Shared decision-making competency and its associated factors among palliative care nurses: a cross-sectional study in China

Palliative care is an integral part of healthcare which aims to enhance the quality of life for patients facing life-limiting illnesses and encompasses a comprehensive range of supportive interventions that address patient’s multi-level care needs [1]. According to the latest data from World Health Organization, an estimated 56.8 million people require palliative care annually [2]. However, only 14% of patients worldwide currently have access to palliative care and the shortage of palliative care coverage is particularly acute in China, where only 10% of patients requiring palliative care have access [2, 3].

Nurses are essential members of the palliative care team. Their role is multifaceted involving the management of physical symptoms and facilitation of communication between patients, their families, and other healthcare providers [4]. In 1996, the Chinese government promoted the concept of “patient-centered care” across all aspects of healthcare services [5]. Patient-centered communication serves as a cornerstone of patient-centered care, with shared decision-making (SDM) playing an integral and pivotal role in its implementation [6]. SDM is a process by which health care providers share information and communicate with patients and family members about the clinical risks and benefits of particular healthcare options based on empirical evidence, align clinical decisions with patient preferences and values, and work together [7, 8]. SDM places patients and their families at the heart of the decision-making process given that decisions are frequently complex in the field of palliative care and often involve discussions about prognosis, treatment options, quality of life, and end-of-life care [9]. In addition, SDM fosters open dialogue between healthcare providers, patients, and families, facilitating clearer understanding and more informed choices, especially under the influence of traditional Chinese culture, there exists a prevailing reluctance to openly engage in discussions about the topic of dying [10, 11].

In recent years, the role of nurses in SDM within the healthcare decision-making process has increasingly gained attention [12], the National Institute for Health and Care Excellence has proposed the integration of SDM into routine care in the UK [13]. A recent study highlighted the pivotal role of nurses in fostering a collaborative SDM process with patients, and serve as vital conduits for improving the flow of information between physicians and patients, thereby enhancing and facilitating the overall SDM process [12]. Effective SDM allows nurses to develop more personalized care plans that align with patients’ goals and preferences. Research indicates that SDM empowers patients and families by actively involving them in the decision-making process, which can reduce their anxiety and potentially contribute to improved clinical outcomes [14]. Unlike the traditional healthcare model, where patients often play a passive role in the decision-making process. However, SDM changes this inherent relationship and emphasizes patient autonomy, enabling them to voice their preferences and concerns. In palliative care sittings, the role of SDM competencies extends beyond merely facilitating choices about medical interventions, and it also encompasses critical discussions about advance care planning, such as preferences for the place of death [9, 15]. Nurses with SDM competencies are capable of providing essential support to patients, which includes fostering open communication and interdisciplinary collaboration. Whether a patient opts for death at home, in a hospice facility, or in a hospital, nurses help ensure that the patient’s voice is heard and their preferences are respected, and enabling the patient to make a decision that best reflects their wishes for a peaceful and dignified end-of-life experience. This not only enhances patient satisfaction with care, but also further reduces the caregiver burden associated with discussing these topics [7, 16].

Currently, palliative care nurses in many countries are being trained to develop SDM competencies through a combination of formal education and clinical practice. In Australia, the National Palliative Care Outcomes Collaboration has incorporated SDM as a key component of the essentials course [17]. Moreover, in countries such as Saudi Arabia and China, palliative care nurses are educated on SDM through workshops, training sessions, elective courses, and short seminars [16, 18]. Previous studies found that SDM training experience could be a significant factor associated with healthcare practitioners’ SDM competency, with those who have completed training exhibiting higher competency levels than those without such experience [7]. However, the evidence remains limited regarding palliative care nurses. Furthermore, beyond factors like SDM training experience, one essential factor related to SDM competency is empathy ability (EA) [6]. Empathy is the ability to recognize and understand the cognitive and emotional changes in others and to respond from their perspective in a way that takes care of their feelings [19]. A previous review of SDM models identified several key components, including raising awareness of available choices, tailoring information to individual needs, and discussing the preferences of patients receiving care [20]. To better support SDM, empathy plays a critical component in facilitating these discussions and communication [21]. Some studies have shown that EA can help nurses to change decision-making thinking and promote more effective communication in SDM [6, 22]. Nurses who exhibit high levels of EA are more adept at integrating patient values and needs and building mutual trust by placing themselves in the patient’s shoes to better consider decisions [23].

With the rapid growth of demand for palliative care, understanding and addressing the factors that influence SDM competency will be key to enhancing palliative care practices and ensuring that patients receive care that is aligned with their preferences and values. However, research on the current status of SDM competency and factors affecting SDM competency in palliative care settings has yet to be investigated, especially in the context of China. Therefore, this study aimed to investigate the level of SDM competency among palliative care nurses and identify the factors associated with SDM competency.

Despite the recognized importance of SDM in palliative care, there is a scarcity of empirical research examining the SDM competencies of palliative care nurses and the factors that may influence these competencies [9, 11]. Previous studies have mainly focused on SDM in general healthcare settings without specifically addressing the unique context of palliative care [6, 23]. To the best of our knowledge, the present study is the first study to investigate the current situation of SDM competency among palliative care nurses, and fills a gap by providing empirical data on the SDM competencies of palliative care nurses. The total score of SDMCS was 211.72 ± 25.75, which indicated that Chinese palliative care nurses had a high level of SDM competency. The EA, experiences of SDM training, and education background were identified as statistically significant factors associated with nurses’ SDM competency.

A recent study reported that the overall SDM competency scores among Chinese nurses were at a moderate level, which was inconsistent with our results [23]. This discrepancy may be attributed to the study population in our research focused primarily on palliative care nurses, who may receive more specialized training and have greater exposure to SDM processes due to the nature of their work. Palliative care often involves complex, value-laden decisions that require active collaboration with patients and their families, which may foster the development of stronger SDM competencies within this group [30]. The findings of the current study indicate that the dimension of comprehensive quality within SDM competency exhibits the highest average scores for the items, highlighting the profound understanding and acceptance that palliative care nurses possess in integrating multiple aspects of patient-centered care, which is consistent with the study conducted by Hu et al., who investigated SCM competency in general clinical nurses [23]. In recent years, the Chinese government has issued a series of documents to strengthen the advocacy of the “patient-centered care” concept and encourage healthcare practitioners to SDM with patients and their families in clinical practice so as to improve patients’ feelings of engagement and enhance their healthcare experience [31]. As a result of this advocacy, nurses may have developed a greater awareness and understanding of the benefits of implementing SDM. However, the dimension of skills and abilities shows the lowest individual item average score revealing some challenges that palliative care nurses may face in implementing SDM. Firstly, the inherent complexity and emotional intensity of palliative care scenarios could hinder effective communication and decision-making processes. Nurses often deal with patients experiencing severe pain, emotional distress and existential questions about life and death which can complicate discussions about treatment options and care preferences [32]. Furthermore, the practical training content still remains relatively uniform and lacks diversification in China [18]. While nurses may receive education on SDM within the context of palliative care, such training is often predominantly theoretical. As a result, they may not acquire adequate, targeted clinical practice skills essential for effective SDM, such as communication strategies for promoting collaborative relationships with patients and conflict resolution techniques [22]. These practical competencies are critical for implementing SDM in clinical settings. There is an increasing need for more palliative care nurses with SDM skills to partner with patients during the SDM process. It is therefore recommended that nursing educators integrate these skills into existing palliative care structured education programs, as this integration holds the potential to enhance nurses’ skills and practical abilities in implementing SDM within palliative care settings.

Of the factors studied, we found there was a notable association between nurses’ educational background and their SDM competency levels. Nurses who had graduate degrees had higher scores on SDMCS than those with undergraduate degrees or lower. In recent years, many countries have embedded SDM into graduate medical education, such as the Netherlands and the United States [33]. The content of SDM programs in graduate degrees often include more in-depth theoretical knowledge such as the importance and opportunities for use of SDM, the contributions of decision aids to the SDM process, and opportunities for students to develop and refine these skills through practice in simulated or real clinical settings [33]. In addition, we found that nurses who had experiences of SDM training had a higher level of SDM competency than those who had not, aligning with the findings of Wang et al. [34]. The existing research indicates that education and training is the driving force for healthcare providers to embrace and implement SDM [35]. In the process of participating in SDM training, nurses gain an understanding of the concept, framework, and characteristics of SDM, and thus realize the significance of the application of SDM in palliative care and may exhibit greater willingness to practice it in clinical settings. The positive impact of SDM training underscores the need for healthcare organizations to invest in ongoing education for their staff [23]. Incorporating SDM training modules into existing professional development programs may be a strategic approach to elevating the overall competency of the nursing workforce.

In this study, palliative care nurses exhibited a high level of empathy, similar to the findings of Kim et al. [36]. In addition to the nature of palliative care necessitates continuous and intensive patient-nurse interactions, fostering deep emotional connections, the specialized training that palliative care nurses receive generally includes extensive modules on emotional intelligence and compassionate communication [37]. These educational components equip nurses with the essential skills to comprehend and resonate with patients’ emotional states, thereby potential significantly enhancing their empathetic abilities. Furthermore, our findings suggested that palliative care nurses who had a higher level of EA also had a higher degree of the SDM competency, similar to the findings of Hu et al. [23]. Nurses with high level of EA are more adept at creating a compassionate and supportive environment, which is essential for effective SDM. They can more accurately perceive patients’ concerns, preferences, and values, and integrate these elements into the decision-making process [23, 37]. This empathetic approach fosters trust and open communication, enabling patients and their families to engage in discussions about care options [29]. Therefore, nursing administrators can take proactive steps to foster empathy development among palliative care nurses, such as through workshops, reflective practice exercise, and integrate empathy training into both initial education and ongoing professional development in the future [38]. Additionally, fostering a mentorship culture, where experienced nurses support their less experienced peers, can spread best practices and may enhance SDM competency throughout the organization [39].

There are several limitations must be acknowledged in our study. Firstly, this study used a convenience sample and just recruitment participants in China. Given that SDM practices may be influenced by cultural norms, values, and healthcare system structures in China, our findings may not fully reflect SDM competency among palliative care nurses in different cultural or geographical contexts. In China, traditional values such as filial piety and family-centered decision-making may shape how SDM is understood and implemented in clinical practice, and these cultural influences could enhance or hinder the adoption of SDM competencies, depending on the specific dynamics between nurses, patients, and families. Future research could explore how these cultural and systemic factors uniquely impact SDM practices within Chinese palliative care settings. Moreover, this study mainly focused on nurses in hospital settings. Expanding the scope of future research to include community contexts, such as home care or long-term care facilities, could offer valuable insights into how SDM competencies vary across different settings.

Finally, the cross-sectional design limits causal inferences. While the study may reveal associations between SDM competency and various factors, it cannot establish a clear cause-and-effect relationship. Future longitudinal studies that follow the same individuals over an extended period are necessary to gain a better understanding of how SDM competencies develop, evolve, and are influenced by various personal, professional, and systemic factors over time, and this will provide more comprehensive insights into the dynamics of SDM competency among nurses and facilitate the development of a well-structured SDM training program.

SDM is increasingly becoming an integral part of the development of modern, high-quality healthcare systems, especially in palliative care settings. This study found that palliative care nurses in China exhibited high levels of SDM competency and identified that educational background, experiences of SDM training, and EA of nurses were significant factors influencing SDM competency. The findings underscore the importance of incorporating structured SDM training programs in nursing education and professional development initiatives, particularly focused on building empathy skills. Future research could further investigate the impact of these factors across diverse geographical and cultural contexts, thereby enriching the global understanding of SDM practices in palliative care.