An Initiative to Improve Nephrology Clinician Confidence in Shared Decision Making

Abstract

Rationale & Objective

Shared decision making (SDM) is the preferred model for medical decision making, but implementation in kidney failure treatment decisions remains suboptimal. We educated nephrology clinicians to engage in comprehensive SDM with empathetic communication.

Study Design

Single-arm educational intervention with pre-post evaluation.

Setting & Participants

Three virtual educational sessions for 80 nephrology clinicians from 14 nephrology practices in the Expanding and Promoting Alternative Care and Knowledge in Decision-Making (ExPAND) clinical trial.

Quality Improvement Activities

We educated nephrology clinicians to operationalize SDM, including presentation of active medical care without dialysis, using the Ask-Tell-Ask approach and empathetic communication.

Outcomes

Participants rated their pre- and postsession confidence in achieving the learning objectives and provided qualitative feedback.

Analytical Approach

We used the Wilcoxon signed-rank paired test and obtained effect sizes (Cohen’s r) to compare pre-post ratings.

Results

On a 7-point scale, median postsession confidence ratings increased 1 to 2 points from presession ratings for all learning objectives. The effect sizes (Cohen’s r) for the increase were large for 12 of the 13 objectives. The 2 objectives showing the greatest improvement were using the 9 elements of SDM (2.00; 95% CI, 1.50-3.00; P < 0.001, r = 0.84) and delivering kidney disease education with a balanced presentation of all the options including active medical care without dialysis (2.00; 95% CI, 1.50-3.00; P < 0.001, r = 0.75). The qualitative feedback supported the quantitative results.

Limitations

Participant perceptions may not be generalizable to all nephrology clinicians. We did not measure whether improvements were retained over time or applied in practice.

Conclusions

The increase in clinician confidence suggests that our explicit instruction on how to conduct comprehensive SDM with empathetic communication may represent a breakthrough in improving the quality of SDM in the care of older patients with chronic kidney disease and kidney failure.

Plain-Language Summary

Shared decision making, in which patients and clinicians agree on treatment based on patient preferences, is often poorly done in nephrology. We taught practicing nephrology clinicians how to use the Ask-Tell-Ask approach to have more complete and empathetic conversations with patients and discuss all kidney failure treatment options, including active medical care without dialysis, along with their benefits and risks in an unbiased, balanced way. After training, participants felt more confident in conducting shared decision making. Our findings suggest that teaching specific ways to have these conversations may significantly improve how patients and doctors make decisions together. Our results are promising. If confirmed by research measuring patients’ perceptions of the conversations, our approach to shared decision making may lead to better, more personalized patient care.

Introduction

Shared decision making (SDM) is the ethically and legally preferred model for medical decision-making.¹ It is defined as a collaborative, discussion-based model that engages patients, clinicians, and care partners in making health care choices together.² In recent years, SDM has been recognized as essential to providing quality patient-centered care and has been recommended by professional nephrology societies, including the American Society of Nephrology (ASN) and the Renal Physicians Association.^1,3, 4, 5 The ASN promoted SDM before the initiation of long-term dialysis as 1 of its 5 topics in the Choosing Wisely Campaign, an initiative that promotes conversations between clinicians and patients to reduce the overuse of medical services that may not be beneficial to patients.⁶ SDM is the foundation of kidney supportive care because it seeks to ensure that the medical care most important to the patient is prioritized. In turn, kidney supportive care is a core component of integrated kidney care that helps people cope with living with kidney disease.⁷

Despite being recommended in the Renal Physicians Association/ASN clinical practice guideline, Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis, in 2000, the implementation of SDM when discussing kidney failure treatment options has been found by multiple studies to be suboptimal.^5,8, 9, 10 In particular, the option of active medical care without dialysis (AMCWD), which may be appropriate for and chosen by older patients with comorbid conditions, is often not presented. On average, delay in implementation of scientific evidence usually takes 17 years; however, implementation of SDM in nephrology has taken 25 years and is still not widely used in practice.^11,12 SDM requires that all options for treatment with their attendant benefits and risks are presented; however, most patients with kidney failure are not informed of the option to forgo dialysis.^3,8,13 There is still a powerful “dialysis default” and “immense pressure” for patients to start dialysis.^14,15 Over the years, patient decision aids (PDAs) to facilitate SDM in nephrology have omitted AMCWD as a treatment option, have presented it in a biased way, or have been written at too high a health literacy level to facilitate understanding.16, 17, 18 For patients with other chronic diseases, PDAs have helped patients make decisions, reduced decisional conflict, improved patient–provider communication, and increased patient involvement in medical decision making, among other patient-centered outcomes.^2,3,9

A new approach is needed to move SDM forward in the treatment of patients with kidney disease. We obtained funding from the Patient-Centered Outcomes Research Institute for a project, “Improving Shared Decision-Making and Access to Non-Dialytic Treatment for People with Kidney Disease,” which we have branded ExPAND: Expanding and Promoting Alternative Care and Knowledge in Decision-Making.^19,20 Because patient-friendly PDAs can facilitate SDM by presenting comprehensive information in an understandable format for patients, we cocreated PDAs with input on content and delivery from nephrology clinicians, a national patient advisory group, and 4 patient focus groups. Over the course of 3 unique sessions, we provided education to nephrology clinicians on how to optimally conduct SDM including the presentation of AMCWD to older patients using patient cocreated PDAs, the Ask-Tell-Ask communication approach, and empathetic communication.²¹ Following each session, we assessed the impact of the education on the nephrology clinicians, specifically, whether they reported increased confidence and knowledge about implementing SDM for kidney failure treatment options with older patients with advanced chronic kidney disease (CKD) in their practices. This phase of the research did not include study of patients’ perceptions of the quality of SDM with these trained clinicians.

Materials and Methods

Study Design

We conducted an educational intervention to prepare clinician participants to deliver SDM in the context of the ExPAND clinical trial. In voluntary, written evaluations after each educational session, participants rated their pre- and postsession confidence for the learning objectives of the session. ExPAND compares 2 health system-based approaches for offering kidney failure treatment options to older patients with kidney failure to ensure they are actively involved in a SDM process covering a full range of choices and have meaningful access to that full range of choices, including standard in-center or home dialysis, kidney transplantation, AMCWD, a time-limited trial of dialysis, palliative dialysis, and deciding not to decide.^22,23 The study was approved by the Advarra Institutional Review Board Pro00078064, and informed consent was obtained. All ExPAND procedures comply with the ethical standards of the Declaration of Helsinki and the methodological standards prescribed by the Standards for Quality Improvement Reporting Excellence guidelines.²⁴

Setting and Participants

We provided training in SDM for clinicians at 24 ExPAND clinical sites. Clinicians were invited to attend a 3-session educational series hosted via Zoom between July and September of 2024. The faculty for these sessions were Alvin H. Moss, MD; Christine M. Corbett, DNP; and Elizabeth B. Anderson, DSW, LCSW.

Clinicians from participating nephrology practices included physicians, nurse practitioners, physician assistants, nurses, and social workers, from both academic and private practice settings. Some participants had nonclinical roles, such as office administrators. Participating United States-based nephrology organizations included Clinical Renal Associates, DNA, Interwell Health, MedStar Health: Nephrology at Medstar Washington Hospital Center, North Texas Kidney Disease Associates, Ochsner Health, Renal Care Associates, Renal-Electrolyte & Hypertension Clinic at the University of Pennsylvania Health System, Southeast Kidney Associates, St. Clair Nephrology, The Rogosin Institute, UCSF, Virginia Nephrology Group, and West Virginia University School of Medicine Division of Nephrology.

Quality Improvement Activities

The facilitator-led, synchronous, online training was designed to maximize participant engagement and learning by complementing faculty lectures with real-world, experiential learning activities, including role plays, video demonstrations of clinician–patient interactions, case-based discussions, and sharing of participants’ practice experiences. The goal was to educate nephrology clinicians on how to conduct SDM, with each session focusing on a specific set of learning objectives (Box 1). The first session introduced kidney supportive care for the nephrology clinician. Faculty discussed the need to improve SDM by expanding patient awareness and knowledge of all alternatives to standard home and in-center dialysis and provided an overview of the elements of comprehensive SDM. Participants observed and reflected on a live role play illustrating the Ask-Tell-Ask approach and discussed a case study of a patient with stage 5 CKD, who was opting for AMCWD.

Box 1. Training Session Learning Objectives.

Session	Learning Objectives
Session 1: Kidney Supportive Care for Nephrology Clinician	Describe evidence supporting the need to improve SDM and expand patient knowledge of all kidney replacement alternatives, including kidney transplant, home and in-center dialysis, and active medical care without dialysis (AMCWD).
	Discuss how to present ExPAND to nephrology clinician colleagues to encourage them to refer patients to ExPAND Kidney Disease Education (KDE).
	Inform patients of all alternative treatment plans (ATPs) and why dialysis might not benefit older patients with comorbid conditions, frailty, and/or cognitive or functional impairment.
	Describe how kidney supportive care (KSC) can improve patient care in real-world nephrology practices.
Session 2: Shared Decision Making	Explain the 9 elements of SDM and engage patients in SDM for kidney failure treatment options.
	Apply a cultural humility and trauma-informed care lens for patient-centered care and SDM.
	Deliver KDE using an enriched National Kidney Foundation Council of Advanced Practice Providers (CAPP) curriculum that includes an expanded and balanced presentation of AMCWD.
	Facilitate the use of an evidence-based PDA and video that include unbiased presentations of ATP options.
Session 3: Communication: Building Rapport and Trust	Recall a framework and best practices for a SDM conversation.
	Apply Ask-Tell-Ask with empathy to conduct a SDM conversation.
	Describe stages of change theory as it applies to SDM.
	Respond to patient emotion and ambivalence.
	Apply best practices for engaging patients and their families.

Abbreviations: AMCWD, active medical care without dialysis; ATP, alternative treatment plans; CAPP, Council of Advanced Practice Providers; KSC, kidney supportive care; PDA, patient decision aids; SDM, shared decision making.

The second session took a deeper dive into SDM and the Ask-Tell-Ask approach. Participants learned how to operationalize SDM using the 9 elements of SDM, patient cocreated decision aids on AMCWD (Items S1-S3), and trauma-informed care principles. The SDM-Q-9 is a measure of the patient’s perception of the quality and completeness of the SDM process.²⁵ It was chosen for this study because of its patient acceptance, brevity, and reliability. The elements include the following 9 statements to which the patient indicates the extent of agreement from completely disagree to completely agree:

• 1.“My doctor told me there is a decision to be made.”
• 2.“My doctor wanted to know how I wanted to be involved in the decision.”
• 3.“My doctor told me there are different options for treating my medical condition.”
• 4.“My doctor explained the advantages and disadvantages of the treatment options.”
• 5.“My doctor helped me understand all the information.”
• 6.“My doctor asked me which treatment I preferred.”
• 7.“My doctor weighed with me the different treatment options.”
• 8.“My doctor selected a treatment option together with me.”
• 9.“My doctor reached an agreement on how to proceed together with me.”

In introducing the SDM-Q-9, we wanted clinicians to understand both how we would be measuring SDM in ExPAND and how they could operationalize the 9 elements of SDM in their practice. Based on patient input about cultural tailoring of Kidney Disease Education (KDE), the second session encouraged cultural humility by providers when engaging in SDM. Faculty (EBA) urged attendees to be self-reflective when presenting KDE and taught them techniques to minimize power imbalances. In addition, attendees were introduced to a revised and enriched National Kidney Foundation Council of Advanced Practice Providers curriculum that includes the ExPAND patient cocreated decision aids and an expanded and balanced presentation of all treatment options with their pros and cons, including AMCWD (Items S1-S3).

The third session was centered on patient–provider communication and ways to build rapport and trust. Through interactive discussion, participants reflected on how their values and biases can affect communication with patients, the importance of empathetic listening in SDM, how to identify and respond to emotion, and how to integrate motivational interviewing principles into the SDM process.

Outcomes

All participants were asked to complete a brief evaluation immediately after each educational session while allowing for delayed responses. These confidential, online evaluations were created in collaboration with the West Virginia University Office of Continuing Education using an online form builder (Wufoo) and were distributed to participants via email as web links. Attendees were asked to complete each evaluation in exchange for one continuing education credit hour or a certificate of completion.

In each evaluation, participants were asked to assess their own confidence before and after the session in achieving the learning objectives on a scale from 1 (not confident) to 7 (very confident). In addition, there were open-ended questions, in which participants could provide qualitative feedback including the perceived effect of each session on their competence and skills.

Statistical Analysis

All statistical analyses were performed using statistical software R, version 4.4.2. Descriptive statistics (medians and interquartile ranges [IQRs]) were obtained. The Shapiro–Wilk test for normality showed that our data were not normally distributed; as a result, we pursued nonparametric approaches for our analyses. The Wilcoxon signed-rank paired test was used to compare attendees’ self-reported confidence ratings before and after the training sessions. P < 0.05 was considered significant, and effect sizes (Cohen’s r) were calculated to assess the magnitude of paired differences.²⁶

Results

Participants

Eighty unique individuals attended at least one of the 3 training sessions. There were 74 attendees for the first session, 61 for the second, and 53 for the third, with 39 participants (49%) attending all 3 sessions. We received session evaluations from 33 (45%) first-session participants, 25 (41%) second-session participants, and 19 (36%) third-session participants; 41 of the 80 returned evaluations for 1 or more sessions for an overall response rate of 51%. Of the 41, 37 were clinicians actively engaged in decision making with patients about kidney failure treatment options. Table 1 lists all participants by profession and number of sessions attended. Nurses showed the highest engagement, with 22 of 29 (76%) attending all 3 sessions, followed by advanced practice nurses (7 of 15 [47%]) and nephrologists (4 of 10 [40.0%]). Furthermore, 80.0% of attending nephrologists completed at least one survey evaluation, followed by 67% of social workers, 62% of nurses, and 60% of advanced practice nurses (Table S1). Most attendees 65 (81%) came from private practice settings (Table S2).

Table 1.

KDE Session Attendees by Profession and Number of Sessions Attended

Profession	Total Attendees	Mean Sessions	1 Session	2 Sessions	3 Sessions	Survey Completion Rate
Advanced practice nurse	15	2.4	1 (6.7%)	7 (46.7%)	7 (46.7%)	60.0%
Nurse	29	2.7	1 (3.4%)	6 (20.7%)	22 (75.9%)	62.1%
Nephrologist	10	2.1	3 (30.0%)	3 (30.0%)	4 (40.0%)	80.0%
Physician assistant	4	2.0	1 (25.0%)	2 (50.0%)	1 (25.0%)	50.0%
Social worker	3	2.0	0 (0.0%)	3 (100.0%)	0 (0.0%)	66.7%
Other (administrators and care coordinators)	15	2.2	2 (13.3%)	8 (53.3%)	5 (33.3%)	6.7%
Missing	4	1.2	3 (75.0%)	1 (25.0%)	0 (0.0%)	25.0%
Total	80	2.4	11 (13.8%)	30 (37.5%)	39 (48.8%)	51.2%

Learning Objectives: Self-Reported Confidence Ratings

On a 7-point scale, median postsession confidence ratings increased 1 to 2 points from presession ratings for all learning objectives across all 3 sessions. Explaining the SDM 9 elements and participating with patients in SDM for kidney failure treatment options was the learning objective with the largest median difference in self-reported confidence ratings (2.00, 95% confidence interval [CI], 1.50-3.00; P < 0.001) and the largest effect size (r = 0.84). Table 2 shows all learning objectives sorted from largest to smallest median differences in self-reported confidence ratings and effect size. In total, 4 of these learning objectives were from the first session, 4 from the second, and 5 from the third. All paired differences in scores were left-skewed, failing the Shapiro–Wilk test for normality; as a result, all statistical tests used were nonparametric. Median differences in confidence ratings ranged from 1.0 to 2.0, with effect sizes (Cohen’s r) ranging from 0.45 to 0.84. Effect size estimates were used to standardize the magnitude of a statistical effect.²⁷ For Cohen’s r statistic, |r| ≥ 0.5 is considered a large effect; by this criterion, 12 out of 13 of the increases in confidence were large effects.²⁶ In addition, survey respondents provided qualitative feedback on their experience (Table 3).

Table 2.

Learning Objectives by Largest Increase in Confidence and Effect Size

Objective	Session	Respondents (N)	Pre-Median	Post-Median	Median Differencea	95% Confidence Interval	P Value	Effect Size (r)
Explain the 9 elements of SDM and participate with patients in SDM for kidney failure treatment options.	2	25	5.00	7.00	2.00	1.50-3.00	<0.001	0.84
Discuss how to present ExPAND to nephrology clinician colleagues to encourage them to refer patients to ExPAND kidney disease education.	1	33	5.00	6.00	2.00	1.50-2.50	<0.001	0.75
Deliver kidney disease education using an enriched NKF Council of APP curriculum that includes an expanded and balanced presentation of active medical care.	2	25	5.00	6.00	2.00	1.50-3.00	<0.001	0.75
Describe evidence supporting the need to improve SDM and ExPAND.	1	33	5.00	6.00	1.50	1.00-1.50	<0.001	0.73
Facilitate use of evidence-based patient decision aid videos that include unbiased presentations of alternative treatment plan options.	2	25	5.00	7.00	1.50	1.00-3.00	<0.001	0.73
Apply a cultural humility and trauma-informed care lens to patient-centered care.	2	25	6.00	7.00	1.50	1.00-1.50	0.001	0.68
Describe stages of change theory as it applies to SDM.	3	19	5.00	6.00	1.50	1.00-2.50	0.005	0.67
Describe how kidney supportive care can improve patient care in real-world nephrology practices.	1	33	6.00	7.00	1.50	1.00-2.00	<0.001	0.65
Inform patients of all alternatives to dialysis and why dialysis might not benefit older patients with comorbid conditions, frailty, and/or cognitive or functional impairment.	1	33	6.00	7.00	1.50	0.50-2.50	0.01	0.45
Recall a framework and best practices for SDM conversation.	3	19	5.00	6.00	1.00	1.00-1.00	<0.001	0.79
Apply Ask-Tell-Ask with empathy to conduct a SDM conversation.	3	19	5.00	6.00	1.00	1.00-1.50	0.003	0.75
Respond to patient emotion and ambivalence.	3	19	6.00	6.00	1.00	0.00-0.00	0.002	0.73
Apply best practices for engaging patients and families.	3	19	6.00	6.00	1.00	1.00-1.00	0.008	0.65

Abbreviations: APP, advanced practice provider; NKF, National Kidney Foundation; SDM, shared decision making.

^aTechnically, a pseudomedian, a measure of centrality for non-normally distributed populations.

Table 3.

Open-ended Responses to Evaluation Questions

Planned Changes to Practice and Lessons Learned
Theme	Subtheme	Example quotes
Present AMCWD among kidney failure treatment options	Balanced presentation about AMCWD vs dialysis	Incorporate more discussion and data around the survival benefits of HD vs AMCWD (Nurse)
		I have always counseled patients on supportive care however I have more information…about how it impacts patients. Possible 14 months of life survival and a lower hospitalization rate (Advanced Practice Nurse)
		Helping the patient make their choices by offering all options without feeling uncomfortable doing so (Advanced Practice Nurse)
Apply communication skills	Use Ask-Tell-Ask	Use more Ask-Tell-Ask approach rather than entering visit with my own agenda (Physician Assistant)
		Use Ask-Tell-Ask open-ended questions (Renal Care Coordinator)
	Use silence and active listening	I will try to allow patients more time to speak even if I have to find a different area in the office so this may happen (Nurse)
		Provide areas of silence to allow patient to absorb, think and speak (Nurse)
		Allowing more silence and allowing the patient to guide the conversation (RN, soon to be APN)
	Empathy and responding to emotion	Not use the phrase “I understand” but use reflective language (Nephrologist)
		More actively reflecting patient emotions (Physician Assistant)
	Take time	Allow more time to build trustworthy relationships and discussions (Renal Care Coordinator)
		Allow more time for patients to be able to express feelings and not feel that they are rushed (Nurse)
Incorporate ExPAND tools		Incorporate the tools in the class, like printing the 9 values, emotion wheel, and be more aware of biases (Social Worker)
Reinforced current practice		Knowing evidence base information reinforced my practice (Nephrology)
		Reiterated what I am doing well and alter key points in my conservative care talk (Physician Assistant)
		Provided reassurance that current techniques are successful (Advanced Practice Nurse)

Abbreviations: APN, Advanced practice nurse; AMCWD, active medical care without dialysis; HD, hemodialysis; RN, registered nurse.

We pooled pre-post confidence ratings across the learning objectives for each session (Table S3) and found a significant difference in median pre-post ratings for all 3 (all P = 0.001). Their respective effect sizes all exceeded 0.50, indicating large effects (r = 0.64, r = 0.81, r = 0.79, respectively). As illustrated in Table S4, we conducted the same analysis for participants who attended all 3 sessions and found a significant difference in median pre-post ratings for the second (P = 0.009) and third sessions (P = 0.005) and large effect sizes (r = 0.80, r = 0.82, respectively).

Fig 1 shows the response patterns of the 25 participants in the second session for the learning objective to explain the 9 elements of SDM and participate with patients in SDM for kidney failure treatment decisions. Each line represents one participant’s confidence rating before and after a session. Before the second session, respondents’ confidence scores ranged from 1 to 7 (median 5), covering the full range of the rating scale. After the session, however, all confidence ratings were 4 or higher (median 7). Of the 25 respondents, 20 (80%) scored their postsession confidence higher, whereas 5 (20%) indicated no change in confidence.

Figure 1.

Confidence in explaining the 9 elements of SDM before and after session 2 (N = 25). Each line represents one participant’s self-reported confidence before and after the learning session.

Open-Ended Response Themes

The qualitative feedback (Table 3) supported and reinforced the quantitative findings. Clinicians reported that education about the SDM elements, role modeling of how to present the KDE, provision of patient cocreated decision aids to facilitate SDM, and communication skills training significantly increased their confidence in being able to conduct SDM with their patients.

Discussion

The importance of SDM was first recognized in 1982 by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. In Making Health Care Decisions: A Report on the Ethical and Legal Implications of Informed Consent in the Patient-Practitioner Relationship, the commission articulated that SDM was necessary for ethically valid consent. They conceptualized informed consent as active SDM.²⁸ The challenge has been how to educate nephrology clinicians to engage in high-quality SDM that informs patients of all their kidney failure treatment options including the benefits and risks of each and encourages them to participate in SDM with their patients as equal partners.

Contributing to the problem, as found in more recent studies, many, if not most, nephrologists do not inform patients of one of the kidney failure treatment options—AMCWD—despite the cumulative evidence showing that dialysis may not confer a survival advantage over AMCWD for some older CKD patients with comorbid conditions.29, 30, 31, 32, 33, 34 Until recently, PDAs for older CKD patients have included little or no content about AMCWD.^16,35 In the context of the importance of SDM and the failure to optimally implement it in the care of patients with kidney disease in the past 25 years, the findings from the ExPAND clinician education are instructive. Clinicians valued education that increased their knowledge of SDM and provided them with communication skills and PDAs to facilitate it. Specifically, in their quantitative evaluations, the clinicians indicated the greatest increases in their confidence for 3 learning objectives: explaining the 9 elements of SDM and participating with patients in SDM for kidney failure treatment options; discussing how to present the ExPAND intervention to their clinician colleagues to encourage them to refer their patients to the ExPAND KDE; and delivering KDE using the ExPAND-enriched NKF Council of advanced practice provider curriculum that includes a balanced presentation of AMCWD using slides and PDAs (Items S1-S3). Large increases in confidence were also reported for describing the evidence supporting the need to improve SDM, facilitating use of evidence-based PDAs that include unbiased presentations of alternatives to standard in-center and home dialysis, and applying a cultural humility and trauma-informed care lens to patient-centered care.

Most noteworthy is the fact that despite being recommended by nephrology professional societies for decades and touted in hundreds of nephrology articles, these clinicians seemed to appreciate explicit instruction on how to conduct SDM including the Ask-Tell-Ask communication approach, conversation openers, terminology, and video demonstrations, all of which showed how to operationalize SDM in their conversations with patients.³⁶ Schell et al³⁷ have conducted communication skills training with nephrology fellows and in a pre- and post-training evaluation demonstrated improvement in fellows’ ability to deliver bad news. Our training with a before and after evaluation was with nephrologists, nurse practitioners, nurses, and social workers in nephrology practices and assessed their increase in confidence in using SDM to discuss kidney failure treatment options using patient cocreated PDAs with an empathetic communication approach. As Schell et al³⁷ note and citing Curtis et al,³⁸ there are no positive studies of communication workshops or trainings in which the learned skills have been translated into sustained clinical practice improvements.

The ExPAND education boosted the confidence of these learners. These findings are limited to the short-term self-perceived impact of the education. We are currently collecting data to assess impact on patient perceptions of their SDM experience using the SDM-Q-9 survey. We are also collecting data on whether patient decisional conflict decreased after participating in the ExPAND clinical trial.

It is noteworthy that only 10 of the 80 participants in the training were nephrologists (12.5%). Multidisciplinary teams including nurse practitioners, nurses, and social workers have been useful to leverage the bottleneck created by limited nephrologist time for activities such as KDE and advance care planning.39, 40, 41 In one of our previous studies, nephrologists initially assumed they would lead goals of care and advance care planning conversations but lacked time. As their teams became comfortable with conversations, the nephrologists delegated more to nurse practitioners, nurses, and social workers.⁴² In ExPAND, nurse practitioners and nurses are providing most of the KDE. Indeed, the American Nephrology Nurses Association has endorsed the role that nurse practitioners and nurses can play in these activities and others to promote patient choice and quality of life.⁴³

Limitations

This study has several limitations. First, the perceptions of the participants may not be generalizable to all nephrology clinicians. The participants accepted that AMCWD should be presented as part of SDM to older patients with CKD, and they were from nephrology practices whose leadership “bought in” to the importance of their clinicians learning how to implement SDM in their care of patients. Research suggests that many nephrologists may not be comfortable with presenting AMCWD to their patients.²⁹ Second, the number of participants in the educational sessions was modest. Third, findings may be biased if the 41 respondents tended to have different opinions about the sessions than the 39 nonrespondents. Fourth, we did not demonstrate positive patient outcomes in our study; we only reported an increase in confidence and knowledge of clinicians in providing the ExPAND intervention. There is a need to show that there is a benefit to patients from communication skills training for SDM to their clinicians. Finally, we did not measure whether the training impact was sustained over time.

Conclusions

The ExPAND clinician education in shared SDM using PDAs was conducted to address the challenges to implementing SDM for older patients with CKD in a culturally sensitive, trauma-informed way. The marked increase in clinician confidence in participating in SDM with their patients suggests that the education may represent a significant advance in the implementation of high-quality SDM in the care of older patients with CKD. Future study of the ExPAND clinical trial outcomes will show whether clinicians implemented their new knowledge and confidence in conducting SDM in their practice, how highly patients evaluated their SDM conversations with their clinicians, and whether improvements in SDM were sustained.

Supplementary Materials

Supplementary File (PDF)

Items S1-S3; Tables S1-S4.