Perceived Factors Influencing Shared Decision-Making in Mental Health Risk Assessment and Management: A Cross-Sectional Survey with Service Users and Professionals

This cross-sectional survey utilizing the Theoretical Domains Framework reveals that while mental health professionals are motivated to practice shared decision-making in risk assessment, significant barriers including time constraints, communication gaps, and service user concerns hinder its consistent implementation, highlighting a critical need for improved communication, organizational support, and targeted training.

The Gist

Imagine you and your doctor are trying to navigate a stormy sea together. In the past, the doctor would sit at the helm, look at the charts, and tell you exactly where the ship is going and how to avoid the waves. You, the passenger, would just sit quietly and hope for the best.

This paper is about changing that dynamic. It asks: What happens when we try to make the passenger a co-captain? Specifically, it looks at how people with severe mental health issues and the professionals who help them work together to spot dangers (risks) and plan safety (decision-making).

Here is a simple breakdown of what the researchers found, using some everyday metaphors.

1. The Goal: From "Passenger" to "Co-Captain"

The study focuses on Shared Decision-Making (SDM). Think of this as moving from a "take me to the doctor" model to a "let's figure this out together" model.

• The Ideal: The doctor and the patient sit down, look at the map together, discuss the stormy weather (risks like self-harm or suicide), and agree on a route.
• The Reality: The researchers found that while many people talk about the storm, they often aren't actually steering the ship.

2. The Service Users' Experience: "I'm on the boat, but I don't have the map"

The researchers asked people living with mental health conditions: "Are you part of the plan?"

• The Good News: Most people said, "Yes, we talked about the risks."
• The Bad News: Only about half felt they were actually helping to make the decisions. Even worse, two-thirds said they never got a copy of the safety plan.
  • The Analogy: Imagine your boss tells you, "We are changing the office layout to make it safer," but they never show you the blueprints or ask for your opinion. You know a change is happening, but you don't know the rules of the new building.
• The Feeling: People felt that talking about safety was scary and emotional. They agreed that communication needs a major upgrade. They want to be involved, but the conversation often feels too heavy or confusing.

3. The Professionals' Experience: "I want to help, but my hands are tied"

The researchers also asked the doctors, nurses, and social workers: "What stops you from letting the patient steer?"

• The Motivation: The professionals are actually very eager! They want to work together. They believe it's their job and that it helps people recover.
• The Barriers:
  • Time: The biggest hurdle is time. It's like trying to bake a complex cake while someone is yelling at you to hurry up. They feel they don't have enough time to have a deep, meaningful conversation.
  • Fear: Some newer professionals worry, "If I talk about the scary stuff (like suicide), will it make the patient worse?" It's like a parent worrying that mentioning a spider might make a child afraid of the whole house.
  • Experience Matters: The study found that older, more experienced professionals were less afraid. They knew that talking about the storm didn't cause the storm; it helped them navigate it. Newer staff were more anxious about causing distress.

4. The Four "Weather Patterns" (The Findings)

The researchers used a special math tool (Principal Component Analysis) to group all the answers into four main "weather patterns" that influence how well this teamwork works:

1. Motivation (The Engine): Everyone wants to go. Both patients and doctors want to collaborate. The engine is running hot.
2. Social Influences & Memory (The Crew & The Map): This is about how the team talks to each other and how well they remember the plan. If the crew (family, friends, team) supports the patient, the journey is smoother.
3. Beliefs About Consequences (The Fear of the Storm): This is the "What if?" factor. Do we think talking about risk will cause a panic attack? The study found that experienced pros know the answer is usually "No," but new pros are still worried.
4. Team, Environment & Training (The Boat & The Gear): This is the practical stuff. Do we have a sturdy boat? Do we have the right tools? The study found that the "gear" (time, training, team support) is often lacking, especially for newer staff.

5. The Bottom Line: What Needs to Change?

The paper concludes that while everyone wants to work together, the system isn't set up to make it easy.

• Give the passengers the map: Patients need to actually see and keep their safety plans.
• Train the new captains: Newer professionals need more training and mentorship so they stop fearing that talking about risk will make things worse.
• Buy more time: The system needs to give professionals enough time to have these deep, human conversations without rushing.
• Change the language: Instead of using scary medical jargon, we need to speak in a way that feels safe and understandable to everyone.

In a nutshell: We are trying to move from a world where the doctor says, "Sit still, I know what's best," to a world where the doctor says, "Let's look at the map together and decide the best path forward." The heart is in the right place, but we need better tools, more time, and less fear to make it happen.

Technical Summary

1. Problem Statement

Mental health care is increasingly shifting from paternalistic models toward person-centred, collaborative care involving Shared Decision-Making (SDM). However, current evidence suggests that SDM is inconsistently applied during Risk Assessment (RA) and Risk Management (RM), particularly regarding severe mental illness (SMI).

• The Gap: While policy guidelines (e.g., NICE, NHS England) mandate collaborative safety planning, research indicates service users are often excluded from identifying safety concerns or are unaware of the contents of their risk management plans.
• The Consequence: Lack of involvement limits therapeutic alliances, reduces the potential for personalized risk formulation, and fails to capture broader social and systemic risks.
• The Need: There is a scarcity of quantitative research systematically examining the specific barriers and enablers to SDM in risk contexts, necessitating a study grounded in behavioral science frameworks.

2. Methodology

Study Design:

• Type: Exploratory, cross-sectional, online survey.
• Framework: Guided by the Theoretical Domains Framework (TDF), a synthesis of 33 behavior change theories comprising 14 domains. The analysis was also interpreted through the COM-B model (Capability, Opportunity, Motivation).
• Data Collection: Conducted via Qualtrics from August to December 2019.

Participants:

• Service Users (n=48): Adults (18+) with SMI (psychosis, schizophrenia, bipolar, major depression) receiving care from community mental health teams.
• Mental Health Professionals (n=195): Psychiatrists, psychologists, nurses, social workers, and occupational therapists involved in RA/RM.
• Sampling: Convenience sampling via charities (National Survivor User Network, MQ), social media, and closed support groups.

Instrumentation:

• Professional Survey: 39 items covering 13 TDF domains, rated on a 5-point Likert scale.
• Service User Survey: Two versions based on screening questions:
  • Lived Experience (n=36): For those who had prior RA/RM contact.
  • Hypothetical (n=12): For those without prior contact.
• Analysis:
  • Descriptive Statistics: Means, frequencies, and standard deviations.
  • Reliability: Cronbach's alpha and mean inter-item correlations.
  • Inferential Statistics: Principal Component Analysis (PCA) with Oblimin rotation to identify underlying factors. Group comparisons (t-tests, ANOVA, Kruskal-Wallis) based on demographics (age, experience, profession).

3. Key Contributions

• Quantitative Validation of TDF: This study is one of the first to quantitatively map barriers and enablers to SDM in risk assessment using the TDF, moving beyond qualitative interviews to broader survey data.
• Dual-Perspective Analysis: Simultaneously captures the perceptions of both service users and professionals, highlighting the "disparity" between reported involvement and actual access to documentation.
• Experience-Based Differentiation: Identifies that professional experience (years qualified) significantly influences beliefs about the consequences of SDM, offering a nuanced view on how training and mentorship impact practice.
• Component Identification: Reduces complex behavioral data into four actionable components: Motivation, Social Influences/Memory, Beliefs about Consequences, and Team/Environment factors.

4. Key Results

Service User Findings:

• Involvement Gap: While 68.8% reported risk was discussed, only 50% felt involved in the assessment/management process.
• Documentation Access: A critical finding is that 66.7% of service users reported never receiving a copy of their risk assessment or management plan.
• Perceptions: Service users strongly agreed that communication needs improvement and that discussing risk is difficult and emotive. However, they expressed a strong desire for involvement (Mean scores >4.5 on importance/goal items).

Professional Findings:

• Motivation: Professionals reported high motivation, confidence, and a sense of professional responsibility to implement SDM (94% agreement on importance).
• Barriers:
  • Time: 41% disagreed that they have enough time to implement SDM effectively.
  • Service User Factors: Professionals cited service user capacity, insight, and engagement levels as key determinants.
  • Negative Beliefs: Some professionals worried that discussing risk could cause distress, relapse, or disengagement, though these were generally not the dominant view.
• PCA Components: Four distinct components emerged:
  1. Motivation (Goals, Reinforcement, Role Identity).
  2. Social Influences & Memory/Decision-making (Team support, situational dependence).
  3. Beliefs about Consequences (Fears of causing harm/distress).
  4. Team, Environment, and Training (Resources, time, structure).

Demographic Differences:

• Experience Matters: Professionals with >16 years of experience scored significantly higher on "Team, Environment, and Training" factors and held fewer negative beliefs about consequences (e.g., less fear of causing distress or disengagement) compared to those with ≤6 years of experience.
• Age: Older professionals (47+) also held fewer negative beliefs about consequences compared to younger groups (≤36).

5. Significance and Implications

• Transparency is Critical: The finding that two-thirds of service users do not receive their risk plans suggests a procedural rather than collaborative approach to risk management. Transparency is essential for true SDM.
• Training Needs: The data indicates that less experienced professionals are more prone to negative beliefs (fear of causing harm) and feel less supported by their environment. This highlights an urgent need for targeted training, mentoring, and supervision for junior staff to build confidence in collaborative risk formulation.
• Organizational Support: Time constraints are a primary barrier. Systemic changes are required to provide professionals with the time and resources necessary to build trust and engage in meaningful SDM.
• Language and Communication: Both groups identified the "language of risk" as a barrier. Professionals need training to adapt language to be less stigmatizing and more focused on "safety" and "recovery" to facilitate engagement.

Limitations:

• Sample Size: The service user sample (n=48) was small, limiting statistical power for that group.
• Sampling Bias: Reliance on social media and convenience sampling may have excluded marginalized groups (e.g., ethnic minorities, those not engaged with digital platforms), potentially skewing the demographic representation.
• Self-Report: Data relies on self-reported perceptions rather than observed clinical practice.

Conclusion:
The study concludes that while the intent for shared decision-making is high among professionals, implementation is hindered by time, lack of organizational support, and varying levels of confidence based on experience. To improve practice, interventions must focus on clearer communication, organizational resource allocation, and targeted training for less experienced staff to reduce fear-based barriers to collaboration.