheir needs. Strategies
(and time) for building
trust, rapport, and for encouraging engagement in the research
process are prerequisites
for successful data gathering.
McKillip (1998) defines another group serving as a common
source of data, key infor-
mants, as "opportunistically connected individuals with the
knowledge and ability to
report on community needs. Key info rmants arc lawyers,

judges, physicians, ministers,
minority group leaders, and service providers who are aware of
the need and services per-
ceived as important by a community" (pp. 272- 273). An
advantage of gathering data
from key informants is that they may have a broader knowledge
of serv ices available in
the community than the target population, and they may be
better at articulating what
needs must be effectively addressed. One disadvantage is that
key informants sometimes
have a vested interest in developing new services or preserving
established resources even
152 PART II • Q UANTITAIIVE A PPROACHES: T YPES OF
STUOIES
though they arc less than adequate (we all develop loyalties, and
these can affect our judg-
ment). McKfllip (1998) also notes that key informants may
underesti1nate the willingness
of members of the target population to participate in programs
while overestimating the
extent of the problems.
The third group, community members, comprises the entire
citizen ry of a comm unity.
This group encompasses members of the target population but
also includes those not
directly affected by these needs. Approaching community
members for information has
the advantage of identifying how broadly based the needs are,
rather than assuming that
they are restricted to the target population. lt also offers the

opportunities to learn about
how needs (and the strategies Lo ameliorate them) are perceived
in the community at
large and to think about how that v.rill affect efforts to
implement changes. A disadvan-
tage, though, is that community members m ay be relatively
t111awarc of the needs of its
more marginalized citizens.
In summary, each of these groups may be the focus of the needs
assessmen t methods
documented in the next several sections. The choice of whom to
engage may be based on
access to the group or limitations of tin1e and resources. If
possible, representation from
each of the target population, key community stakeholders, and
members of the general
public is worth considering as each provides valuable but
somewhat different information.
Methods of Needs Assessment
As mentioned previously, one ca n conduct needs assessments u
sing a variety of strategies.
We will d£scuss methods in lwo broad categories, quantitative
and qualitative.
Quantitative methods gather data that are translated into
numerical form and described
using statistics. Using such methods, it is possible, for example,
to conclude that in a sam-
ple of 102 shelter residents, 70.5% of these women abused by
intimate partners were
abused themselves as children and described 73.7% of their par
tners as also having been
abused (Tutty & Rothery, 2002). Such high proportions may be
interpreted as suggesting

the need for early in tervention with children in shelters in the
hope of preventing the
cycle of violence from affecting a new generation.
Providing statistics about the extent of a need can be a powerful
method of raising
awareness of the severity of gaps in services. The section on
quantilative needs assessment
will describe three such methods: surveys, s tandardized needs
assessment measures, and
using existing statistical databases.
In cont rast, qualitative needs assessments ask questions that are
more open-ended and
allow the research info rmant to describe in detail the
complexities of the issues at hand.
for example, a qualital ive needs assessment conducting in
terviews with another group of
,63 abused women residing in a shelter noted that providing for
their basic needs such as
safety and food was of great importance (Tutty, Weaver, &
Rothery, 1999) . However, some
women expressed concerns about the fact that a few residents
were difficult to live with,
and some mothers did not m anage lhcir children's aggressive
behavior or ignored them.
These results suggest a somewhat different focus for
intervention by crisis counselors and
the need to provide parenting programs for some residents.
Results from qualitative needs assessments often lack s
tatistical dat a that could convey
the extent of the problem, but they tend to be rich in detail that
conveys the complexities
and uniqueness of the experiences of different individuals. The
quali tative needs assess-

ments methods described in the chapter include interviews
(either face-to-face or by tele-
~!1~ll~h f8EU~ KrGUp~. nomtm1 groupg, ~nd t CMh halt
meetings.
CHAPTER 9 • NEEDS ASSESSMENTS 153
Quantitative Methods of Needs Assessment Surveys
Allhough surveys may ask open-ended qualitative questions, the
great majority are devel-
oped for quantitative data analysis. Quantitatively oriented
surveys, particularly those
employing questionnaires, are the most frequent method of
assessing needs. The tasks
involved in developing a survey to assess needs are identical to
those undertaken when
surveys arc developed for other purposes, so they will not be
detailed here. The major
steps involve
1. Deciding who Lo survey (e.g., target groups, key informants)
2. Selecting a method of sampling (e.g., random or systematic
sample)
3. Determining the content of items (through reviewing the
literature or holding
focus groups with key informants, as only two examples)
4. Choosing what type of question to use (e.g., open-ended,
multiple choice, or scaled
with respect to the extent of agreement)

5. Selecting a method of distribution (e.g., the Internet, mail, or
telephone)
The advantages of surveys include the ease and flexibility with
which they can be
administered compared to other methods and the relative lack of
expense to collect a con-
siderable amount of data. Disadvantages include the extent to
which a set questionnaire
can predetermine the issues that respondents address and the
consequent danger of not
hearing about needs that would emerge in a more open-ended
process.
With such risks in mind, Witkin and Altschuld (1995)
recommend being cautious about
assuming that a written questionnaire is the most appropriate
tool when considering con-
ducting a needs assessment. While a questionnaire can be an
important tool, they suggest
that it should not be used until after more exploratory methods
have been employed to
ensure that the factors measured by questionnaire items are as
well chosen as possible.
Furthermore, some cultural groups find surveys strange or
difficult (especially if
English is not one's first language) and respond negatively to
them. Weaver (1997), for
example, described a questionnaire developed to assess the
needs of an off-reservation
Native American community in an urban area. A large number
of questionnaires were
mailed out, with virtually no returns. The alternative of a
qualitative approach including
focus groups and individual interviews was adopted with

considerably greater success.
An example of a needs assessment that employed survey
methods more appropriately
is Brennan Homiak and Singletary's (2007) study that surveyed
Christian clergy members
from 15 denominations in central Texas with respect Lo their
perceptions of the number
in their congregation experiencing intimate partner violence and
what clergy needed to
better address this serious concern. Of the 100 surveys mailed,
44 were returned, a some-
what low but not unusual return rate for mailed surveys.
The clergy members estimated that less than IOo/o of their
congregation members
experienced partner violence--low when compared to incidence
studies in Texas that
cited lifetime rates of 47%. Only about one third of the clergy
had received domestic
violence-specific training; they were more likely to have
resource materials in their
churches and were familiar with local agencies and shelters for
abused women. While a
small proportion of the clergy considered themselves very
equipped to counsel victims of
domestic violence or make referrals, the majority did not. The
authors recommend that
social workers take the lead in offering training to assist the
clergy in promoting violence-
free congregations.
154 PART II • Q uANTilATIVE A PPROACHES: TYPES OF
STUDIE~

As mentioned previously, surveys may usc both check-lis t type,
predetermined
responses and open-ended questions that allow for m ore
context ual detai led responses
and arc analyzed using qualitat ivc methods. A recent example
of using open-ended ques-
tions is a survey with 206 agency-based social work field
instructors, querying their initial
awareness, personal and professional needs, and field issues
that arose in response to the
World Trade Center disaster of September lith, 2001. The field
instructors had clearly
been weary but retained sensitivity to studen t and client needs.
The results suggest the
importance of developing an integrated crisis plan to better link
the school, students, and
field instructors in the event of future disasters.
Standardized Needs Assessment Measures
A relatively new needs assessme11t methodology entails
developing stand ardized measures
to assess the needs of a specific population group. For example,
Wancata and colleagues
(2006) initially used focus groups and in depth individual
interviews to develop a mea-
sure comprising 18 common problems experienced by caregivers
of adults diagnosed
with schizophrenia. The difficulties were translated into items
such as "not enough infor-
mation on the illness, its symptoms and course," "fear of
stigmatization and discrimina-
t ion," and "burnout or illness of the carer."
Using such a measure in other needs assessment research has
the advantage of building

on the work that has gone into identifying and conceptualizing
potentially important
n eeds and of using a measure for whi ch reliabil ity and
validity will often have been estab-
lished. A possible disadvantage is that needs proven relevant to
caregivers of adults diag-
nosed 'l'ith schizophrenia in one location may not have the
same importance in others.
Conversely, items about other needs tha t are important in a new
loca le may be m issing
from the standardized measure.
Using Existing Statistical Information
Another quantitative method of conducting needs assessments is
using data that have been
previously collected. Existing data may be available in agency
fi les or governmen t data
banks, for example. Such secondary analyses have the
advantage of sparing researchers the
time and expense of gathering new data. A d isadvantage is that
one is lim ited to data that
someone else considered worth gathering, and potentially
important variables may be
absent or may need to be inferred indirectly from the data that
were recorded.
Reviewing case fil es can be challenging. As a follow-up to a
previously completed study
on the outcomes of a specialized domestic violence court
(Tutty, McNichol, & Christensen,
2008), we are using district attorney files to collect a number of
variables, including the
demographic characteristics of tbe accused and the victim,
whether the victims testified or
provided a victims impact statement to the court, and hov,, the
trial was resolved.

In contested cases, the files can be very large, literally inches
thick! The fi les are created
for the criminal justice system, not researchers, so there is no
consistent organization. As
such, collecting data from one file can take several hours.
Considerable information may
not be recorded. Lawyers are not necessarily as interested in
demographic characteristics
such as ethnicity or age as most researchers are, and so lit tle of
this can be found in the
files. Despite these challenges, if we are to evaluate the
specialized courts, paper flle
reviews are our only option to assess whether the courts are
meeting Lhe needs of both the
victims and the accused.
The following needs assessment used case records to assess
whether the needs of abused
and neglected children were adequately addressed by the child
welfare intervention. Tracy,
CHAPTER 9 • N EFDS A SSLSSMENTS 155
Green, and Bremseth (1993) reviewed case records of
supportive services for abused and
neglected children in one U.S. state. Five hundred child welfare
cases were sampled to
explore facto rs associated with decisions to offer one of two
services, family preservation if
children at risk were still at horne, or reunification fo r families
with children who had been
placed. The authors collected information on demographic
variables, presenting problems,

service history, service needs, services planned and provided,
service characteristics, and
service outcomes. This enterprise, the aLlthors noted, consumed
thousands of hours.
The analysis uncovered significant stresses affect ing the
children sampled, parental
substance abuse, economic difficulties, and poor living
conditions, which were infre-
quen tly addressed in case plans, whi ch emphasized indications
of child abuse. The
authors conclutled that "there was little one-to-one d irect
correspondence between the
service need and the service offered" (Tracy eL al., L993, p.
26), raising serious questions
about the quality of service planning (and the training of child
welfare workers).
Qualitative Methods of Needs Assessment
Qualitative needs assessment research may be conducted via
individual interviews, small
group discussions, or even large town hall meetings, each of
which allow for more open
exploration of issues than the quantitative methods previously
outlined. Such studies
tend to involve a greater t ime commitment from respondents
but offer much more
opportunity to identify and discuss issues in depth.
Individual Interviews
Face- to-face and telephone interviews are one method of
gathering in-depth information
about the needs of particular groups. Preparation involves
thinking through the purpose
of the interview, constructing an interview schedule, and train

ing interviewers (Vitkin &
Ahschuld, J 995). When a good rapport develops between
interviewer and respondent, the
result can be disclosure of information and ideas about sensitive
issues that would not
emerge when more formal, structured approaches are used.
Also, in a more open-ended
process, respondents may identify needs that no one had
anticipated.
The disadvantages of this approach include the fact that it is
notoriously labor intensive.
Interviews arc time-consuming to conduct, often lasting one to
two hours, especially if
asking individuals to reveal their personal stories. As a result,
often only a relatively small
sample of individuals may or can realistically be interviewed.
Training the interviewers also
takes time, and the job of transcribing and analyzing interviews
is normally a lengthy, com-
plex task. The following needs assessment is an example of
using face-to-face interviews.
In the past 30 years, intimate partner violence has become an
issue of significant soci-
etal concern, resulting in specialized justice and physical and
mental health shifts to more
adequately safeguard the women and children who are the
primary vict ims. Yet certain
ethnocultural groups, including immigrants and refugees, are
underrepresented among
those seeking assistance from formal supports such as the police
and emergency shelters.
With respect to the question of what would constitute culturally
appropriate responses

to domestic violence, Pan ct al. (2006) conducted 120 face- to-
face interviews with
members of three ethnic communities in San Diego: Somali,
Vielnamese, and Latino. The
interviews were provided in the appropriate language, and
within each cultural group,
10 women, 10 men, 10 boys, and 10 girls participated.
Because of tl1e sensitive nature of the issue, the topic of
domestic violence was intro-
duced using vignettes, rather than asking interviewees whether
they had personally been
abused. This allowed the respondents to speak about abuse in
their culture in more gen-
eral terms and to suggest possible resolutions to the problem.
156 PART II • QUANTITITIVE APPROACHES: TYPES OF
STUDIES
The analysis of the interviews highlighted six core issues,
including "varying defmi-
tions of violence, specific definitions of family harmony, strict
gender roles, varying con-
flict resolution strategies, cultural identity and spirituality"
(Pan et al., 2006, p. 42) . The
differing perspectives from the three ethnic communities
suggested the need to develop
diverse culture-specific services.
Focu s Groups
Focus groups are relatively unstructured small group
experiences, typically with about 8
to 12 participants. The group composition is usually

homogeneous in that members share
a particular experience or interest, like the members of what we
described earlier as the
target population. Focus group interviews typically take from
one and a half to two and a
half hours, and a number may be conducted for a given study.
Witkin and Altschuld ( 1995) summarize the process of a typical
focus group. Initially,
members hear a general statement of the purpose of the session
and are given a question
related to this purpose designed to elicit perceptions about
important needs. Often, par-
ticipants are asked to write down the ideas that the question
stimulates and then to share
them with the group. The leader typically writes ideas as they
are shared, summarizing
them and making sure th at there is agreement among members
with what is being
recorded. This process is then repeated with other
predetermined questions.
Leadership is important to a focus group's success, especially
since there is no highly
structured agenda (except for the posing and answering
questions aspect). According to
Witkin and Altschuld (1995), "The leader must be
nonjudgmental, create a supportive
group atmosphere, be able to keep the interview process going,
be a good listener,
and be alert to sense when a group is deviati ng from the
prescribed question route in
meaningful and non-meaningful directions" (pp. 172-173).
These are by no means easy
demands.

One advantage of group approaches over individual interviews
can also be a disadvan-
tage. Whi le participants do not have the same opportunity to
explore their own perceptions
or experiences in depth as in individual interviews, a group
approach can elicit information
that would not emerge without the stimulus of i nterC~cting
with others and reacting to their
ideas. When group discussions detour in innovative ways, this
may lead to original and cre-
ative ideas. Brainstorming, or encouraging members to present
any solution to a problem
without prejudging it, is one way to encourage such innovation.
Alternatively, without effec-
tive facilitation, the groups may pmsue unproductive tangents,
and there is a heightened
risk of interpersonal conflict detracting from the effectiveness
with which research goals are
pursued. The following study used focus group methodology.
A relatively new role for sociaJ work graduates is working with
seniors and their
ramilies to assist these clients in a number of ways. Yet, how
readily are social workers per-
ceived as resources to this population? Naito-Chan, Damron-
Rodriguez, and Simmons
(2004) used focus groups to explore what skills social work
practitioners need to ade-
q uately address the Heeds of older persons and their families.
The four focus groups
included older adults and caregivers of older adults (consumers)
as well as providers of
care and recent social work graduates, both working in
gerontology settings.
Notably, the analysis highlighted that a number of the

consumers had little under-
standing of how social workers could assist them. Key among
the consumer needs was
resource finding, which the consumers did understt~nd as a
social worker role. However,
other social work competencies such as assessments and case
management were not men-
tioned by the consumers. The results suggested the need for
public education abo ut the
roles of social workers in the field of aging.
CHAPTER 9 • NEEDS AsSESSMENTS 157
Nom i nal Groups
An alternate group approach to needs assessment has been
developed (McKill ip, 1998).
Nominal groups are more structured than focus groups: The
agenda allows group discus-
sion but with a more consistent attention to the goal of
achieving consensus about needs.
Fewer needs assessments that use a nominal group approach can
be found in the litera-
ture. Although more than a decade old, the following study
provides a model of nominal
groups with respect to issues that remain current.
It is com monly acknowledged that interpersonal and social
problems, whether at
home, in the neighborhood, or on school grounds, can seriously
affect students' abi lity to
learn. Gerdes and Benson ( 1995) used a nominal group process
Lo assess problems expe-
rienced by inner-city African American schoolchildren. The

goal was to identify the most
serious problems faced by students from their own perspectives.
The authors used a strat-
ified random sample of students from Grades 1 to 9 who were
assigned to groups based
on whether they were from primary grades (l-3), middle grades
(4-6), or junior high
grades (7-9). Ninth-grade students who had experienced the
nominal group process
acted as facil itators.
The group members were first asked to list the problems that
they faced at school on a
sheet of paper. Using a round-robin format, every student
identified one problem, adding
a new item to a list on a flip chart, until it was agreed that the
list was complete. From this
list, each student identified the seven most serious problems and
rated their severity. The
facilita to r then calculated the group ranking of the items.
The 1·ankings of concerns varied across the d ifferent age
groups. Fighting and prob-
lems with teachers were priority issues for Grades 1 to 3,
fighting and drugs were the most
serious to Grade 4 to 6 students, and pregnancy, drugs, and drug
deals were the strongest
concerns for the junior high students.
Teachers from the studen ts' schools also participated in
nominal groups, registering
additional concerns about student issues such as low parental
support, parental problems,
and lac.k of mot ivation. Both students and teachers expressed a
sense of powerlessness in
addressing the problems that they were identifying. While the

nominal group iden tified
needs very effectively and in a way that encouraged partnership,
it was but the first step in
the process of change.
Community Forum Approach
Large open public hearings or community forums may be used
to g<1ther information from
the diverse individuals comprising a community whose needs
are being assessed (McKillip,
1998). Similar to a town hall meeting lasting for several hours
with large numbers of par-
ticipants (sometimes 50 or more), this method aims to ensure
thaL the b roadest possible
sampling of opinions results in a data set reAecting a
community consensus regarding the
issues being scrutinized. Clearly, this approach aims to give a
voice to all community
memhers, including many who are immediately affected by the
problems of interest.
Witkin and Altschuld (1995) note tha t special leadership skiJJs
are vital to the success
of this approach. Not everyone has the skills to facilitate large
meetings that encourage
group members to participate actively and trust that they can
openly share ideas that may
be different from the majority view.
The advantages of community forums include the fact that they
arc a relatively inex-
pensive way to hear from large numbers of interested
individuals. Another advantage is
that pubHc meetings serve to sensitize lhc general public to the
problems or to highlight

potential resistance to proposed solutions. Also, engaging a
cross section of community
158 PART I I • QUAN TITATIVt APPROACHES: TYPFS or
SIUDIES
members may have valuable secondary benefits. For example,
when the time comes to
implement recommendations, important people may have bought
into the changes being
suggested.
A primary disadvantage to this method is that there is no means
of ensuring rhat the
participants are a representative sample of their community.
lndeed, this will normally
not be the case: The ideas and perceptions collected will be
those of people who, for some
reason, are motivated to influence what happens. Citizens who
are less interested will not
attend and will not be heard, even though they may have
reactions to the needs being
assessed and the eventual recommendations for dealing with
them.
reeds assessments using a community forum approach were
rarely described in the
literature. The following study is an in triguing model of using
the forum t·o both present
the results of a previously conducted needs assessment to the
research respondents, which
subsequently used the forum to further refine and develop
action plans arising from the
initial study.

The author included a community forum as one aspect of a
study of the relative con-
tribution of social class and ethnicity Lo the differential
functioning of Puerto Rican
elders in Springfield, Massachusells. The first phase of the
study consisted of individual
interviews with 591 elders. The purpose of the community
forum was both to present a
number of the research respondents with the interview results
and to ask subsequent
questions. A total of 41 elders participated in the fo rum.
The forum discussion questions grew from the quantitative
survey findings. Two of the
five forum questions were, "Why are cultural support systems
not playing a mo re active
role in helping elders with their needs?" and "Why are churches
not playing a more active
role?" The author highlighted the extent to which the forum
participants assisted in inter-
preting the previous quantitative needs assessment findings,
resulting in rccom menda
tions that fit closely with this unique and previously
marginalized community.
Triangulation of Needs Assessment Information
To obviate risks of bias from using limited sources of
information, Yegidis, Weinbach, and
Morrison-Rodriguez (1999) recommend "triangulating" or
"collecting data from three
(or more) sources, each having different perspectives!' Witkin
and Altschuld (1995) argue
for this step more strongly, suggesting that studies using only
one method should be con-
sidered seriously flawed.

'lo illustrate, suppose one is researching the need in a
community for a shelter for
women. One could condu ct a survey of key informants (social
workers, the police,
women's organizaLions, self-help group leaders, etc.), host a
community forum, and per
form a secondary analysis of existing data in police and social
service agency files about
the incidence of women requiring shelter. Congruence in the
perceptions obtained from
each study aspect would clearly represent a stronger case than if
only one source was
accessed. rr the results contradict each other, however, the
researcher has the difficult task
of assessing which set of perceptions enjoys Lhe greatest
credibil ity.
A number of the examples provided in this chapter illustrate the
use of more than one
m ethod of data collection. An assessment of the health needs of
transgendered individu-
als in Philadelphia (Kenagy, 2005) is a case in point.
Transgendered individuals have or are in the process of
undergoing medical proce-
dures to change their gender. Wbile this process entails
considerable involvemen t with
the medical system, it is not clear what health needs
transgendered people experience
C HAPTER 9 • NEEDS A SSESSMENTS 159
afterwards. Kenagy (2005) used face-to-face interviews or self

administered mail surveys
with 182 individuals (1 13 male-to-female and 69 female-to -
male individuals).
The responses to queries about health needs were primarily
concerns with respect to
HIV/AIDS status {6% were HIV positive), risk ofHIV infection
or rein fection (60% had
engaged in unprotected sex within the past year), suicide (30%
had attempted), their
experiences of violence (54% had been forced to have sex; 52%
had been physically
ab used), and access to health care (about two thirds had a
doctor or primary care physi-
cian). Importantly, though, more than one quarter of the
informants had been refused
medical care because they were transgendcred. The results were
used to argue the need for
prevention services specific to the transgendered population.
It is n ot uncommon for various constituents to have different
views about needs. As
noted by Revere et al. ( 1996),
It is relatively easy to decide that a starving man needs food or
a homeless person
needs shelter. But what if an assessment points to areas of need
that are not
acknowledged by the individuals themselves, who may believe
they need something
else altogether? What if the target population and the service
providers in the com-
munity recognize different areas of need or disagree as to what
will best meet that
need? (p. 4)

For example, a needs assessment standardized instrument was
developed by M. Carter,
Crosby, Geertshuis, and Startup ( 1996) to assess the needs of
people with a chronic
mental illness. Thiny-two questions measured perceptions as to
whether clients needed
assistance with a variety of tasks and issues, such as shopping
and cooking, family
relationships, making use of spare time, and motivation.
Two forms were developed, one for clients and one for staff
members, so that the
perceptions of the clients and the key informants could be
triangulated. The results
showed poor agreement between workers and clients on many
items, suggesting critical
differences in perceptions. The issue in such a case is not who
to believe but how to
address the discrepancies so that they do not negatively affect
services.
Another sense in which discrepancies can be problematic has lo
do with who priori-
tizes needs once they are identified. How and whether research
results get used is often a
political decision, and different social issues are given
importance al different times.
For example, child abuse has existed throughout recorded
history, but its perceived
importance as a problem varies considerably over time and
place, and the resources avail-
able to reduce it and ameliorate its effects fl uctuate as well.
Over the past several decades, we have come to recognize the
surprisingly large number
of children who have been sexually abused. Identifying this

problem entailed measuring its
prevalence and also clarifying Lhe needs of child victims, for
child welfare intervention and
psychotherapeutic help and so on . As these efforts absorbed
scarce research resources, some
have argued that our push to assist sexual abuse victims has
been given such a strong prior-
ity that we have not attended sufficiently well to the needs of
other mistreated children,
those who are neglected or who witness violence between their
parents, for example.
Implementing the Results of Needs Assessments
Although needs assessments are, by defini tion, research with
practical implications,
ensuring that the results are implemented is freque ntly
challenging. Several issues are part
160 PAin II • QuANTITATi v~ API'ROACHES: TvPes Ol·
STuDIES
of this general problem. First, the results must be presented in a
form in which the sug-
gestions and how to implement them are clearly outlined. This
has been problematic in
the past, as C. Carter ( 1996) noted in her review of needs
assessments from the late 1970s
through 1989. She found that, while authors usuaHy detailed the
research process, they
offered few suggestions about how to carry out the required
changes. Second, Carter
observes that researchers often write for other academics.
Important as the academic

audience is, with needs assessments, the people we want to
i.nlluence with our work
include service providers, policy makers, and the target
population. These groups may
require a report different from professors and their students.
The organization of mater-
ial and the style of presenting findings and recommendations
should be sensitive lo the
likely interests and priorities of nonacademic readers.
Researchers might even consider
writing more than one report, in the interests of effective
communication with diverse
audiences.
Amodeo and Gal (1997) recommend another strategy for
facilitating utilization of needs
assessment research, which is to involve the sponsor
organi7.ations in all steps of the study.
T his ensures that the sponsor is knowledgeable about the
research and committed to fol-
lowing it up effectively. In their discussion of this theme,
Amodeo and Gal propose that
researchers should allot a generous amount of time after data
collection to help the spon-
sor agency digest the findings and plan a response Lo them.
Conclusions
The examples we have offered illustrate that needs assessments
are a practical research
method with vast potential usefulness to social work. The
results can be especially mean-
ingful in our work because they document the needs of people
experiencing problems,
rather than addressing the more esoteric interests of social
scientists bent on testing or

developing theory. Needs assessment can raise important
questions, identify what aspects
of services or policies are useful, indicate what needs to be
improved, and highlight gaps
or misapplica tions of services. The results can challenge us in
the same ways that all good
J"escarch does, inviting us to test our assumptions against
evidence gathered from the
clients and wmmunities we serve, changing our beliefs and
interventions in beneficial
ways as a result.
References
Amodeo, M., & Gal, C. (1997). Strategies for ensuring use of
needs assessment findings:
Experiences of a community substance abuse prevention
program. journal of Primary
Prevention, 18, 227-242.
Brem1an Homiak, K., & Singletary, J. E. (2007). Family
violence in congregalions: An exploralory
study of clergy's needs. Social Work and Christia11ity, 31, 18-
46.
Carter, C. (1996). Using and communicating findings. In K.
Revere, S. Berkowitz, C. Carter, &
C. Ferguson (Eds.), Needs assessment: A creative and practical
guide for social scientists (pp. 185- 20 l ).
WashinglOn, DC: Taylor & Francis.
Carter, M., Crosby, C., Ge('rtshuis, S., & Startup, M. (1996).
Developing reliabili ty in clienL-ccntered
mental health needs assessment. Journal of Mental Health, 5,
233-243.

CHAPTER 9 • NEEDS ASSESSMENTS 161
Gerdes, K. E., & Benson, R. A. (1 995). Problems of inner-city
schoolchildren: Needs assessment by
nominal group process. Social Work in Education, 17, 139-147.
Kenagy, G. P. (2005). Transgender health: Findings from two
needs assessment studies in
Philadelphia. Health artd Social Work, 30( 1 ), 19- 26.
Maslow, A. ( J 970) . Motivation and personality. New York:
llarper & Row.
McKillip, J. (1998) . Needs analysis: Process and techniques. fn
L. Sickman & D. Rag (Eds.),
Handbook of applied social research methods (pp. 261 284).
Thousand Oaks, CA: Sage.
Naito-Chan, E., Damron-Rodriguez,}., & Simmons, W. (2004).
Identifying competencies for geri-
atric social work practice. journal of Gerontological Social
Work, 43( 4 ), 59- 78.
Pan, A., Daley, S., Rivera, L. M., Williams, K., Lingle, D., &
Reznik, V. (2006). Understanding the role
of culture in domestic violence: The Ahimsa Project for Safe
Families. Journal for Immigrant
and Minority Health, 8(1 ), 35-43.
Revere, R., Berkowitz, S., Carter, C., & Ferguson, C. (
l996).lntroduction. Iu R. Revere, S. Berkowit7.,
C. C. Carter, & C. F. Ferguson (Eds.), Needs assessment: A
creative and practical guide for social
scie11t-ists (pp. 1-12). Washington, DC: Taylor & Francis.

Stabb, S. (1995). Needs assessment methodologies. In S. D.
Stabb, S. M. Harris, & ). E. Talley (Eds.),
Multicultural needs assessment for college and university
student populations (pp. 51-115).
Spri11gfield, IL: Charles C Thomas.
' tracy, E. M., Green, R. K., & Bremseth, M.D. {1993). Meeting
the environmental needs of abused
and neglected children: implications from a statewide survey of
supportive services. Social
Work Research & Abstracts, 29(2), 21 - 26.
Tutty, L., & Rothery, M. (2002). How well do emergency
shelters assist women and their children?
In L. TuLly & C. Goard (Eds.), Reclaiming self Issues and
resources for women abused by intimate
partners (pp. 25-42). Halifax, NS: Fernwood and Resolve.
Tutty, L M., McNichol, K. , & Christensen,}. (2008). Calgary's
Homefront specialized domestic vio-
lence court. In J. Ursel, L. Tutty, & }. LeMaistrc (Eds.), What's
law got to do with it? The la"~ spe-
cialized courts and domestic violence in Canada. Toron to, ON:
Cormorant Press.
Tutty, L. M., Weaver, G., & Rothery, M. A. ( 1999). Residents'
views of the efficacy of shelter services
for abused women. Violence Against Women, 5, 869- 925.
Wancata, }., Krautgartncr, M., Berner,}., Scumaci, S., Freid!,
M., Alexandrowic7., It, et al. (2006). The
"Carer's r eeds Assessment for Schizophrenia": An instrument to
assess the needs of relatiYes
caring for schizophrenia patients. Social Psychiatry &
Psychiatric Epidemiology, 41, 221-229.

Weaver, H. W. ( 1997). The challenges of research in Native
American communities: Incorporating
principles of cultural competence. Journal of Social Service
Research, 23, l - 15.
Wilkin, B. R., & Al tschuld, 1. W. ( 1995). Planning and
conducting needs assessments: A practical
guide. Thousand Oaks, CA: Sage.
Yegidis, B. 1.., Weinbach, R. W., & Morrison -Rodriguez, B.
(1999). Research melhodsfor social work-
ers (3rd eel.). Boston: Allyn & Bacon.
http:/ /www.extension.iastate.edu/communitics/tools/assess/
This Web site by the Iowa State University Extension Division
provides a primer on five types of needs
assessments: existing data sources, attitude survey approaches,
key informant approaches, community
forums, and focus groups.
http:/ /ctb.ku.edu/tools/scction_l 042.htm
The Community Tool Box is a service of the Work Groups for
Community Health and Development at
the University of Kansas. This comprehensive Web site presents
information on numerous evaluation
methods for use in the community, with needs assessments
being only one.
162 PART 11 • Q uANTITATIVE A PPROACH ES: TYPES Of
STUDIES
DISCUSSION QUESTIONS -

1. Whal are the disadvantages and advantages of quantitative as
compared to qualitative needs
assessment methods?
1. What are the advantages and disadvantages of asking key
informants about the needs of an iden-
tified population versus speaking to those affected by the
problem themselves?
3. Compare community forums and focus groups. For what
purposes might one be preferred over the
other?
4. Discuss the concepts of "needs" and "wants." How can those
developing needs assessment ensure
that the needs that are being identified are necessary and
important?
5. What are the best strategies to ensure that needs assessment
recommendations are implemented?
Shared Decision-Making in Intensive Care Units
Executive Summary of the American College of Critical Care
Medicine and
American Thoracic Society Policy Statement
Shared decision-making is a central component of patient-
centered
care in the intensive care unit (ICU) (1–4); however, there
remains
confusion about what shared decision-making is and when
shared decision-making ought to be used. Further, failure to
employ appropriate decision-making techniques can lead to

significant problems. For example, if clinicians leave decisions
largely to the discretion of surrogates without providing
adequate
support, surrogates may struggle to make patient-centered
decisions and may experience psychological distress (5).
Conversely, if clinicians make treatment decisions without
attempting to understand the patient’s values, goals, and
preferences, decisions will likely be predominantly based on the
clinicians’ values, rather than the patient’s, and patients or
surrogates may feel they have been unfairly excluded from
decision-making (1, 2). Finding the right balance is therefore
essential. To clarify these issues and provide guidance, the
American College of Critical Care Medicine (ACCM) and
American Thoracic Society (ATS) recently released a policy
statement that provides a definition of shared decision-making
in the ICU environment, clarification regarding the range of
appropriate models for decision-making in the ICU, a set of
skills
to help clinicians create genuine partnerships in decision-
making
with patients/surrogates, and ethical analysis supporting the
findings (6).
To develop a unified policy statement, the Ethics Committee of
the ACCM and the Ethics and Conflict of Interest Committee of
the
ATS convened a writing group composed of members of these
committees. The writing group reviewed pertinent literature
published in a broad array of journals, including those with a
focus
in medicine, surgery, critical care, pediatrics, and bioethics, and
discussed findings with the full ACCM and ATS ethics
committees
throughout the writing process. Recommendations were
generated
after review of empirical research and normative analyses

published
in peer-reviewed journals. The policy statement was reviewed,
edited, and approved by consensus of the full Ethics Committee
of the ACCM and the full Ethics and Conflict of Interest
Committee
of the ATS. The statement was subsequently reviewed and
approved
by the ATS, ACCM, and Society of Critical Care Medicine
leadership,
through the organizations’ standard review and approval
processes.
ACCM and ATS endorse the following definition: Shared
decision-making is a collaborative process that allows patients,
or
their surrogates, and clinicians to make health care decisions
together, taking into account the best scientific evidence
available, as well as the patient’s values, goals, and
preferences.
Clinicians and patients/surrogates should use a shared
decision-making process to define overall goals of care
(including
decisions regarding limiting or withdrawing life-prolonging
interventions) and when making major treatment decisions that
may be affected by personal values, goals, and preferences (7,
8).
Once clinicians and the patient/surrogate agree on general goals
of
care, clinicians confront many routine decisions (e.g., choice of
vasoactive drips and rates, laboratory testing, fluid rate). It is
logistically impractical to involve patients/surrogates in each of
these decisions. Partnerships in decision-making require that the
overall goals of care and major preference-sensitive decisions
be

made using a shared decision-making approach. The clinician
then
has a fiduciary responsibility to use experience and evidence-
based
practice when making day-to-day treatment decisions that are
consistent with the patient’s values, goals, and preferences.
Throughout the ICU stay, important, preference-sensitive
choices
often arise. When they do, clinicians should employ shared
decision-making.
Clinicians should generally start with a default shared decision-
making approach that includes the following three main
elements:
information exchange, deliberation, and making a treatment
decision. This model should be considered the default approach
to
shared decision-making, and should be modified according to
the
needs and preferences of the patient/surrogate. Using such a
model,
the patient or surrogate shares information about the patient’s
values, goals, and preferences that are relevant to the decision
at
hand. Clinicians share information about the relevant treatment
options and their risks and benefits, including the option of
palliative care without life-prolonging interventions. Clinicians
and
the patient/surrogate then deliberate together to determine
which
option is most appropriate for the patient, and together they
agree
on a care plan. In such a model, the authority and burden of
decision-making is shared relatively equally (9). Although data
suggest that a preponderance of patients/surrogates prefer to
share

responsibility for decision-making relatively equally with
clinicians,
many patients/surrogates prefer to exercise greater authority in
decision-making, and many other patients/surrogates prefer to
defer even highly value-laden choices to clinicians (10–13).
Ethically justifiable models of decision-making include a broad
range to accommodate such differences in needs and
preferences.
In some cases, the patient/surrogate may wish to exercise
significant authority in decision-making. In such cases, the
clinician
should understand the patient’s values, goals, and preferences to
a
sufficient degree to ensure the medical decisions are congruent
with these values. The clinician then determines and presents
the
range of medically appropriate options, and the
patient/surrogate
chooses from among these options. In such a model, the
patient/surrogate bears the majority of the responsibility and
burden of decision-making. In cases in which the
patient/surrogate
demands interventions the clinician believes are potentially
inappropriate, clinicians should follow the recommendations
presented in the recently published multiorganization policy
statement on this topic (14).
In other cases, the patient/surrogate may prefer that clinicians
bear the primary burden in making even difficult, value-laden
choices. Research suggests that nearly half of surrogates of
critically
ill patients prefer that physicians independently make some
types of treatment decisions (10–13). Further, data suggest that
approximately 5–20% of surrogates of ICU patients want
clinicians

to make highly value-laden choices, including decisions to limit
or
1334 American Journal of Respiratory and Critical Care
Medicine Volume 193 Number 12 | June 15 2016
EDITORIALS
withdraw life-prolonging interventions (12, 13). In such cases,
using a clinician-directed decision-making model is ethically
justifiable (15–24).
Employing a clinician-directed decision-making model
requires great care. The clinician should ensure that the
surrogate’s
preference for such a model is not based on inadequate
information, insufficient support from clinicians, or other
remediable causes. Further, when the surrogate prefers to defer
a
specific decision to the clinician, the clinician should not
assume
that all subsequent decisions are also deferred. The surrogate
should therefore understand what specific choice is at hand and
should be given as much (or as little) information as the
surrogate
wishes. Under such a model, the surrogate cedes decision-
making
authority to the clinician and does not need to explicitly agree
to (and thereby take responsibility for) the decision that is
made.
The clinician should explain not only what decision the
clinician is
making but also the rationale for the decision, and must then
explicitly give the surrogate the opportunity to disagree. If the

surrogate does not disagree, it is reasonable to implement the
care
decision (19–24). Readers may review references 19–24 for
detailed
descriptions and ethical analyses of clinician-directed decision-
making.
The statement was intended for use in all ICU environments.
Patients and surrogate decision-makers have similar rights both
to participate in decision-making when appropriate and to rely
more
heavily on providers when they wish to do so, regardless of the
type
of ICU. Similarly, the statement is equally applicable in
pediatric and
neonatal settings, where decision-making partnerships between
parents and the ICU team are equally important. As noted in the
statement, including children in some decisions can often be
appropriate as well. The statement is also intended to be
applicable
internationally. Although patient and surrogate decision-making
preferences may differ globally, the default approach presented
and the recommendation to adjust the decision-making model to
fit
the preferences of the patient or surrogate are universal. Both
ACCM and ATS are international organizations, and the
literature
review included publications from many countries. The
statement
focuses on the ICU environment because critically ill patients
are
often, but not always, unable to participate in decision-making
themselves, and because many decisions in the ICU are value-
sensitive. The recommendations in the statement, however,
could be
equally applicable in all patient care settings.

To optimize shared decision-making, clinicians should be
trained in specific communication skills. Core categories of
skills include establishing a trusting relationship with the
patient/surrogate; providing emotional support; assessing
patients’/surrogates’ understanding of the situation; explaining
the patient’s condition and prognosis; highlighting that there
are options to choose from; explaining principles of surrogate
decision-making; explaining treatment options; eliciting
patient’s
values, goals, and preferences; deliberating together; and
making
a decision. The full policy statement provides significant
guidance
and examples in these areas (6).
Finally, ACCM and ATS recommend further research to
assess the use of various approaches to decision-making in the
ICU. The use of decision aids, communication skills training,
implementation of patient navigator or decision support
counselor
programs, and other interventions should be subjected to
randomized controlled trials to assess efficacy. Considerations
regarding the cost and time burdens should be weighed against
anticipated benefits from such interventions when determining
which efforts to implement. n
Author disclosures are available with the text of this article at
www.atsjournals.org.
Acknowledgment: The views expressed in this article represent
the official
position of the American College of Critical Care Medicine, the
Society
of Critical Care Medicine, and the American Thoracic Society.

These views
do not necessarily reflect the official policy or position of the
U.S. Department
of the Navy, U.S. Department of Defense, U.S. National
Institutes of Health,
U.S. Department of Veterans Affairs, U.S. Food and Drug
Administration,
or U.S. Government.
Alexander A. Kon, M.D.
Naval Medical Center San Diego
San Diego, California
and
University of California San Diego
Judy E. Davidson, D.N.P., R.N.
University of California Health System
Wynne Morrison, M.D.
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Marion Danis, M.D.
National Institutes of Health
Bethesda, Maryland
Douglas B. White, M.D., M.A.S.
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
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Hill NS, Hinds
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Med 2004;32:1781–1784.
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Shepard E,
Spuhler V, Todres ID, Levy M, Barr J, et al.; American College
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Critical Care Medicine Task Force 2004-2005, Society of
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Medicine. Clinical practice guidelines for support of the family
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