User Manual Decisional Conflict Scale

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1 User Manual – Decisional Conflict Scale Table of Contents 1. Definition ... ...1 2. Conceptual Framework ... ...2 sional Conflict Scale (DCS) [Table] ...3 3. Comparison of Versions of the Deci 4. Versions of the Decisi onal Conflict Scale (DCS) 4.1 Traditional DCS: Statement form at 16 item 5 response categories ...4 Sample Tool Scoring and Interpretation Psychometric Properties Applications Using this Tool Other Languages Availability Suggested Citation 4.2 Question Format DCS: 16 item 5 response categories ...7 Sample Tool Scoring and Interpretation Psychometric Properties Applications Using this Tool Other Languages Availability Suggested Citation 4.3 Question Format DCS: 10 item 3 response categories ...9 Sample Tool Scoring and Interpretation Psychometric Properties Applications Using this Tool Other Languages Availability Suggested Citation 4.4 SURE tool version for clinical pr actice: 4 items 2 response categories ...12 Sample Tool Scoring and Interpretation Psychometric Properties Applications Using this Tool Other Languages Availability Suggested Citation 5. Annotated References ... ...15 1. Definition The decisional conflict scale measures personal percep tions of : a) uncertainty in choosing options; b) modifiable factors contributing to un certainty such as feeling uninformed, unclear about personal values and feeling the choice is informed, effective decision making such as unsupported in decision making; and c) values-based, likely to be implemented a on with the choice. nd expressing satisfacti 1 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

2 User Manual – Decisional Conflict Scale 2. Conceptual Framework The conceptual framework guiding the scale development is reported in detail elsewhere [1]. It was derived from the construct of decisional conflict developed by Janis and Mann [16] and refined as a diagnosis by the North American Nursing Diagnosis Asso ciation [17]. Decisional c onflict is a state of uncer tainty about a course with decisions involving risk or likely when a person is confronted of action. Such uncertainty is more significant potential gains and losses are entertained, uncertainty of outcomes, when high-stakes choices with when there is a need to make value tradeoffs in selecti ng a course of action, or when anticipated regret over the in behavioural manifestations of decisional conflict positive aspects of rejected options is probable. The ma include verbalized uncertainty about choices, verbalization of the undesi red consequences of alternatives; vacillation between choices, and delayed decision maki ng. Minor manifestations in clude verbalized distress tension, and questioning personal ocusing, physical signs of distress or while attempting decision making, self-f values and beliefs while attempting to make a decision. ccurs as a consequence of the difficulty Although decisional conflict o inherent in the type of decision being made, several modifiable cognitive, affective and soci the perceived uncertainty. al factors can exacerbate Uncertainty is greater when a person: 1) feels uninformed a bout the alternatives, benefits and risks; 2) is unclear about personal values; 3) feels unsup ported in making a choice or pressu red to choose on course of action. Decisional conflict can be lowered w ith decision supporting interventions. Information about options, benefits, clarified using strategies such as: risks, and side effects can make peopl e feel more informed. Values can be better judge their cial impacts) to (including physical, emotional, and so describing outcomes in sufficient detail value; and asking patients to rate the personal importance of outcomes. People may feel more supported in on and shared decision making. As a decision making if they are guided or coached in the steps of deliberati consequence, their uncertainty stemming from these modi fiable factors may decline, and they may feel they have made a better decision. By better decision, they ma y feel that they have made a more informed value- based decision, are more likely to stick with their choice, and are more sati sfied with the decision. There is considerable empirical data to support the effects of decision supporting interventions on decisional fiable constructs [1,3]. conflict and its related modi 2 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

3 User Manual – Decisional Conflict Scale lict Scale (DCS) Decisional Conf 3. Comparison of Versions of the There are 4 versions of the scale: 1 for clinical practice (see page 12) and 3 for research. This table compares versions are also provided the research versions. More details on these three on subsequent pages. A. STATEMENT FORMAT B. QUESTION FORMAT C. LOW LITERACY 16 items 10 items 16 items 3 response categories 5 response categories 5 response categories statements questions questions  Easier response format Response format most useful Used in most studies to date   for people with limited reading Many respondents like this version   More precision than 3 item or response skills response format because it is personal  Willing to forgo precision  Those with limited response skills find Least tested: now being tested  it harder to respond to with hundreds of patients Second most tested version  RESPONSE FORMATS strongly agree, agree, neither agree or yes, probably yes, unsure, probably yes, no, unsure no, no disagree, disagree, strongly disagree INFORMED SUBSCALE Do you know which options are I know which options are available to me. Do you know which options are available to you? available to you? I know the benefits of each option. Do you know the benefits of each Do you know the benefits of each option? option? effects of each option. Do you know the risks and side effects Do you know the risks and side effects I know the risks and side of each option? of each option? VALUES CLARITY SUBSCALE Are you clear about which benefits Are you clear about which benefits I am clear about which benefits matter most to me. matter most to you? matter most to you? I am clear about which risks and side effects Are you clear about which risks and Are you clear about which risks and side effects matter most to you? matter most. side effects matter most to you? I am clear about which is more important to me Are you clear about which is more (the benefits or the risks and side effects). important to you (the benefits or the risks and side effects)? SUPPORT SUBSCALE Do you have enough support from Do you have enough support from I have enough support from others to make a choice. others to make a choice? others to make a choice? Are you choosing without pressure Are you choosing without pressure I am choosing without pressure from others. from others? from others? I have enough advice to make a choice. Do you have enough advice to make a Do you have enough advice to make a choice? choice? UNCERTAINTY SUBSCALE Are you clear about the best choice for Are you clear about the best choice for I am clear about the best choice from me . you? you? Do you feel sure about what to choose? Do you feel sure about what to choose? I feel sure about what to choose. This decision is easy for me to make. Is this decision easy for you to make? EFFECTIVE DECISION SUBSCALE I feel I have made an informed choice. Do you feel you have made an informed choice? My decision shows what is important to me. Does your decision show what is important to you? Do you expect to stick with your I expect to stick with my decision. decision? Are you satisfied with your decision? I am satisfied with my decision. 3 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

4 User Manual – Decisional Conflict Scale 4. Versions of the Decision al Conflict Scale (DCS) Statement Format: 16 item 5 response categories 4.1 Traditional Decisional Conflict Scale (DCS) - This is our most tested version. Many people like the personal response format. However it is more difficult with limited reading and response skills. to respond to than questions in those Note: ence question, which is not included in scoring. We always precede the DCS with an option prefer [See item ‘A’ below]. 4.1.1 Scale My difficulty in making this choice A. Which [insert treatment/screening] option do you prefer? Please check  one. [Option 1] [Option 2] [Option 3] Unsure B. Considering the option you prefer, pl ease answer the following questions: Disagree Neither Strongly Agree Strongly Disagree Agree Agree Or Disagree [2] [1] [0] [3] [4] 1. I know which options are available to me. 2. I know the benefits of each option. I know the risks and side effects of each option. 3. 4. I am clear about which benefits matter most to me. 5. I am clear about which risks and side effects matter most. I am clear about which is more important to me (the benefits 6. or the risks and side effects). I have enough support from others to make a choice. 7. 8. I am choosing without pressure from others. 9. I have enough advice to make a choice. I am clear about the best choice for me. 10. 11. I feel sure about what to choose. 12. This decision is easy for me to make. I feel I have made an informed choice. 13. My decision shows what is important to me. 14. I expect to stick with my decision. 15. 16. I am satisfied with my decision. Decisional Conflict Scale © AM O’Connor, 1993, revised 2005 4 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

5 User Manual – Decisional Conflict Scale 4.1.2 Scoring and interpretation Items are given a score value of: disagree’; 3 = ‘disagree’; 4 = ‘strongly disagree’. 0 = ‘strongly agree’; 1 = ‘agree’; 2 = ‘neither agree nor TOTAL SCORE 1-16 inclusive] are: a) summed; b) divided by 16; and c) multiplied by 25. 16 items [items to 100 [extremely hi gh decisional conflict]. Scores range from 0 [no decisional conflict] UNCERTAINTY SUBSCORE 3 items [ 10, 11, 12 ] are: a) summed; b) divided by 3; and c) multiplied by 25. Scores range from 0 [feels extremely eels extremely uncertain about best certain about best choice] to 100 [f choice]. INFORMED SUBSCORE 3 items [ 1, 2, 3 ] are: a) summed; b) divided by 3; and c) multiplied by 25. Scores range from 0 [feels extremely info rmed] to 100 [feels extremely uninformed]. VALUES CLARITY SUBSCORE 3 items [ 4, 5, 6 ] are: a) summed; b) divided by 3; and c) multiplied by 25. Scores range from 0 [feels extremely clear about personal values for bene fits & risks/side effects] to 100 [feels extremely unclear about personal values] SUPPORT SUBSCORE 7, 8, 9 3 items [ by 3; and c) multiplied by 25. ] are: a) summed; b) divided Scores range from 0 [feels extrem 100 [feels extremely unsupported in ely supported in decision making] to decision making]. EFFECTIVE DECISION SUBSCORE 4 items [ 13, 14, 15, 16 ] are: a) summed; b) divided by 4; and c) multiplied by 25. Scores range from 0 [good decision] to 100 [bad decision]. NOTE: The Cochrane systematic review of trials of patient d ecision aids [3] uses this scoring method; other papers may present scores ranging from 1 [low decisional conflict] to 5 [high decisional conflict]. If the SCORE or SUBSCORE is reported as a percentage or on a 0-100 scale no conversion is required. If the average SCORE or SUBSCORE is reported on the 1-5 scale th en to convert these scores to the equivalent 0-100 scale: a) b) then multiply by 25. subtract 1 from the score; e then to convert these scores to the a sum of items that used the 1-5 scal If the SCORE or SUBSCORE is reported as items summed; b) then subtract 1; c) then multiple by 25. equivalent 0-100 scale: a) divide the score by the number of 4.1.3 Psychometric Properties Reliability:  test-retest correlations and Cronb ack alpha coefficients exceed 0.78. Construct Validity:  correlated to related cons tructs of knowledge, regr et, and discontinuance. and delay decisions (effect size [ES] ranges 0.4  discriminates between known groups: those who make to 0.8). 5 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

6 User Manual – Decisional Conflict Scale Responsive to change:  in before/after studies of decisi on supporting interventions, effect size ranges from 0.4 to 1.2 for the total scale. discriminates between different decision supporting interventions:  Informed subscale consistently discriminates (ES 0.3 to 0.4). o o Total score and other sub-scores less consis tent [especially when decision supporting intervention compared to alte rnative intervention rather than to usual care controls - total scale ES: 0.2 to 0.3 uncertainty scale: 0.06 to 0.3 - - unclear values ES: 0.3 to 0.4 unsupported ES: 0.0 to 0.3 - - quality of choice: 0.2 to 0.3 Predictive validity: Sun [18] found that for every unit increase in the DCS, people were: • 59 times more likely to change their mind delay their decision 23 times more likely to • • 5 times more likely to express decisional regret • a knowledge test on options 3 times more likely to fail Gattelari and Ward [19] found that for were 19% more likely to blame their every unit increase in DCS, patients doctor for bad outcomes. Decisional conflict was an i ndependent predictor of blam e, separate from other predictors such as knowledge sc ores and age of the patient. Meaningful differences:  we usually base sample sizes on dete cting an effect size of 0.30 to 0.40;  scores lower than 25 are associated with implemen ting decisions; scores exceeding 37.5 are associated with decision delay or feeling unsure about implementation. 4.1.4 Applications using this tool The scale has been used in more than 30 studies for numerous decisions. 4.1.5 Availability You may use any of these scales at no cost without permission. These tools are protected by copyright but are freely available for you to use, provided you cite the reference in any questionnaires or publications. 4.1.6 Suggested Citations O’Connor AM. Validation of a deci sional conflict scale. Med Dec Ma king 1995; 15(1): 25-30. The classic psychometric paper. O'Connor AM. User Manual - Decisional Conflict Scale (16 item statement fo rmat) [document on the Internet]. 993 [updated 2010; cited YYYY MM DD]. 16 p. Available Ottawa: Ottawa Hospital Research Institute; © 1 . User_Manuals/UM_Decisional_Conflict.pdf http://decisionaid.ohri.ca/docs/develop/ from 6 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

7 User Manual – Decisional Conflict Scale . Question Format Decisional Conflict Sc 4.2 ale (DCS) - 16 item 5 response categories This version is being tested by the Foundation for Informed Medical Decision Making as part of a standardized suite of decision pro cess quality and decision quality m easures using IPDAS Collaboration. Note: ence question, which is not included in scoring. We always precede the DCS with an option prefer [See item ‘A’ below]. 4.2.1 Scale My difficulty in making this choice A. Which [insert treatment/screening] option do you prefer? Please check  one. a. [Option 1] b. [Option 2] c. [Option 3] Unsure d. ease answer the following questions: Considering the option you prefer, pl B. No Yes Probably Unsure Probably no yes [1] [3] [2] [0] [4] Do you know which options are available to you? 1. 2. Do you know the benefits of each option? Do you know the risks and side effects of each option? 3. 4. Are you clear about which benefits matter most to you? Are you clear about which risks and side effects matter most 5. to you? 6. Are you clear about which is more important to you (the benefits or the risks and side effects)? 7. Do you have enough support from others to make a choice? 8. Are you choosing without pressure from others? 9. Do you have enough advice to make a choice? 10. Are you clear about the best choice for you? Do you feel sure about what to choose? 11. 12. Is this decision easy for you to make? 13. Do you feel you have made an informed choice? 14. Does your decision show what is important to you? 15. Do you expect to stick with your decision? 16. Are you satisfied with your decision? © AM O’Connor, 1993, revised 2005 Decisional Conflict Scale 7 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

8 User Manual – Decisional Conflict Scale 4.2.2 Scoring and Interpretation Items are given a score value of: 0 = ‘yes’; 1 = ‘probably yes’; 2 = ‘u nsure’; 3 = ‘probably no’; 4 = ‘no’. TOTAL SCORE 1-16 16 items [items divided by 16; and c) multiplied by 25. inclusive] are: a) summed; b) Scores range from 0 [no decisional conflict] to 100 [extremely hi gh decisional conflict]. UNCERTAINTY SUBSCORE 3 items [ d by 3; and c) multiplied by 25. ] are: a) summed; b) divide 10, 11, 12 certain about best choice] to 100 [f eels extremely uncertain about best Scores range from 0 [feels extremely choice]. INFORMED SUBSCORE 3 items [ 1, 2, 3 ] are: a) summed; b) divided by 3; and c) multiplied by 25. Scores range from 0 [feels extremely info rmed] to 100 [feels extremely uninformed]. VALUES CLARITY SUBSCORE by 3; and c) multiplied by 25. ] are: a) summed; b) divided 3 items [ 4, 5, 6 clear about personal values for bene Scores range from 0 [feels extremely fits & risks/side effects] to 100 [feels extremely unclear about personal values] SUPPORT SUBSCORE 3 items [ ] are: a) summed; b) divided by 3; and c) multiplied by 25. 7, 8, 9 Scores range from 0 [feels extrem ely supported in decision making] to 100 [feels extremely unsupported in decision making]. EFFECTIVE DECISION SUBSCORE 4 items [ 13, 14, 15, 16 ] are: a) summed; b) divide d by 4; and c) multiplied by 25. Scores range from 0 [good decision] to 100 [bad decision]. 4.2.3 Psychometric Properties We will have psychometric data on the scale’s performance shortly. 4.2.4 Applications using this Tool tested in several clinical services with larg e scale populations in New Hampshire The scale is currently being [breast cancer, back surgery, hi p and knee surgery, PSA testing]. 4.2.5 Availability You may use any of these scales at no cost without permission. These tools are protected by copyright but are freely available for you to use, provided you cite the reference in any questionnaires or publications. 4.2.6 Suggested Citation O'Connor AM. User Manual - Decisiona l Conflict Scale (16 item question fo rmat) [document on the Internet]. Ottawa: Ottawa Hospital Research Institute; © 1 993 [updated 2010; cited YYYY MM DD]. 16 p. Available from . User_Manuals/UM_Decisional_Conflict.pdf http://decisionaid.ohri.ca/docs/develop/ 8 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

9 User Manual – Decisional Conflict Scale Question Format DCS - 10 item 3 response categories 4.3 This version is recommended for those with limited reading or response skills. ence question, which is not included in scoring. Note: We always precede the DCS with an option prefer [See item ‘A’ below]. 4.3.1 Scale My difficulty in making this choice Which A. option do you prefer? Please check  one. [insert treatment/screening] [Option 1] a. b. [Option 2] c. [Option 3] d. Unsure Considering the option you prefer, pl B. ease answer the following questions: Unsure Yes No [0] [4] [2] 1. Do you know which options are available to you? 2. Do you know the benefits of each option? 3. Do you know the risks and side effects of each option? Are you clear about which benefits matter most to you? 4. Are you clear about which risks and side effects matter most to you? 5. 6. Do you have enough support from others to make a choice? Are you choosing without pressure from others? 7. Do you have enough advice to make a choice? 8. Are you clear about the best choice for you? 9. 10. Do you feel sure about what to choose? Decisional Conflict Scale © AM O’Connor, 1993, revised 2005 4.3.2 Scoring and Interpretation Items are given a score value of: 0 = ‘yes’; 2 = ‘ unsure’; 4 = ‘no’. TOTAL SCORE 10 items [items 1-10 inclusive] are: a) summed; b) di vided by 10; and c) multiplied by 25. Scores range from 0 [no decisional conflict] to 100 [extremely hi gh decisional conflict]. UNCERTAINTY SUBSCORE ] are: a) summed; b) divide 9, 10 d by 2; and c) multiplied by 25. 2 items [ certain about best choice] to 100 [f eels extremely uncertain about best Scores range from 0 [feels extremely choice]. 9 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

10 User Manual – Decisional Conflict Scale INFORMED SUBSCORE 1, 2, 3 3 items [ by 3; and c) multiplied by 25. ] are: a) summed; b) divided rmed] to 100 [feels extremely uninformed]. Scores range from 0 [feels extremely info VALUES CLARITY SUBSCORE d by 2; and c) multiplied by 25. 4, 5 2 items [ ] are: a) summed; b) divide Scores range from 0 [feels extremely fits & risks/side effects] to 100 clear about personal values for bene [feels extremely unclear about personal values] SUPPORT SUBSCORE 3 items [ 6, 7, 8 ] are: a) summed; b) divided by 3; and c) multiplied by 25. ely supported in decision making] to 100 [feels extremely unsupported in Scores range from 0 [feels extrem decision making]. 4.3.3 Psychometric Properties English Alpha coefficient was : The scale has been tested with 63 women consid ering breast cancer options. to the time following use of a video decision aid 0.86. The scale is responsive to cha nge from baseline (time 1) (T2) and counseling about options (T3). 10 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

11 User Manual – Decisional Conflict Scale ng women in disadvantaged areas in has been tested with Spanish speaki Spanish: The low literacy version Chile. The alpha coefficient was 0.72 and the scale disc riminated significantly be tween those who were: a) actively deliberating among options; a nd b) not contemplating options or had already made their choice. 4.3.4 Applications using this Tool ), USA (New Hampshire, Washington teracy populations in Canada (Ottawa The scale has been used in low li DC, Texas) and Chile. 4.3.5 Availability You may use any of these scales at no cost without permission. copyright but are freely available for you to use, provided you cite the reference in These tools are protected by any questionnaires or publications. 4.3.6 Suggested Citation O'Connor AM. User Manual - Decisiona l Conflict Scale (10 item question fo rmat) [document on the Internet]. 993 [updated 2010; cited YYYY MM DD]. 16 p. Available Ottawa: Ottawa Hospital Research Institute; © 1 User_Manuals/UM_Decisional_Conflict.pdf . http://decisionaid.ohri.ca/docs/develop/ from 11 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

12 User Manual – Decisional Conflict Scale SURE test version for clinical pr response categories 4.4 The actice: 4 items 2 This version is recommended for use in everyday clinical practice. Note: ence question, which is not included in scoring. We always precede the DCS with an option prefer [See item ‘A’ below]. 4.4.1 Scale A. Which option do you prefer? Please check  one. [insert treatment/screening] [Option 1] a. b. [Option 2] [Option 3] c. d. Unsure Yes No [1] [0] Do you feel SURE about the best choice for you? S ure of myself Do you know the benefits and risks of each option? U nderstanding information Are you clear about which benefits and risks matter most to you? isk-benefit ratio R Do you have enough support and advice to make a choice? E ncouragement The SURE Test © O’Connor and Légaré, 2008. Non Oui [0] [1] Êtes-vous certain de ce qui constitue le meilleur choix pour vous? S ûr Est-ce que vous connaissez les bénéfices et risques de chacune des tilité de l’information U options? Avez-vous le sentiment de savoir ce qui est le plus important pour R isques-bénéfices à vous à l’égard des risques et bénéfices? balancer n afin de faire votre choix? Avez-vous suffisamment de soutie ncouragement E The SURE Test © O’Connor and Légaré, 2008. 4.4.2 Scoring and Interpretation Items are given a score value of: 0 = ‘no’; 1 = ‘yes’. TOTAL SCORE (UNCERTAINTY) Can only be calculated if all items are answered. The 4 items are summed. decisional conflict]. onal conflict] to 4 [no Scores range from 0 [extremely high decisi A score of 3 indicates decisional conflict ≤ 12 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

13 User Manual – Decisional Conflict Scale 4.4.3 Psychometric Properties In English: The scale has been tested with 1474 patients re ferred to watch condition- specific video decision aids as part of their standard proc ess of care. Alpha coefficient was 0.86 . The scale is responsive to change from baseline (time 1) to the time following use of a video decision aid (T2) and c ounseling about options (T3) [22]. The SURE test was completed by 123 French-sp eaking pregnant women registered at family In French: medicine clinics in Quebec City [23]. SURE score N (%) Proportion who had Proportion who had not made choices made choices 96 % 4% 4 981 (67%) 3 272 (18%) 66% 34% 2 147 (10%) 59% 41% 1 54 (4%) 54% 46% 0 20 (1%) 65% 35% Table 1. the SURE scores of patient s in the treatment-opti on group (N=1474) and the proportion of them who had not made treatment choices. Reliability of the SURE SURE was moderate (Cronbach The internal reliability of α was 0.54 in French-speaking pregnant women and 0.65 in English-speaking tr eatment-option patients). In the group of pregnant women, removing 1 item (ie, support) produced a higher value (Cronbach α = 0.61). In the group of treatment-option patients, all item-to- item correlations were positive and ranged from 0.46 to 0.71. Construct validation ted negatively with the DCS score egnant women, the SURE score correla In the group of French-speaking pr s who had not made choices about speaking treatment-option group, patient (r=-0.46; P < .0001). In the English- treatment (n=225) had lower mean (SD) SURE scores than those who had (n=1249) (2.6 (1.0) vs 3.6 (0.8), respectively; P < .0001) (See table 1). A factorial analysis of the SURE test in the group of pregnant women i ndicated that 2 factors accounted for and certainty) loaded under 1 factor. The other item 72% of the variance. Three items (ie, knowledge, value, (ie, support) loaded under the second f actor. In the treatment-option group, 1 factor accounted for 49% of the variance. Yes Responses, % Risk-benefit Understand Sure of Ecouragement myself information ratio Patient group and Conditions N French-speaking pregnant women 123 87 98 94 98 Prenatal screening  English-speaking treatment-option patients, Total N=1474 160 80 99 95 94  Hip osteoarthritis 90 98 292 75 95 Knee osteoarthritis  93 99 177 76 93  Herniated disk 13 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

14 User Manual – Decisional Conflict Scale Yes Responses, % Understand Risk-benefit Sure of Ecouragement myself information ratio Patient group and Conditions N 84 90 95 295 71 Spinal stenosis  80 89 89 171 75  Chronic back pain 204 59 96 90 77  Prostate cancer 86 74 86 93 97  Breast cancer reconstruction 84 87 96 89 60  Early-stage breast cancer surgery each of the 4-item SURE questions, by conditions Table 2. Percentage of participants responding yes to Correlation with Total Risk-benefit Understand Sure of Encouragement N Participant group myself information ratio French-speaking pregnant women 0.07 0.32 0.59 123 0.47 English-speaking treatment-option 0.49 0.33 0.45 1474 0.46 patients Table 3. Item-to-total Pearson correlation coefficient results for the 2 participant groups 4.4.4 Applications using this Tool The tool has been used in 2 studies . Further research should assess the pe rformance of the SURE test with a more diverse group of patients. 4.4.5 Other Languages This tool is available in English and in French. 4.4.6 Availability at no cost without permission. You may use any of these scales e, as long as you cite the reference in These tools are protected by c opyright but are freely available for you to us any questionnaires or publications. 4.4.7 Suggested Citations For the SURE tool: Légaré F, Kearing S, Clay K, Gagnon S, D’Amours D, Rousseau M, O’Connor AM. Are you SURE? Assessing patient decisional conflict with a 4-item sc reening test. Can Fam Physician 2010; 56:e308-314. For this User Manual: Ottawa: Ottawa Hospital document on the Internet]. O'Connor AM. User Manual - Decisiona l Conflict Scale [ Research Institute; © 1993 [updated 2010; cited YYYY MM DD]. 16 p. Available from User_Manuals/UM_D ecisional_Conflict.pdf http://decisionaid.ohri.ca/docs/develop/ . © 1993 [updated 2010]. Available fr 14 om www.ohri.ca/decisionaid. AM O'Connor, User Manual - Decisional Conflict Scale.

15 User Manual – Decisional Conflict Scale 5. Annotated References 1. O’Connor AM. Validation of a deci sional conflict scale. Med Dec Ma king 1995; 15(1): 25-30. The classic psychometric paper. 2. Brehaut JC, O’Connor AM, Wood TJ, Hack TF, Siminoff L, Gordon E, Feldman-Stewart D. Validation of a decision regret scale. Medica l Decision Making 2003; 23:000-000. S hows correlation between DCS and regret. 3. O’Connor AM, Stacey D, Rover D, Holmes-Rovner M, Tetroe J, Llewellyn-Thomas H, Entwistle V, Rostom A, Fiset V, Barry M, Jones J. The Cochrane Databases of Systematic Reviews. The Cochrane that used DCS...note the smaller effect size when a Library, Volume (1) 2003. There are several studies simpler decision aid is compared to decision aid than when decision aid compared to usual care. 4. O’Connor AM, Fiset V, DeGrasse C, Graham ID, Ev ans W, Stacey D, Laupacis A, Tugwell P. Decision ncer Outcomes: Evidence of Efficacy and Policy Aids for Patients Considering Options Affecting Ca itute Monographs, No. 25, 1999. Several before/after Implications. Journal of the National Cancer Inst studies cited here. rd O’Connor AM, Decisional conflict (Specify ). Nursing diagnosis and intervention, 3 5. ed., 486-496. Construct defined in first ( 1989) and subsequent editions. 6. Patient Decision Aid Research Group url fo r accessing evaluation measure information . http://decisionaid.ohri.ca/eval.html 7. Hollingworth G, McPherson R, Drake E, Hopman O’Connor AM, Tugwell P, Wells GA, Elmslie T, Jolly E, Self-administered Decision Aid for Postmenopausal W, Mackenzie T. Randomized Trial of a Portable, Women Considering Long-term Preventive Hormone Therapy. Medical Decision Making 1998; 18:295- 303. USED TRADITIONAL DCS. 8. Laupacis A, O’Connor AM, Drake ER, Rubens FD, R obblee JA, Grant FC, Wells PS. A decision aid for autologous pre-donation in cardiac surgery – a randomi zed trial. Patient Education and Counselling (in press). USED TRADITIONAL DCS. 9. Man-Son-Hing M, Laupacis A, O’Connor AM, Biggs J, Drake E, Yetisir E, Hart RG. A Patient Decision Aid Regarding Antithrombotic Therapy for Stroke Prevention in Atrial Fibrillation, A Randomized Controlled Trial. JAMA. 1999; 282: 737-743. USED TRADITIONAL DCS AM. Prise de décision en matière d’hormonothérapie Dodin S, Legare F, Daudelin G, Tetroe J, O’Connor 10. dian Family Physician 2001; 47: 1586-1593. USED de replacement, Essai clinique randomise. Cana FRENCH TRADITIONAL DCS Feldman Stewart D, Brundage MD, Manen LV. A decisi on aid for men with early stage prostate cancer: 11. theoretical basis and a test by surrogate patients. Health Expe ctations 2001; 4: 221-234. USED TRADITIONAL DCS 12. Siminoff LA, Ravdin P, Colabianchi N, Saunders Stur m CM. Doctor-patient comm unication patterns in breast cancer adjuvant therapy di scussions. Health Expectations 2000; 3: 26-36. USED TRADITIONAL DCS 13. Morgan MWA randomized trial of the ischemic h eart disease shared decision making program: an evaluation of a decision aid. University of Toronto; 1997. USED TRADITIONAL DCS Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomised controlled trial of an interactive 14. erapy in primary care. BMJ 2001; 323: 490-3. USED multimedia decision aid on hormone replacement th TRADITIONAL DCS 15 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

16 User Manual – Decisional Conflict Scale 15. Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypert rophy in primary care. BMJ 2001; 323: 493-6. USED TRADITIONAL DCS Janis IL, Mann L. Decision Making. New York: The Fr 16. ee Press, 1977. Psychological basis for defining the construct. Association. 10th Conference on Clas 17. North American Nursing Diagnosis sification of Nursing Diagnoses. San Diego: California, 1992. Definition from a standard taxonomy of nursing problems. ecisional Conflict: Meta-analyses of the Decisional Sun, Qiao. Predicting Downstream Effects of High D 18. Conflict Scale Unpublished MSc thesis trates the predictive validity of . University of Ottawa, 2005. Demons the DCS on option knowledge, decision de lay, discontinuance, and regret. 19. Gattelari & Ward J Med Screen 200 4;11:165-169. Shows independent e ffect of decisional conflict on tendency to blame doctor for bad outcomes if th ey forgo PSA testing for prostate cancer. Urrutia M, Campos S, O’Connor A. Validación de una la Escala de Conflicto versión en español de 20. Decisional. Revita Médi ca de Chile 2008; 136:1439-1447. s and their physicians: a 21. LeBlanc A, Kenny DA, O'Connor AM, Légaré F. Deci sional conflict in patient dyadic approach to shared decision making. Me d Decis Making. 2009 Jan-Feb;29(1):61-8. Epub 2009 Feb 4. 22. Légaré F, Kearing S, Clay K, Gagnon S, D’Amours D, Rousseau M, O’Connor AM. Are you SURE? Assessing patient decisional conflic Can Fam Physician 2010; 56:e308-314. t with a 4-item screening test. ch do family physicians ues S, Légaré F. How mu 23. Gagnon S, Labrecque M, Njoya M, Rousseau F, St-Jacq screening for Down syndrome? Prenat Diagn. 2010 involve pregnant women in decisions about prenatal Feb; 30(2): 115-121. 16 AM O'Connor, User Manual - Decisional Conflict Scale. © 1993 [updated 2010]. Available fr om www.ohri.ca/decisionaid.

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