The Meaning of Shared Decision-Making in Mental Care: A Hermeneutical Study


Keywords: Content analysis, existential responsibility, focus group interviews, hermeneutics, in-depth interviews, interpretive thematic analysis, mental care, mental healthcare professionals, patients, shared decision-making, qualitative method


Background: Shared decision-making is understood to be a process where the patients and the mental healthcare professionals are engaged in a dialogue of information in order to understand each other’s preferences and values regarding care and to agree on a plan of action. This understanding is mainly derived from a medical context. It is important that the scientific knowledge of shared decision-making is linked to the practice where it is to be carried out. The understanding of shared decision-making and its meaning in mental care needs to be developed, based on a caring science perspective.

Aims: The overall aim of this study was to develop a deeper understanding of the meaning of shared decision-making in mental care. The specific aims of the three sub-studies were: I) To describe patient participation in shared decision-making in the context of indoor mental care. II) To explore how mental healthcare professionals describe shared decision-making in a therapeutic milieu as expressed through clinical supervision. III) To interpret the meaning of shared decision-making in mental care as perceived by patients and mental healthcare professionals.

Methods: This thesis has a hermeneutical approach with an explorative design. Data were collected by means of three empirical sub-studies (Papers I, II and III), which contain in-depth interviews with 16 patients and multistage focus group interviews with eight mental healthcare professionals. Data analysis methods include qualitative content analysis (Papers I and II) and thematic interpretive analysis (Paper III). A deeper understanding of the meaning of shared decision-making was developed based on the empirical inductive findings, through deductive interpretation and finally an abductive interpretation.

Findings: The first sub-study revealed the main theme thriving in relation to participating actively in a complementary ensemble of care, and the two themes having mental space to discover my way forward and being in a position to express my case. In the second sub-study, the theme was practising shared decision-making when balancing between power and responsibility to form safe care, comprising the three categories internalizing the mental healthcare professionals’ attributes, facilitating patient participation and creating a culture of trust. The third sub-study revealed the overall theme being in a space of sharing decision-making for dignified mental care, comprising the three themes engaging in a mental room of values and knowledge, relating in a process of awareness and comprehension and responding anchored in acknowledgement. The three sub-studies represented parts of a larger whole of the investigated phenomenon and a synthesis of them was developed. Through a deductive interpretation the understanding Shared decision-making - a healing process and an integral part of mental care as well as Shared decision-making - a process of understanding emerged. The final abductive stage illuminated the comprehensive understanding: The meaning of shared decision-making in mental care is being partners with an existential responsibility.

Conclusion: The meaning of shared decision-making in mental care is being partners with an existential responsibility. The relationship between a person in need of care and the carer constitutes the existential responsibility, which acknowledges the being in human beings and is essential for mental growth. The mental healthcare professionals should be the patients’ partner and supporter throughout care. This understanding conveys that shared decision-making requires great attention to emotional and relational qualities, scoping the existential dimensions in mental care.

Key words: Content analysis, existential responsibility, focus group interviews, hermeneutics, in-depth interviews, interpretive thematic analysis, mental care, mental healthcare professionals, patients, shared decision-making, qualitative method.

Author Biography

Lise Sæstad Beyene

Assistant Professor
VID Specialized University


Aase, T. H., & Fossåskaret, E. (2014). Skapte virkeligheter: Om produksjon og tolkning av kvalitative data: Universitetsforlaget.

Alguera-Lara, V., Dowsey, M. M., Ride, J., Kinder, S., & Castle, D. (2017). Shared decision making in mental health: the importance for current clinical practice. Australasian Psychiatry, 25(6), 578-582.

Borge, L., & Hummelvoll, J. K. (2019). Milieu Therapy - Collaboration and Learning in Healing Environments. An Update. . Klinisk Sygepleje, 33 (1), 40-54.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.

Carlsson, I.-M., Blomqvist, M., & Jormfeldt, H. (2017). Ethical and methodological issues in qualitative studies involving people with severe and persistent mental illness such as schizophrenia and other psychotic conditions: a critical review. Int J Qual Stud Health Well-being, 12(sup2), 1-10.

Castillo, H., & Ramon, S. (2017). "Work with me": service users' perspectives on shared decision making in mental health. Mental Health Review Journal, 22(3), 166-178.

Charles, C., Gafni, A., & Whelan, T. (1999). Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Social Science and Medicine, 49(5), 651-661.

Charles, C., Whelan, T., Gafni, A., Willan, A., & Farrell, S. (2003).

Shared treatment decision making: what does it mean to physicians? Journal of Clinical Oncology, 21(5), 932-936.

Colucci, E. (2007). "Focus groups can be fun": The use of activity- oriented questions in focus group discussions. Qualitative Health Research, 17(10), 1422-1433.

Coulter, A., & Collins, A. (2011). Making Shared Decision Making a Reality, No Decision About Me, Without Me. London: Kings Fund.

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science, 4(1), 1-15.

Davidson, L., Tondora, J., Pavlo, A. J., & Stanhope, V. (2017). Shared decision making within the context of recovery-oriented care. Mental Health Review Journal, 22(3), 179-190.

Deci, E. L., & Ryan, R. M. (2008). "Facilitating optimal motivation and psychological well-being across life's domains": Correction to Deci and Ryan (2008). Canadian Psychology, 49(1), 14-23.

Dwyer, S. C., & Buckle, J. L. (2009). The space between: On being an insider-outsider in qualitative research. International journal of qualitative methods, 8(1), 54-63.

Elwyn, G., & Fisher, E. (2014). Higher integrity health care: evidence- based shared decision making. Circulation: Cardiovascular Quality and Outcomes, 7(6), 975-980.

Elwyn, G., Frosch, D. L., & Kobrin, S. (2016). Implementing shared decision-making: consider all the consequences. Implementation science, 11, 114.

Eriksson, K. (2002). Caring science in a new key. Nursing Science Quarterly, 15(1), 61-65.

Fangen, K. (2010). Deltagende observasjon (2. utgave ed.). Bergen: Fagbokforlaget.

Farrelly, S., Lester, H., Rose, D., Birchwood, M., Marshall, M., Waheed, W., . . . Thornicroft, G. (2016). Barriers to shared decision making in mental health care: qualitative study of the Joint Crisis Plan for psychosis. Health Expectations, 19(2), 448- 458.

Flyvbjerg, B. (2006). Five misunderstandings about case-study research. Qualitative inquiry, 12(2), 219-245.

Frankl, V. E. (2014). The will to meaning: Foundations and applications of logotherapy: Penguin.

Fredriksson, L. (2014). Teoribegreppet i hermeneutik och vårdande praxis. In E. Lassenius & E. Severinsson (Eds.), Hermeneutik I Vårdpraxis. Det Nära, Det Flyktica, Det Dolda: Gleerups.

Gadamer, H.-G. (1996). The enigma of health (J. Gaiger & N. Walker, Trans.). In. Stanford, CA:: Stanford University Press.

Gadamer, H.-G. (2013). Truth and method : translation revised by Joel Weinsheimer and Donald G. Marshall. In. London, England: Bloomsbury Academic.

Graneheim, U., Lindgren, B.-M., & Lundman, B. (2017). Methodological challenges in qualitative content analysis: A discussion paper. Nurse Education Today, 56, 29-34.

Graneheim, U., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105-112.

Guest, G., Namey, E., & McKenna, K. (2017). How many focus groups are enough? Building an evidence base for nonprobability sample sizes. Field methods, 29(1), 3-22.

Gulbrandsen, P., Clayman, M. L., Beach, M. C., Han, P. K., Boss, E. F., Ofstad, E. H., & Elwyn, G. (2016). Shared decision-making as an existential journey: aiming for restored autonomous capacity. Patient education counseling, 99(9), 1505-1510.

Hansen, F. T. (2014). Vad innebär förundran-eller praxis? In E. Lassenius & E. Severinsson (Eds.), Hermeneutik I Vårdpraxis. Det Nära, Det Flyktica, Det Dolda: Gleerups.

Ho, K. H., Chiang, V. C., & Leung, D. (2017). Hermeneutic phenomenological analysis: the 'possibility'beyond 'actuality'in thematic analysis. Journal of Advanced Nursing, 73(7), 1757- 1766.

Holm, A. L. (2009). The meaning of emotional pain : analytic interpretative research on women's experiences of mental health problems. (no. 70), University of Stavanger, Faculty of Social Sciences, Department of Health Studies, Stavanger.

Holm Wiebe, A.-K., Johansson, I., Lindquist, I., & Severinsson, E. (2011). Nurses' experiences of core phenomena in the supervisor training programme. In J. Cutcliffe, K. Hyrkas, & J. Fowler (Eds.), Routledge Handbook of Clinical Supervision.

Fundamental International Themes. (pp. 241-249). New York: Routledge.

Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualtitative content analysis. Qualitative Health Research, Vol.15 No. 9, 1277-1288.

Hummelvoll, J. K. (2006). En helhetlig-eksistensiell psykiatrisk sykepleietilnærming i et lokalsamfunnsperspektiv. Klinisk Sygepleje, 20(01), 13-23.

Hummelvoll, J. K. (2008). The multistage focus group interview: A relevant and fruitful method in action research based on a co-operative inquiry perspective. Norsk Tidsskrift for Sykepleieforskning, 10, 3-14.

James, K., & Quirk, A. (2017). The rationale for shared decision making in mental health care: a systematic review of academic discourse. Mental Health Review Journal, 22(3), 152-165.

Jayasekara, R. S. (2012). Focus groups in nursing research: methodological perspectives. Nursing Outlook, 60(6), 411-416.

Kaminskiy, E., Senner, S., & Hamann, J. (2017). Attitudes towards shared decision making in mental health: a qualitative synthesis. Mental Health Review Journal, 22(3), 233-256.

Lassenius, E. (2014). En bro till en annan-förståelse i vårdande praxis. In E. Lassenius & E. Severinsson (Eds.), Hermeneutik i vårdpraxis. Det nära, det flyktiga, det dolda (pp. 81-96): Gleerups.

Launsø, L., Olsen, L., & Rieper, O. (2011). Forskning om og med mennesker: forskningstyper og forskningsmetoder i samfundsforskning (6. ed.). København Nyt Nordisk Forlag.

Légaré, F., Adekpedjou, R., Stacey, D., Turcotte, S., Kryworuchko, J., Graham, I. D., . . . Elwyn, G. (2018). Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews(7).

Levinas, E. (2003). Humanism of the Other: University of Illinois Press.

Liamputtong, P. (2007). Researching the vulnerable : a guide to sensitive research methods. London: SAGE.

Liamputtong, P. (2011). Focus Group Methodology: Principles and Practice (Vol. 224). London: SAGE Publications

Long, C. G., Knight, C., Bradley, L., & Thomas, M. (2012). Effective therapeutic milieus in secure services for women: the service user perspective. J Ment Health, 21(6), 567-578.

Lyth, G. M. (2000). Clinical supervision: a concept analysis. Journal of Advanced Nursing, 31(3), 722-729.

Lyttle, D. J., & Ryan, A. (2010). Factors influencing older patients' participation in care: a review of the literature. International Journal of Older People Nursing, 5(4), 274-282.

Mahoney, J. S., Palyo, N., Napier, G., & Giordano, J. (2009). The Therapeutic Milieu Reconceptualized for the 21st Century. Psychiatric Nursing, 23(6), 423-429.

Makoul, G., & Clayman, M. L. (2006). An integrative model of shared decision making in medical encounters. Patient Education and Counseling, 60(3), 301-312.

Malt, U. (2019). Store norske leksikon. Retrieved from

Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample size in qualitative interview studies: guided by information power. Qualitative Health Research, 26(13), 1753-1760.

Martinsen, K., & Eriksson, K. (2009). Å se og å innse: om ulike former for evidens: Akribe.

McCance, T., Slater, P., & McCormack, B. (2009). Using the caring dimensions inventory as an indicator of person-centred nursing. Journal of Clinical Nursing, 18(3), 409-417.

Morant, N., Kaminskiy, E., & Ramon, S. (2016). Shared decision making for psychiatric medication management: Beyond the micro‐social. Health Expectations, 19(5), 1002-1014.

Morgan, D. L. (1997). Qualitative Research Methods: Focus groups as qualitative research (2 ed. Vol. 16). Thousand Oaks, California: Sage Publications.

Morgan, M. S. (2015). Case Studies. In N. Cartwright & E. Montuschi (Eds.), Philosophy of Social Science: A New Introduction. Oxford: Oxford University Press.

Norwegian Health Directorate. (2015). Internasjonalt perspektiv på psykisk helse og helsetjenester til mennesker med psykiske lidelser (IS-2314). Norwegian Health Directorate

Norwegian Ministry of Health & Care Services. (2015-2016). Nasjonal helse- og sykehusplan (2016-2019) (Report No. 11 to the Storting). Oslo: Norwegian Ministry of Health & Care Services

Peplau, H. (1991). Interpersonal relations in nursing : a conceptual frame of reference for psychodynamic nursing. New York: Springer.

Polit, D. F., & Beck, C. T. (2010). Essentials of nursing research : appraising evidence for nursing practice : Study guide for Essentials of nursing research : appraising evidence for nursing practice (7th ed. ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Ramon, S., Brooks, H., Rae, S., & O'Sullivan, M.-J. (2017). Key issues in the process of implementing shared decision making (DM) in mental health practice. Mental Health Review Journal, 22(3), 257-274.

Råholm, M.-B. (2014). Abduktion, en form av hermeneutisk förståelse. In E. Lassenius & E. Severinsson (Eds.), Hermeneutik i vårdpraxis. Det nära, det flyktiga, det dolda: Gleerups.

Sartre, J.-P. (2007). Existentialism is a Humanism: Yale University Press.

Scholl, I., & Barr, P. J. (2017). Incorporating shared decision making in mental health care requires translating knowledge from implementation science. World Psychiatry, 16(2), 160-161.

Schreier, M. (2012). Qualitative content analysis in practice: Sage Publications.

Schön, U.-K., Grim, K., Wallin, L., Rosenberg, D., & Svedberg, P. (2018). Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study. Int J Qual Stud Health Well-being, 13(1), 1421352.

Sjögren, R. (2012). Ansvar. In L. Wiklund Gustin & I. Bergbom (Eds.), Vårdvetenskapliga begrepp i teori och praktik (1 ed., Vol. 1, pp. 350-360). Lund: Studentlitteratur.

Skårderud, F., & Sommerfeldt, B. (2013). Miljøterapiboken : mentalisering som holdning og handling. Oslo: Gyldendal akademisk.

Slade, M. (2017). Implementing shared decision making in routine mental health care. World Psychiatry, 16(2), 146-153.

Smith, V., Devane, D., Begley, C. M., & Clarke, M. (2011). Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC Medical Research Methodology, 11(1), 15.

Storm, M., & Edwards, A. (2013). Models of user involvement in the mental health context: intentions and implementation challenges. Psychiatric Quarterly, 84(3), 313-327.

Stovell, D., Morrison, A. P., Panayiotou, M., & Hutton, P. (2016).

Shared treatment decision-making and empowerment-related outcomes in psychosis: systematic review and meta-analysis. The British Journal of Psychiatry, 209(1), 23-28.

Thompson, A. G. (2007). The meaning of patient involvement and participation in health care consultations: a taxonomy. Social Science & Medicine., 64(6), 1297-1310.

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357.

World Health Organization. (2006). Quality of care: a process for making strategic choices in health systems.

World Medical Association. (2008). Declaration of Helsinki. Retrieved from Oct2008.pdf

Zisman-Ilani, Y., Barnett, E., Harik, J., Pavlo, A., & O'Connell, M. (2017). Expanding the concept of shared decision making for mental health: systematic search and scoping review of interventions. Mental Health Review Journal, 22(3), 191-213.

Cover for The Meaning of Shared Decision-Making in Mental Care: A Hermeneutical Study
May 27, 2020