Perspectives on shared decision making related to medications from patients with multiple long- term conditions transitioning from hospital to home: a qualitative study

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Syversen, Liv Mathiesen, Michael Scott, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7486247/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Apr, 2026 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Persons with multiple long-term conditions (MLTCs) are often reliant on complex medication regimens where decisions surrounding medications are frequent and shared decision making (SDM) is beneficial. Aim The aim was to explore the perspectives of patients with MLTCs regarding SDM related to medications before, during and after a hospital stay. Method Semi-structured interviews with 21 patients and 3 next of kin were conducted. Normally home-dwelling patients ≥ 18 years with MLTCs, using a minimum of 4 medications for a minimum of 2 separate conditions were included from two geriatric wards and one internal medicine ward at a university hospital in Norway, and interviewed approximately 14 days post hospital discharge. The qualitative data was analyzed according to the three-talk model, by Elwyn et.al. 2017. Results Patients reported a lack of invitation from HCPs to be part of the SDM process. Patients perceived their limited medical knowledge as a barrier that prevented HCPs from inviting them to participate in SDM. They reflected on themselves being primarily focused on single details regarding one medication option they had received. Furthermore, they were not encouraged to discuss several options by HCPs. Participants experienced how decisions being made by HCPs were expected to be accepted although the patient did not necessarily understand the treatment adequately. Although most patients trusted HCPs to act in their best interests, this reliance resulted in further disengagement from their own treatment. Conclusion Our findings revealed that patients were in general unfamiliar with SDM related to medications. Additionally, the participants reflected on a lack of invitation to team talk which resulted in limited patient involvement both in option and decision talk. Figures Figure 1 Highlights • The participants reflections revealed that the SDM principle of the clinician and patient being a team during decision making was not highlighted during HCP’s communication with patients. • The patients focused more on how to accept the one option, rather than being invited to discuss different alternatives. Their primary concern centered around the explanation of side effects, ways and time of administration and if the new medication had interactions with the other medication on their list. • Patients reflected that decisions were made by HCPs and presented to patients, leaving little room for the patient to discuss how the decision was made and how it will affect them after discharge. 1. Introduction Shared decision making (SDM) is a collaborative, patient centered process developed to arrive at preference and values based medical decisions surrounding a patient’s medications and other treatments ( 1 ). People with multiple long-term conditions (MLTCs) constitute a vulnerable and diverse patient group who experience frequent transitions of care, and who manage complex medication regimens where decisions surrounding medications are frequent ( 2 ). The principle of “no decision about me without me” describes the ambition of a more person-centered healthcare system promoting SDM, yet this ambition remains largely unrealized in practice ( 1 , 3 , 4 ). Involving the patient in decision making has been shown to lead to: increased patients’ medical knowledge, improved risk perceptions about different treatments, a greater number of decisions consistent with patient’s values, and fewer patients remaining passive or undecided ( 5 ). SDM can be particularly important for patients with MLTCs due to the nature of long-term treatments and frequent changes in medication treatment. However, the complexity of the medication regimens due to MLTCs can often exclude patients from SDM practice ( 6 ). During a period of illness, patients can be in a state of uncertainty, vulnerability and loss of power ( 7 ). SDM is advocated to be a tool that may assist a patient in restoring the autonomous capacity that they would otherwise have. The three-talk model of Elwyn et.al 2017, which revolves around “team talk”, “option talk” and “decision talk”, was developed to assist health care professionals (HCPs) and patients in navigating choice awareness, pros and cons with different options, and medical decisions are based on “what matters most” to the patient ( 8 ). The concept of SDM shifts the power dynamics during the healthcare encounter between HCPs and patients to achieve a more balanced interaction. Research has recognized HCP-perceived barriers and facilitators for implementing SDM, however the perspectives of patients with MLTCs on SDM has been less investigated ( 5 ). The aim was to explore the perspectives of patients with MLTCs regarding SDM related to medications before, during and after a hospital stay. 2. Method 2.1. Study design This was a qualitative interview study where the data was collected during a larger research project (see Supplementary file 1) exploring medication use across healthcare levels. This paper reports qualitative data in accordance with the standards for reporting qualitative research (SRQR) criteria ( 9 ). 2.2. The authors’ background The group of authors that contributed to the data collection and analysis had varying educational backgrounds and experiences. The group included both male and female authors with Northern, Western, and Eastern European backgrounds, a patient user representative and clinical pharmacists. The authors' levels of experience in qualitative research ranged from limited to advanced. Throughout the group meetings, discussions were held to reflect on how the authors' professional and sociocultural backgrounds, as well as their value systems, might have influenced the data analysis ( 10 ) 2.3. Norwegian healthcare context In Norway, patients receive all their medications from the hospital during their hospital stay; however, medications are not dispensed upon discharge. After leaving the hospital, the responsibility for managing medications shifts to the patient, and the general practitioner (GP) has the formal medical responsibility for the patient. The hospital physician prepares a discharge summary that should include a medication list, and which is delivered to both the patient and their GP. Typically, patients living at home visit their preferred community pharmacy to fill the prescribed medications after discharge ( 11 , 12 ). The municipality healthcare system includes home care nursing (HCN) services, which can provide support with medication management, wound care, and personal hygiene ( 13 ). Additionally, information about and participation in decisions around treatment is a fundamental right for patients in Norway ( 14 ). 2.4. Participation inclusion A purposive sample of patients, based on sociodemographic factors including gender, age, education and ethnicity was selected for interviews. Patients were recruited from two geriatric wards and one internal medicine ward at a university hospital in Norway, with the interviews being conducted within 14 days after discharge. Patient inclusion took place from December 2022 to February 2024. Selection was based on predefined inclusion criteria, and guidance provided by the HCPs on the wards in identifying potential participants. Patients were invited to participate in the study 1–3 days before their scheduled discharge, and informed consent was obtained. Approximately 5 days after discharge a study pharmacist contacted the patient via telephone to arrange the interview. Next of kin were invited to participate if they were present at the patient’s home during the time of the interview. 2.4.1. Patient inclusion criteria: ≥ 18 years. Residential address in Oslo, Norway. Home-dwelling. Managing medications independently (may have some assistance from an HCN and/or next of kin). Using a minimum of four medications from a minimum of two therapeutic classes (ATC level 1). Minimum of two long-term conditions. 2.4.2. Next of kin inclusion criteria Involved in the patient’s medication management after hospital discharge. 2.4.3. Patient exclusion criteria (patients were ineligible if one or more criteria were met): Terminally ill. Isolated due to severe infections. Already having been enrolled to the study. Advanced cognitive impairment (as assessed by the hospital physician). Not planned for discharge to their own home. Unable to communicate in Norwegian or English. 2.5. Data collection The interview guide was developed with input from the authors, hospital physicians and a medical scientist. The topics were developed based on the identified knowledge gap and the research groups’ earlier study ( 12 ) and focused on self-management, medication information, and SDM, where the latter was inspired by the three-talk model ( 8 , 15 ). The interview guide (see Supplementary file 2) was constantly evaluated and revised twice (after the fourth and ninth interview) to deepen insights on specific themes during the data collection period. Interviewers (MG and MOS) received training in interviewing methodology by an experienced qualitative researcher (KS), e.g., how questions should be asked and elaborated. Data was collected through semi-structured interviews ( 16 ). Each participant was interviewed individually in their home, or at hospital, according to their preference. At the beginning of every interview a structured medication reconciliation was performed, and demographic variables were collected. Both the medication reconciliations and the interviews were audiotaped. 2.6. Data analysis The audio files were uploaded to NVivo v12. for transcription and qualitative coding. To achieve a broader understanding of the interview data, the medication reconciliation was also included in the analysis. All transcribed data were analyzed using directed content analysis guided by the three-talk model as a theoretical framework ( 8 , 17 , 18 ). Initially, the three elements of team talk, option talk and decision talk were used as broader themes. This involved looking for content where the participants recalled how the HCPs invited them to participate in SDM provide support to the patient (team talk), discussed treatment options (option talk) and how the participants perceived the degree of information sharing, discussions about values and preferences, and reflections on the decision-making outcomes (decision talk) ( 8 ). The researchers MG, ML and LM each reviewed 2 patient interviews individually according to the themes and discussed the categories during a consensus meeting. The initial three themes, (team talk, option talk and decision talk), were broken down into smaller categories that constituted the coding book for the analysis (see Supplementary file 3). After the consensus meeting researcher MG individually categorized 10 additional patient interviews which were audited by ML and LM during two additional consensus meetings. As no substantial changes were made, author MG categorized the rest of the transcripts. Author MG selected representative quotations which were discussed with authors ML, LM, and MS, before agreeing on which will be presented in the results. In the quotations presented the following abbreviations are used: I = Interviewer, P = Patient, PR = Patient relative. Saturation was continuously evaluated during the data collection period reviewing the depth and richness of the findings as well as the diversity of the participants. To enrich the data, some patients were selected for follow up interviews after an additional 3–4 weeks. After 18 individual patient interviews, 3 patient and next of kin interviews and 3 follow-up patient interviews it was concluded that saturation had been reached ( 19 , 20 ). 3. Results Interviews were conducted and analyzed with 18 individual patients and 3 patients accompanied by their next of kin. Demographic data for patients are presented in Table 1. The interviews were carried out at the patient’s home except for one that was undertaken in the hospital according to patient preference. The next of kin were all women, two of them were partners to the patient and one was a daughter of the patient. The interviews, including the medication reconciliation, took on average 95 minutes (± 22) and conducted on average 11 days (±4.3) post hospital discharge. Additionally, 3 follow-up individual patient interviews were conducted with an average length of 49 minutes (±6), 34 days (±2.5) after the first interview. The analysis revealed different insights on how patients experienced the three elements of SDM described by Elwyn et.al. 2017 (8). The participants mainly reflected upon their most recent interactions with HCPs, predominantly related to their last hospital stay and post-discharge. Figure 1 depicts the key patient perspectives of each of the three themes “team talk”, “option talk” and “decision talk”. Table 1 : Characteristics of patients in the analysis population. Characteristic 21 patients Age in years, median (range) 72 (22-94) Female, number (%) 11 (52) Patients living alone, number (%) 13 (62) Country of origin, number (%) - Norway - Other (Scandinavian, European, African) 18 (86) 3 (14) Education, number (%) - No university degree - University degree - No work experience in healthcare - Work experience in healthcare 12 (57) 9 (43) 18 (86) 3 (14) Number of long-term conditions at discharge, median (range) Number of medications in the discharge summary, median (range) 6 (2-13) 9 (5-21) Assistance with medication administration post-discharge, number (%) - Manage themselves - Manage themselves with help from homecare nurse - Manage themselves with help from next of kin - Manage themselves with help from homecare nurse and next of kin 13 (62) 5 (24) 2 (9) 1 (5) 3.1 Team talk Most participants described a lack of invitation by the HCPs to be made aware of choices. The participants recalled on downplaying the importance of their own insights about their health. Instead, patients perceived their own limited medical knowledge to be a barrier which prevented HCPs to invite patients into conversations about medication decisions. When asked about the need of being involved in decision making, the patients expressed a perception of being medically inexperienced. They did not describe HCPs who provided support towards the patient’s own health goals, in other words, the principle of being a team during this step of decision making was not highlighted during their communication with HCPs. “I: What are your thoughts on the importance of being involved in the decision-making process? P: Yes, it is important per se. Although again we must come back to the fact that you are in an unknown world. So, it becomes, even though you are invited to participate, you still become a sort of junior partner in the process.” (Male age 75) For many of the patients, their perspectives on making a choice during hospitalization was also influenced by their health situation. Participation in a decision-making team was difficult to achieve for some patients who lacked the energy due to their health condition during hospitalization, highlighting an interplay between patients perceived lack of autonomy and dependence on HCPs. Additionally, some participants reflected on the power imbalance between them and the HCPs in terms of gratitude for being in the hands of the HCPs, combined with not wanting to exert any more pressure by demanding some sort of involvement. The participants described how their health goals are decided by the HCP, rather than in a collaborative manner. The following quote exemplified this tension. “P: I don’t really know; I don’t feel that I am a big part of my own treatment to be honest. I: And how do you experience that? P: On one level I am not involved, but I also feel that I am, I did have a conversation with the physician. Nevertheless, the whole situation you’re in, when you are in bed, and you are sick… you’re just happy to receive any type of help there. You don’t get the feeling that you can demand any sort of meeting with them “the HCPs”, I can’t do that” (Female age 66) 3.2 Option talk The participant’s descriptions of how options were presented indicate that they were not invited to engage in comparing alternatives or communicating risks during their interactions with HCPs (8). Instead, although making the patient feel informed, the participants described that HCP simply listed the different treatments the patient was going to receive. “I: Have you been presented for different alternatives for your treatment? P: Last time I was there, she (the physician) was talking about an injection first that can take care of this heart flutter. Thereafter, she explained that if it would not work, we could try a weak electrical shock. “Is it okay for you, does this sound fine to you?”, she asked. Yes, I think this sounds very good, and I was a part of the decision there. So that is very nice, and I understood what it was on about.” (Female age 66) However, not every patient expressed a desire to or an understanding of how to be involved in the discussion of different options. For example, one patient articulated the importance of retaining control, yet was not interested in exploring medication alternatives, highlighting the differences in engagement levels. The patients focused more on how they will accept the one option, rather than being invited to discuss different alternatives. The patients primary concern centered around the explanation of side effects, ways and time of administration and if the new medication had no interactions with the other medication on their list. “I: How important is it for you to be involved in what sort of medications you will be using? P: I believe that it is very important that I get involved, because I like to remain in control. I: Yes, do you have a wish to be presented by the different alternatives for your med… P: No, no.” (Male age 86) Additionally, the participants reflected how the idea of discussing different treatments can be overwhelming. “ PR: Maybe they could have given a better explanation of why you should be taking this and that medication and how much of each one. P: Yes, but then you immediately can go into so many details. I believe that a lot of this type of information can be forgotten. I: But did you ask anything yourselves, if there was something you were wondering about? P: No, I don’t think I asked about a single thing.” (Male age 87) PR: (Female age 81) The power imbalance was also apparent when it came to describing option talk. The patients who trusted the HCP had little awareness of anything other than to accept the medication recommendations proposed. “P: The physician recommends something, and I do not think that I have many other alternatives than to say yes, but that is completely natural, it’s him who knows what they “the medications” are, and I believe that’s fine.” (Male age 87) 3.3 Decision talk When asked about arriving at the final decision many patients reflected that they often reach a decision or express a preference without fully comprehending the information provided. This impacts the ability to make truly informed choices. The example below shows how a decision about a patient’s medication management which was affected by the patient agreeing with the decision being made, but without a complete understanding of how the decision would subsequently affect their everyday life. When the patient transitioned from a self-managed medication system using a pill organizer to a more automated multidose dispense system (MDD), it resulted in the patient’s loss of control of the names, shapes and colors of their own medications. “P: For a very long time I’ve been buying medications at the pharmacy, and every Sunday, I would put them in the pill organizer for the whole week. every Sunday, I could see and recognize my tablets inside and out. Now when they’ve taken over (the home care nurses and the MDD system), and it’s probably for the best, but when they started with the different milligrams, and the metoprolol just… if I’m not mistaken it changed the shape. Just these small things confuse me now I don’t know which is which.” (Male age 76) Nevertheless, the importance of preferences and how the patient viewed their knowledge about their health was noticeable, although for a lower fraction of patients. “I: Did you decide on changing the medication or was it he “the physician” who came up with the idea?” P: “We agreed together. I did not want to up the dose of candesartan, then we decided together that we will go forward and give amlodipine a try on the side.” (Female age 68) There were examples where decisions were finalized prior to being communicated to the patient, leaving little room to raise concerns or suggest alternatives to the situation although the solution was impractical for the patient after discharge. This exemplifies how focusing on medication(s) rather than the patient can make patient values less important, and the principle of “what matters most to the patient” is lost. P: “Then I asked him (the physician) if it was necessary for me to take 10 tablets, will I not manage with less? Because it was a bit hard to think that I will need to take so many. Then I got told that it has something to do with the pricing or so he (the physician) thought. So that was a bit stupid. But later I went to the pharmacy and got a more practical dosage, and I understood that it was possible after all.” (Female age 66) On the other hand, conflicting with SDM, some patients were very thankful when situations regarding their health were handled “behind their backs”. This was viewed by some participants as a convenient way of handling the patient’s health status as well as something that reflected trust that the medical authorities are always working for the best ways to treat patients. “I: What gives you trust to the healthcare system? P: That you receive help There was a situation where I noticed some blood in my urine and had to run a few tests surrounding that. Then, a bit later, my GP called me and informed me about a few poor metrics in my kidneys, and that he had called the hospital and that they were already waiting for me there, (laugh) so that the GP feels responsible for you, that gives me trust.” (Male age 77) 4. Discussion Utilizing the three-talk model we describe how the participants experienced limited knowledge about how to participate in SDM practice regarding medication decisions. The participants reflected on the lack of invitation to be a part of the decision by the HCPs ultimately resulting in passive acceptance of decisions. The patients identified their own limited medical knowledge to be a barrier for SDM, complementing the misconception of what SDM practice is about. Authority of and trust in the HCP often led to decisions being made with minimal patient involvement, which was sometimes viewed as convenient and trustworthy. The participants reflected that they were rarely made aware of choices regarding medications when communicating with HCPs. Patients with MLTCs must manage complex medication regimens daily making this patient group particularly vulnerable when changes are being made to their medications ( 21 , 22 ). The goal of team talk is to provide support to patients after they are made aware of choices and to use their goals to guide the decision making process ( 8 ). Our results reflected that this support was not possible to achieve as the participants were not aware that they had the fundamental right to participate to begin with ( 14 ). The participants reflected that their own limited medical knowledge was a barrier for participation, which is also reflected in earlier studies ( 3 , 23 – 25 ). These results show how there is a lack of support for the patient and their next of kin, as the essence of SDM is to prove “the lack of medical school” to be irrelevant for the decision-making process ( 23 , 26 , 27 ). The task of option talk should compare different alternatives, describing the potential benefits and harms of certain medications ( 8 ). At best our participants reflected on the HCPs listing several treatments which the patient will undergo, rather than a comparison of alternatives. Our participants reflected on practical issues regarding medications upon returning home. We also revealed a passive acceptance of option decisions caused by a perceived reduced health status and autonomy. Although seemingly convenient, studies explain how HCPs premature recommendations deny the patient any form of deliberation in the process of choice awareness ( 28 ). Additionally, in vulnerable situations where the patient seemingly hands all decision making over to the HCP, it would help retain patient autonomy to invite a next of kin to participate ( 27 , 29 ). Fostering awareness of different options is linked to a better execution of other SDM steps, such as informing patients about different preferences, thus leading to improved medical outcomes and a better grasp of their complex medication regimens ( 23 , 28 , 30 ). The patients reflected on decisions that were made by HCPs before taking the time to discuss what matters most to them. Lack of time is a barrier widely documented in studies that underscore why SDM might not be prioritized within treatment plans, despite its importance ( 8 , 31 ). Our participants also expressed the thought of not wanting to appear intrusive, viewing themselves as junior partners in the decision-making process regarding their medications. Another study showed similar misconceptions about SDM as patients are unaware that they have a voice in the decision-making process ( 32 ). This confusion leads to patients just being cooperative, simply showing gratitude as the HCPs are taking care of them, without considering if they are actually taking time to listen to “what matters most to you” ( 32 ). If healthcare services aim to focus more on patient empowerment and SDM, a shift will need to happen. 4.1 Strengths and Limitations Patients were interviewed in a comfortable environment, usually in the patient’s own home. This assured that the interviewer was viewed as someone the patient could trust, and that their opinions would not have an influence on the medication treatment or the healthcare they were receiving. Our sample of 21 patients were of a wide demographic background and medical history. Additionally, the patients were included from three different wards at a university hospital in Oslo, Norway. The diversity of the patient group, in addition to the length of the interviews ensured a rich amount of data which most likely is likely generalizable to a wider range of patients and medical wards. Although the interviews took place shortly after hospital discharge, our data was based on the patient’s memories of the encounters with HCPs which can introduce some memory bias into our results. We included a diverse sample of patients, however, it’s important to note that those who consented to participate may be more empowered and confident. This study primarily focused on patient reflections. Although we included 3 next of kin, more next of kin participants would have given a broader understanding of how they can assist patients in SDM. 5. Conclusion Our findings revealed that in general patients were unfamiliar with SDM practice related to medications. Participants perceived lack of invitation from HCPs to engage in SDM, resulting in limited patient involvement in team talk, a limited discussion of options and decisions made without the patient necessarily understanding the treatment adequately. Declarations Funding This work was funded by the University of Oslo (PhD grants for authors MG and MOS). The funders had no influence on data collection, analysis or writing of this manuscript. Authors and Affiliations Mikas Glatkauskas 1 , Malin O. Syversen 1 , Liv Mathiesen 1 , Michael Scott 2 ,Karin Svensberg 3 ,Berit G. Denstad 4 , Marianne Lea 1,5 1 Research group for Clinical pharmacy, Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway 2 Medicines Optimization Innovation Centre, Antrim Area Hospital Site, Antrim, Northern Ireland, UK, 3 Department of Pharmacy, Uppsala University, Uppsala, Sweden, 4 User Representative, Norway, 5 Department of Clinical Pharmacy and Counselling, Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Oslo, Norway, Ethics declaration No conflicts of interest to declare Ethics approval Written, informed consent from patients and next of kin was collected before inclusion in the study. De-identified data was immediately stored in a protected area for sensitive data (TSD) at the University of Oslo. The study was approved by the Regional Committee for Medical and Health Research Ethics (ref.no 420920/REK south-eastern C), and by the data protection office at Oslo University Hospital, Sikt (ref.no 919319). A small gift (value of 50 NOK – 4 EUR or 5 USD) was given to the patients after the interviews. Author Contribution All authors reviewed the manuscript. Authors MG and MOS were responsible for conducting patient interviews and writing interview transcripts. Author MG wrote the main manuscript text, created the codebook and prepared the figures. Authors LM, ML and MG were involved in fellow coding workshops to assess coding consistency and test the three-talk model. Author KS reviewed the manuscript and was involved in preparing MG and MOS to conduct high quality, semi-structured qualitative interviews. Author BD reviewed 4 interviews and provided valuable insights from a patient user representative perspective. 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Supplementary Files ProtokollCIRCLEVersion5.docx Patientandnextofkininterviewenglish.docx Shareddecisionmakingcodebook.docx Cite Share Download PDF Status: Published Journal Publication published 21 Apr, 2026 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted Editorial decision: Revision requested 19 Oct, 2025 Reviews received at journal 12 Oct, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers invited by journal 07 Sep, 2025 Editor assigned by journal 30 Aug, 2025 Submission checks completed at journal 30 Aug, 2025 First submitted to journal 29 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7486247","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513247774,"identity":"17b973a3-75eb-43db-a7b3-506acd1c4450","order_by":0,"name":"Mikas Glatkauskas","email":"data:image/png;base64,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","orcid":"","institution":"University of Oslo","correspondingAuthor":true,"prefix":"","firstName":"Mikas","middleName":"","lastName":"Glatkauskas","suffix":""},{"id":513247775,"identity":"d9c4fe76-cc4d-4b46-ab8f-a5d04a0d9fd2","order_by":1,"name":"Malin O. Syversen","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Malin","middleName":"O.","lastName":"Syversen","suffix":""},{"id":513247776,"identity":"e5787e09-e9c8-47a3-9d08-ef2ab29754ca","order_by":2,"name":"Liv Mathiesen","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Liv","middleName":"","lastName":"Mathiesen","suffix":""},{"id":513247777,"identity":"bf548ed1-f8a9-4b45-9484-3d309057ab60","order_by":3,"name":"Michael Scott","email":"","orcid":"","institution":"Antrim Area Hospital Site","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Scott","suffix":""},{"id":513247778,"identity":"74296e1c-35a4-4a85-b12e-be40151c4f9f","order_by":4,"name":"Karin Svensberg","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Karin","middleName":"","lastName":"Svensberg","suffix":""},{"id":513247779,"identity":"50720144-5619-40cf-914e-b5deb8198dfd","order_by":5,"name":"Berit G. Denstad","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Berit","middleName":"G.","lastName":"Denstad","suffix":""},{"id":513247780,"identity":"1d09b635-d7ff-483e-acd5-08f85786d535","order_by":6,"name":"Marianne Lea","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Marianne","middleName":"","lastName":"Lea","suffix":""}],"badges":[],"createdAt":"2025-08-29 07:53:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7486247/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7486247/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11096-026-02143-x","type":"published","date":"2026-04-21T15:59:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91198328,"identity":"5d8169ca-3d4b-408c-8594-cb37b78d9ead","added_by":"auto","created_at":"2025-09-12 15:14:40","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":510660,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe three main elements of the Shared decision-making framework, described by Elwyn.et.al 2017 (8). The key patient perspectives identified during the analysis are shown in the blue boxes. The curved arrows depict the timeline of the three-talk model and how the consultation process should progress. (HCPs – Health Care Professionals)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7486247/v1/f52b7a1edb50ffe234a727d5.jpeg"},{"id":107928119,"identity":"d3f39ce2-6e64-4883-ac28-e43dbe427e10","added_by":"auto","created_at":"2026-04-27 16:08:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":769833,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7486247/v1/392691b8-671e-4e2b-a531-51b8022c12a3.pdf"},{"id":91198337,"identity":"c12b139f-ee32-401c-9fbc-5eeb7cf36df3","added_by":"auto","created_at":"2025-09-12 15:14:40","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":424827,"visible":true,"origin":"","legend":"","description":"","filename":"ProtokollCIRCLEVersion5.docx","url":"https://assets-eu.researchsquare.com/files/rs-7486247/v1/e82fb4b90acea38c236d0840.docx"},{"id":91198325,"identity":"18e87ee5-629c-42ec-8a5e-182fada91cfe","added_by":"auto","created_at":"2025-09-12 15:14:40","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":56470,"visible":true,"origin":"","legend":"","description":"","filename":"Patientandnextofkininterviewenglish.docx","url":"https://assets-eu.researchsquare.com/files/rs-7486247/v1/28c63c6668793fc329f484ad.docx"},{"id":91198359,"identity":"50ba95c5-8033-4745-af38-50929d1de9cc","added_by":"auto","created_at":"2025-09-12 15:14:42","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":179751,"visible":true,"origin":"","legend":"","description":"","filename":"Shareddecisionmakingcodebook.docx","url":"https://assets-eu.researchsquare.com/files/rs-7486247/v1/667653254abec85ff7f21a01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePerspectives on shared decision making related to medications from patients with multiple long- term conditions transitioning from hospital to home: a qualitative study\u003c/p\u003e","fulltext":[{"header":"Highlights","content":"\u003cp\u003e\u0026bull; The participants reflections revealed that the SDM principle of the clinician and patient being a team during decision making was not highlighted during HCP\u0026rsquo;s communication with patients.\u003c/p\u003e\u003cp\u003e\u0026bull; The patients focused more on how to accept the one option, rather than being invited to discuss different alternatives. Their primary concern centered around the explanation of side effects, ways and time of administration and if the new medication had interactions with the other medication on their list.\u003c/p\u003e\u003cp\u003e\u0026bull; Patients reflected that decisions were made by HCPs and presented to patients, leaving little room for the patient to discuss how the decision was made and how it will affect them after discharge.\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eShared decision making (SDM) is a collaborative, patient centered process developed to arrive at preference and values based medical decisions surrounding a patient\u0026rsquo;s medications and other treatments (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). People with multiple long-term conditions (MLTCs) constitute a vulnerable and diverse patient group who experience frequent transitions of care, and who manage complex medication regimens where decisions surrounding medications are frequent (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The principle of \u0026ldquo;no decision about me without me\u0026rdquo; describes the ambition of a more person-centered healthcare system promoting SDM, yet this ambition remains largely unrealized in practice (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInvolving the patient in decision making has been shown to lead to: increased patients\u0026rsquo; medical knowledge, improved risk perceptions about different treatments, a greater number of decisions consistent with patient\u0026rsquo;s values, and fewer patients remaining passive or undecided (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). SDM can be particularly important for patients with MLTCs due to the nature of long-term treatments and frequent changes in medication treatment. However, the complexity of the medication regimens due to MLTCs can often exclude patients from SDM practice (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). During a period of illness, patients can be in a state of uncertainty, vulnerability and loss of power (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). SDM is advocated to be a tool that may assist a patient in restoring the autonomous capacity that they would otherwise have. The three-talk model of Elwyn et.al 2017, which revolves around \u0026ldquo;team talk\u0026rdquo;, \u0026ldquo;option talk\u0026rdquo; and \u0026ldquo;decision talk\u0026rdquo;, was developed to assist health care professionals (HCPs) and patients in navigating choice awareness, pros and cons with different options, and medical decisions are based on \u0026ldquo;what matters most\u0026rdquo; to the patient (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe concept of SDM shifts the power dynamics during the healthcare encounter between HCPs and patients to achieve a more balanced interaction. Research has recognized HCP-perceived barriers and facilitators for implementing SDM, however the perspectives of patients with MLTCs on SDM has been less investigated (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The aim was to explore the perspectives of patients with MLTCs regarding SDM related to medications before, during and after a hospital stay.\u003c/p\u003e"},{"header":"2. Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study design\u003c/h2\u003e\u003cp\u003eThis was a qualitative interview study where the data was collected during a larger research project (see Supplementary file 1) exploring medication use across healthcare levels. This paper reports qualitative data in accordance with the standards for reporting qualitative research (SRQR) criteria (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. The authors\u0026rsquo; background\u003c/h2\u003e\u003cp\u003eThe group of authors that contributed to the data collection and analysis had varying educational backgrounds and experiences. The group included both male and female authors with Northern, Western, and Eastern European backgrounds, a patient user representative and clinical pharmacists. The authors' levels of experience in qualitative research ranged from limited to advanced. Throughout the group meetings, discussions were held to reflect on how the authors' professional and sociocultural backgrounds, as well as their value systems, might have influenced the data analysis (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Norwegian healthcare context\u003c/h2\u003e\u003cp\u003eIn Norway, patients receive all their medications from the hospital during their hospital stay; however, medications are not dispensed upon discharge. After leaving the hospital, the responsibility for managing medications shifts to the patient, and the general practitioner (GP) has the formal medical responsibility for the patient. The hospital physician prepares a discharge summary that should include a medication list, and which is delivered to both the patient and their GP. Typically, patients living at home visit their preferred community pharmacy to fill the prescribed medications after discharge (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The municipality healthcare system includes home care nursing (HCN) services, which can provide support with medication management, wound care, and personal hygiene (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Additionally, information about and participation in decisions around treatment is a fundamental right for patients in Norway (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Participation inclusion\u003c/h2\u003e\u003cp\u003eA purposive sample of patients, based on sociodemographic factors including gender, age, education and ethnicity was selected for interviews. Patients were recruited from two geriatric wards and one internal medicine ward at a university hospital in Norway, with the interviews being conducted within 14 days after discharge. Patient inclusion took place from December 2022 to February 2024. Selection was based on predefined inclusion criteria, and guidance provided by the HCPs on the wards in identifying potential participants. Patients were invited to participate in the study 1\u0026ndash;3 days before their scheduled discharge, and informed consent was obtained. Approximately 5 days after discharge a study pharmacist contacted the patient via telephone to arrange the interview. Next of kin were invited to participate if they were present at the patient\u0026rsquo;s home during the time of the interview.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1. Patient inclusion criteria:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026ge;\u0026thinsp;18 years.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eResidential address in Oslo, Norway.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHome-dwelling.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eManaging medications independently (may have some assistance from an HCN and/or next of kin).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eUsing a minimum of four medications from a minimum of two therapeutic classes (ATC level 1).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMinimum of two long-term conditions.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2. Next of kin inclusion criteria\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eInvolved in the patient\u0026rsquo;s medication management after hospital discharge.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.4.3. Patient exclusion criteria (patients were ineligible if one or more criteria were met):\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eTerminally ill.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIsolated due to severe infections.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAlready having been enrolled to the study.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAdvanced cognitive impairment (as assessed by the hospital physician).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNot planned for discharge to their own home.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eUnable to communicate in Norwegian or English.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Data collection\u003c/h2\u003e\u003cp\u003eThe interview guide was developed with input from the authors, hospital physicians and a medical scientist. The topics were developed based on the identified knowledge gap and the research groups\u0026rsquo; earlier study (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and focused on self-management, medication information, and SDM, where the latter was inspired by the three-talk model (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The interview guide (see Supplementary file 2) was constantly evaluated and revised twice (after the fourth and ninth interview) to deepen insights on specific themes during the data collection period. Interviewers (MG and MOS) received training in interviewing methodology by an experienced qualitative researcher (KS), e.g., how questions should be asked and elaborated.\u003c/p\u003e\u003cp\u003eData was collected through semi-structured interviews (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Each participant was interviewed individually in their home, or at hospital, according to their preference. At the beginning of every interview a structured medication reconciliation was performed, and demographic variables were collected. Both the medication reconciliations and the interviews were audiotaped.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e2.6. Data analysis\u003c/h2\u003e\u003cp\u003eThe audio files were uploaded to NVivo v12. for transcription and qualitative coding. To achieve a broader understanding of the interview data, the medication reconciliation was also included in the analysis. All transcribed data were analyzed using directed content analysis guided by the three-talk model as a theoretical framework (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Initially, the three elements of team talk, option talk and decision talk were used as broader themes. This involved looking for content where the participants recalled how the HCPs invited them to participate in SDM provide support to the patient (team talk), discussed treatment options (option talk) and how the participants perceived the degree of information sharing, discussions about values and preferences, and reflections on the decision-making outcomes (decision talk) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The researchers MG, ML and LM each reviewed 2 patient interviews individually according to the themes and discussed the categories during a consensus meeting. The initial three themes, (team talk, option talk and decision talk), were broken down into smaller categories that constituted the coding book for the analysis (see Supplementary file 3). After the consensus meeting researcher MG individually categorized 10 additional patient interviews which were audited by ML and LM during two additional consensus meetings. As no substantial changes were made, author MG categorized the rest of the transcripts. Author MG selected representative quotations which were discussed with authors ML, LM, and MS, before agreeing on which will be presented in the results. In the quotations presented the following abbreviations are used: I\u0026thinsp;=\u0026thinsp;Interviewer, P\u0026thinsp;=\u0026thinsp;Patient, PR\u0026thinsp;=\u0026thinsp;Patient relative.\u003c/p\u003e\u003cp\u003eSaturation was continuously evaluated during the data collection period reviewing the depth and richness of the findings as well as the diversity of the participants. To enrich the data, some patients were selected for follow up interviews after an additional 3\u0026ndash;4 weeks. After 18 individual patient interviews, 3 patient and next of kin interviews and 3 follow-up patient interviews it was concluded that saturation had been reached (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eInterviews were conducted and analyzed with 18 individual patients and 3 patients accompanied by their next of kin. Demographic data for patients are presented in Table 1. The interviews were carried out at the patient\u0026rsquo;s home except for one that was undertaken in the hospital according to patient preference. The next of kin were all women, two of them were partners to the patient and one was a daughter of the patient. The interviews, including the medication reconciliation, took on average 95 minutes (\u0026plusmn; 22) and conducted on average 11 days (\u0026plusmn;4.3) post hospital discharge. Additionally, 3 follow-up individual patient interviews were conducted with an average length of 49 minutes (\u0026plusmn;6), 34 days (\u0026plusmn;2.5) after the first interview. The analysis revealed different insights on how patients experienced the three elements of SDM described by Elwyn et.al. 2017 (8). The participants mainly reflected upon their most recent interactions with HCPs, predominantly related to their last hospital stay and post-discharge. Figure 1 depicts the key patient perspectives of each of the three themes \u0026ldquo;team talk\u0026rdquo;, \u0026ldquo;option talk\u0026rdquo; and \u0026ldquo;decision talk\u0026rdquo;. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e: Characteristics of patients in the analysis population.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e21 patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003eAge in years, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e72 (22-94)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003eFemale, number (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e11 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003ePatients living alone, number (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e13 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003eCountry of origin, number (%)\u003c/p\u003e\n \u003cp\u003e- Norway\u003cbr\u003e\u0026nbsp;- Other (Scandinavian, European, African)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (86)\u003cbr\u003e\u0026nbsp;3 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003eEducation, number (%)\u003cbr\u003e\u0026nbsp;- No university degree\u003cbr\u003e\u0026nbsp;- University degree\u003cbr\u003e\u0026nbsp;- No work experience in healthcare\u003cbr\u003e\u0026nbsp;- Work experience in healthcare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;12 (57)\u003cbr\u003e\u0026nbsp;9 (43)\u003cbr\u003e\u0026nbsp;18 (86)\u003cbr\u003e\u0026nbsp;3 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003eNumber of long-term conditions at discharge, median (range)\u003c/p\u003e\n \u003cp\u003eNumber of medications in the discharge summary, median (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e6 (2-13)\u003c/p\u003e\n \u003cp\u003e9 (5-21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 479px;\"\u003e\n \u003cp\u003eAssistance with medication administration post-discharge, number (%)\u003cbr\u003e\u0026nbsp;- Manage themselves\u0026nbsp;\u003cbr\u003e\u0026nbsp;- Manage themselves with help from homecare nurse\u003cbr\u003e\u0026nbsp;- Manage themselves with help from next of kin\u003cbr\u003e\u0026nbsp;- Manage themselves with help from homecare nurse and next of kin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;13 (62)\u003cbr\u003e\u0026nbsp;5 (24)\u003cbr\u003e\u0026nbsp;2 (9)\u003cbr\u003e\u0026nbsp;1 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1\u0026nbsp;Team talk\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants described a lack of invitation by the HCPs to be made aware of choices. The participants recalled on downplaying the importance of their own insights about their health. Instead, patients perceived their own limited medical knowledge to be a barrier which prevented HCPs to invite patients into conversations about medication decisions. When asked about the need of being involved in decision making, the patients expressed a perception of being medically inexperienced. They did not describe HCPs who provided support towards the patient\u0026rsquo;s own health goals, in other words, the principle of being a team during this step of decision making was not highlighted during their communication with HCPs. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I: What are your thoughts on the importance of being involved in the decision-making process?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: Yes, it is important per se. Although again we must come back to the fact that you are in an unknown world. So, it becomes, even though you are invited to participate, you still become a sort of junior partner in the process.\u0026rdquo; (Male age 75)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor many of the patients, their perspectives on making a choice during hospitalization was also influenced by their health situation. Participation in a decision-making team was difficult to achieve for some patients who lacked the energy due to their health condition during hospitalization, highlighting an interplay between patients perceived lack of autonomy and dependence on HCPs. Additionally, some participants reflected on the power imbalance between them and the HCPs in terms of gratitude for being in the hands of the HCPs, combined with not wanting to exert any more pressure by demanding some sort of involvement. The participants described how their health goals are decided by the HCP, rather than in a collaborative manner. The following quote exemplified this tension.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;P: I don\u0026rsquo;t really know; I don\u0026rsquo;t feel that I am a big part of my own treatment to be honest.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI: And how do you experience that?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: On one level I am not involved, but I also feel that I am, I did have a conversation with the physician. Nevertheless, the whole situation you\u0026rsquo;re in, when you are in bed, and you are sick\u0026hellip; you\u0026rsquo;re just happy to receive any type of help there. You don\u0026rsquo;t get the feeling that you can demand any sort of meeting with them \u0026ldquo;the HCPs\u0026rdquo;, I can\u0026rsquo;t do that\u0026rdquo; (Female age 66)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2\u0026nbsp;Option talk\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participant\u0026rsquo;s descriptions of how options were presented indicate that they were not invited to engage in comparing alternatives or communicating risks during their interactions with HCPs (8). Instead, although making the patient feel informed, the participants described that HCP simply listed the different treatments the patient was going to receive.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I: Have you been presented for different alternatives for your treatment?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: Last time I was there, she (the physician) was talking about an injection first that can take care of this heart flutter. Thereafter, she explained that if it would not work, we could try a weak electrical shock. \u0026ldquo;Is it okay for you, does this sound fine to you?\u0026rdquo;, she asked. Yes, I think this sounds very good, and I was a part of the decision there. So that is very nice, and I understood what it was on about.\u0026rdquo; (Female age 66)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, not every patient expressed a desire to or an understanding of how to be involved in the discussion of different options. For example, one patient articulated the importance of retaining control, yet was not interested in exploring medication alternatives, highlighting the differences in engagement levels. The patients focused more on how they will accept the one option, rather than being invited to discuss different alternatives. The patients primary concern centered around the explanation of side effects, ways and time of administration and if the new medication had no interactions with the other medication on their list. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I: How important is it for you to be involved in what sort of medications you will be using?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: I believe that it is very important that I get involved, because I like to remain in control.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI: Yes, do you have a wish to be presented by the different alternatives for your med\u0026hellip;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: No, no.\u0026rdquo; (Male age 86)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, the participants reflected how the idea of discussing different treatments can be overwhelming.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003ePR: Maybe they could have given a better explanation of why you should be taking this and that medication and how much of each one.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: Yes, but then you immediately can go into so many details. I believe that a lot of this type of information can be forgotten.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI: But did you ask anything yourselves, if there was something you were wondering about?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: No, I don\u0026rsquo;t think I asked about a single thing.\u0026rdquo; (Male age 87) PR: (Female age 81)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe power imbalance was also apparent when it came to describing option talk. The patients who trusted the HCP had little awareness of anything other than to accept the medication recommendations proposed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;P: The physician recommends something, and I do not think that I have many other alternatives than to say yes, but that is completely natural, it\u0026rsquo;s him who knows what they \u0026ldquo;the medications\u0026rdquo; are, and I believe that\u0026rsquo;s fine.\u0026rdquo; (Male age 87)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3\u0026nbsp;Decision talk\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen asked about arriving at the final decision many patients reflected that they often reach a decision or express a preference without fully comprehending the information provided. This impacts the ability to make truly informed choices. The example below shows how a decision about a patient\u0026rsquo;s medication management which was affected by the patient agreeing with the decision being made, but without a complete understanding of how the decision would subsequently affect their everyday life. When the patient transitioned from a self-managed medication system using a pill organizer to a more automated multidose dispense system (MDD), it resulted in the patient\u0026rsquo;s loss of control of the names, shapes and colors of their own medications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;P: For a very long time I\u0026rsquo;ve been buying medications at the pharmacy, and every Sunday, I would put them in the pill organizer for the whole week. \u0026lt;\u0026hellip;\u0026gt; every Sunday, I could see and recognize my tablets inside and out. Now when they\u0026rsquo;ve taken over (the home care nurses and the MDD system), and it\u0026rsquo;s probably for the best, but when they started with the different milligrams, and the metoprolol just\u0026hellip; \u0026lt;\u0026hellip;\u0026gt; if I\u0026rsquo;m not mistaken it changed the shape. Just these small things confuse me \u0026lt;\u0026hellip;\u0026gt; now I don\u0026rsquo;t know which is which.\u0026rdquo; (Male age 76)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNevertheless, the importance of preferences and how the patient viewed their knowledge about their health was noticeable, although for a lower fraction of patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I: Did you decide on changing the medication or was it he \u0026ldquo;the physician\u0026rdquo; who came up with the idea?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: \u0026ldquo;We agreed together. I did not want to up the dose of candesartan, then we decided together that we will go forward and give amlodipine a try on the side.\u0026rdquo; (Female age 68)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere were examples where decisions were finalized prior to being communicated to the patient, leaving little room to raise concerns or suggest alternatives to the situation although the solution was impractical for the patient after discharge. This exemplifies how focusing on medication(s) rather than the patient can make patient values less important, and the principle of \u0026ldquo;what matters most to the patient\u0026rdquo; is lost. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: \u0026ldquo;Then I asked him (the physician) if it was necessary for me to take 10 tablets, will I not manage with less? Because it was a bit hard to think that I will need to take so many. Then I got told that it has something to do with the pricing or so he (the physician) thought. So that was a bit stupid. But later I went to the pharmacy and got a more practical dosage, and I understood that it was possible after all.\u0026rdquo; (Female age 66)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, conflicting with SDM, some patients were very thankful when situations regarding their health were handled \u0026ldquo;behind their backs\u0026rdquo;. This was viewed by some participants as a convenient way of handling the patient\u0026rsquo;s health status as well as something that reflected trust that the medical authorities are always working for the best ways to treat patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I: What gives you trust to the healthcare system?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: That you receive help \u0026lt;\u0026hellip;\u0026gt; There was a situation where I noticed some blood in my urine and had to run a few tests surrounding that. Then, a bit later, my GP called me and informed me about a few poor metrics in my kidneys, and that he had called the hospital and that they were already waiting for me there, (laugh) \u0026lt;\u0026hellip;\u0026gt; so that the GP feels responsible for you, that gives me trust.\u0026rdquo; (Male age 77)\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eUtilizing the three-talk model we describe how the participants experienced limited knowledge about how to participate in SDM practice regarding medication decisions. The participants reflected on the lack of invitation to be a part of the decision by the HCPs ultimately resulting in passive acceptance of decisions. The patients identified their own limited medical knowledge to be a barrier for SDM, complementing the misconception of what SDM practice is about. Authority of and trust in the HCP often led to decisions being made with minimal patient involvement, which was sometimes viewed as convenient and trustworthy.\u003c/p\u003e\u003cp\u003eThe participants reflected that they were rarely made aware of choices regarding medications when communicating with HCPs. Patients with MLTCs must manage complex medication regimens daily making this patient group particularly vulnerable when changes are being made to their medications (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The goal of team talk is to provide support to patients after they are made aware of choices and to use their goals to guide the decision making process (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Our results reflected that this support was not possible to achieve as the participants were not aware that they had the fundamental right to participate to begin with (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The participants reflected that their own limited medical knowledge was a barrier for participation, which is also reflected in earlier studies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). These results show how there is a lack of support for the patient and their next of kin, as the essence of SDM is to prove \u0026ldquo;the lack of medical school\u0026rdquo; to be irrelevant for the decision-making process (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe task of option talk should compare different alternatives, describing the potential benefits and harms of certain medications (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). At best our participants reflected on the HCPs listing several treatments which the patient will undergo, rather than a comparison of alternatives. Our participants reflected on practical issues regarding medications upon returning home. We also revealed a passive acceptance of option decisions caused by a perceived reduced health status and autonomy. Although seemingly convenient, studies explain how HCPs premature recommendations deny the patient any form of deliberation in the process of choice awareness (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Additionally, in vulnerable situations where the patient seemingly hands all decision making over to the HCP, it would help retain patient autonomy to invite a next of kin to participate (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Fostering awareness of different options is linked to a better execution of other SDM steps, such as informing patients about different preferences, thus leading to improved medical outcomes and a better grasp of their complex medication regimens (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe patients reflected on decisions that were made by HCPs before taking the time to discuss what matters most to them. Lack of time is a barrier widely documented in studies that underscore why SDM might not be prioritized within treatment plans, despite its importance (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Our participants also expressed the thought of not wanting to appear intrusive, viewing themselves as junior partners in the decision-making process regarding their medications. Another study showed similar misconceptions about SDM as patients are unaware that they have a voice in the decision-making process (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This confusion leads to patients just being cooperative, simply showing gratitude as the HCPs are taking care of them, without considering if they are actually taking time to listen to \u0026ldquo;what matters most to you\u0026rdquo; (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). If healthcare services aim to focus more on patient empowerment and SDM, a shift will need to happen.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Strengths and Limitations\u003c/h2\u003e\u003cp\u003ePatients were interviewed in a comfortable environment, usually in the patient\u0026rsquo;s own home. This assured that the interviewer was viewed as someone the patient could trust, and that their opinions would not have an influence on the medication treatment or the healthcare they were receiving. Our sample of 21 patients were of a wide demographic background and medical history. Additionally, the patients were included from three different wards at a university hospital in Oslo, Norway. The diversity of the patient group, in addition to the length of the interviews ensured a rich amount of data which most likely is likely generalizable to a wider range of patients and medical wards.\u003c/p\u003e\u003cp\u003eAlthough the interviews took place shortly after hospital discharge, our data was based on the patient\u0026rsquo;s memories of the encounters with HCPs which can introduce some memory bias into our results. We included a diverse sample of patients, however, it\u0026rsquo;s important to note that those who consented to participate may be more empowered and confident. This study primarily focused on patient reflections. Although we included 3 next of kin, more next of kin participants would have given a broader understanding of how they can assist patients in SDM.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur findings revealed that in general patients were unfamiliar with SDM practice related to medications. Participants perceived lack of invitation from HCPs to engage in SDM, resulting in limited patient involvement in team talk, a limited discussion of options and decisions made without the patient necessarily understanding the treatment adequately.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by the University of Oslo (PhD grants for authors MG and MOS). The funders had no influence on data collection, analysis or writing of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMikas Glatkauskas\u003csup\u003e1\u003c/sup\u003e, Malin O. Syversen\u003csup\u003e1\u003c/sup\u003e, Liv Mathiesen\u003csup\u003e1\u003c/sup\u003e, Michael Scott\u003csup\u003e2\u003c/sup\u003e,Karin Svensberg\u003csup\u003e3\u003c/sup\u003e,Berit G. Denstad\u003csup\u003e4\u003c/sup\u003e, Marianne Lea\u003csup\u003e1,5\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003cem\u003eResearch group for Clinical pharmacy, Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, Norway \u003csup\u003e2\u003c/sup\u003eMedicines Optimization Innovation Centre, Antrim Area Hospital Site, Antrim, Northern Ireland, UK,\u003csup\u003e\u0026nbsp;3\u003c/sup\u003eDepartment of Pharmacy, Uppsala University, Uppsala, Sweden, \u003csup\u003e4\u003c/sup\u003eUser Representative, Norway,\u003csup\u003e\u0026nbsp;5\u003c/sup\u003e\u003c/em\u003e \u003cem\u003eDepartment of Clinical Pharmacy and Counselling, Oslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Oslo, Norway,\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflicts of interest to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten, informed consent from patients and next of kin was collected before inclusion in the study. De-identified data was immediately stored in a protected area for sensitive data (TSD) at the University of Oslo. The study was approved by the Regional Committee for Medical and Health Research Ethics (ref.no 420920/REK south-eastern C), and by the data protection office at Oslo University Hospital, Sikt (ref.no 919319). A small gift (value of 50 NOK – 4 EUR or 5 USD) was given to the patients after the interviews. \u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors reviewed the manuscript. Authors MG and MOS were responsible for conducting patient interviews and writing interview transcripts. Author MG wrote the main manuscript text, created the codebook and prepared the figures. Authors LM, ML and MG were involved in fellow coding workshops to assess coding consistency and test the three-talk model. Author KS reviewed the manuscript and was involved in preparing MG and MOS to conduct high quality, semi-structured qualitative interviews. Author BD reviewed 4 interviews and provided valuable insights from a patient user representative perspective.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the participants of this study who kindly shared their time, knowledge, and homes with us. Wealso thank the hospital staff who allowed us in to the wards and helped us include patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCoulter A, Collins A. Making shared decision-making a reality. London: King\u0026apos;s Fund. 2011;621.\u003c/li\u003e\n\u003cli\u003eCassell A, Edwards D, Harshfield A, Rhodes K, Brimicombe J, Payne R, Griffin S. The epidemiology of multimorbidity in primary care: a retrospective cohort study. British Journal of General Practice. 2018;68(669):e245-e51.\u003c/li\u003e\n\u003cli\u003eJoseph-Williams N, Elwyn G, Edwards A. 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Application of a human factors approach to investigate the hospital to home transition for patients with multiple long-term conditions. Human Factors in Healthcare. 2025;7:100100.\u003c/li\u003e\n\u003cli\u003eGulbrandsen P, Clayman ML, Beach MC, Han PK, Boss EF, Ofstad EH, Elwyn G. Shared decision-making as an existential journey: aiming for restored autonomous capacity. Patient Education and Counseling. 2016;99(9):1505-10.\u003c/li\u003e\n\u003cli\u003eElwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. bmj. 2017;359.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for Reporting Qualitative Research: A Synthesis of Recommendations. Academic Medicine. 2014;89(9):1245-51.\u003c/li\u003e\n\u003cli\u003eMaxwell C, Ramsayer B, Hanlon C, McKendrick J, Fleming V. Examining Researchers\u0026rsquo; Pre-Understandings as a Part of the Reflexive Journey in Hermeneutic Research. International Journal of Qualitative Methods. 2020;19:1609406920985718.\u003c/li\u003e\n\u003cli\u003eSvensberg K, Trapnes E, Nguyen D, Hasan R, Sund J, Mathiesen L. Patients\u0026rsquo; perceptions of medicines information received at hospital discharge in Norway: a qualitative interview study. International Journal of Clinical Pharmacy. 2021;43(1):144-53.\u003c/li\u003e\n\u003cli\u003eRognan SE, K\u0026auml;lvemark Sporrong S, Bengtsson KR, Lie HB, Andersson Y, Mow\u0026eacute; M, Mathiesen L. Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway. BMJ Open. 2021;11(6):e044850.\u003c/li\u003e\n\u003cli\u003eHellz\u0026eacute;n O, Ness TM, Ingstad K, Ludvigsen MS, Nissen AM, Devik SA. Adapting to home care in Norway: A longitudinal case study of older Adults\u0026apos; experiences. Journal of Aging Studies. 2024;68:101215.\u003c/li\u003e\n\u003cli\u003eLov om pasient- og brukerrettigheter (pasient- og brukerrettighetsloven), (1999).\u003c/li\u003e\n\u003cli\u003eRognan SE, K\u0026auml;lvemark Sporrong S, Bengtsson K, Lie HB, Andersson Y, Mow\u0026eacute; M, Mathiesen L. Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway. Health Expect. 2021;24(3):892-904.\u003c/li\u003e\n\u003cli\u003eJamshed S. Qualitative research method-interviewing and observation. J Basic Clin Pharm. 2014;5(4):87-8.\u003c/li\u003e\n\u003cli\u003eHsieh H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qualitative Health Research. 2005;15(9):1277-88.\u003c/li\u003e\n\u003cli\u003eAssarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42-55.\u003c/li\u003e\n\u003cli\u003eHennink MM, Kaiser BN, Marconi VC. Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qual Health Res. 2017;27(4):591-608.\u003c/li\u003e\n\u003cli\u003eFusch PI, Ness LR. Are We There Yet? Data Saturation in Qualitative Research. The Qualitative Report. 2015;20(9):1408-16.\u003c/li\u003e\n\u003cli\u003eBanerjee S. Multimorbidity\u0026mdash;older adults need health care that can count past one. The Lancet. 2015;385(9968):587-9.\u003c/li\u003e\n\u003cli\u003eNguyen H, Manolova G, Daskalopoulou C, Vitoratou S, Prince M, Prina AM. Prevalence of multimorbidity in community settings: A systematic review and meta-analysis of observational studies. J Comorb. 2019;9:2235042x19870934.\u003c/li\u003e\n\u003cli\u003eMontori VM, Ruissen MM, Hargraves IG, Brito JP, Kunneman M. Shared decision-making as a method of care. BMJ Evid Based Med. 2023;28(4):213-7.\u003c/li\u003e\n\u003cli\u003ePieterse AH, Brandes K, de Graaf J, de Boer JE, Labrie NH, Knops A, et al. Fostering patient choice awareness and presenting treatment options neutrally: a randomized trial to assess the effect on perceived room for involvement in decision making. Medical Decision Making. 2022;42(3):375-86.\u003c/li\u003e\n\u003cli\u003eShay LA, Lafata JE. Understanding patient perceptions of shared decision making. Patient education and counseling. 2014;96(3):295-301.\u003c/li\u003e\n\u003cli\u003eKeij SM, van Duijn-Bakker N, Stiggelbout AM, Pieterse AH. What makes a patient ready for Shared Decision Making? A qualitative study. Patient Education and Counseling. 2021;104(3):571-7.\u003c/li\u003e\n\u003cli\u003eElwyn G, Price A, Franco JVA, Gulbrandsen P. The limits of shared decision making. BMJ Evid Based Med. 2023;28(4):218-21.\u003c/li\u003e\n\u003cli\u003eKunneman M, Branda ME, Hargraves I, Pieterse AH, Montori VM. Fostering choice awareness for shared decision making: a secondary analysis of video-recorded clinical encounters. Mayo Clinic Proceedings: Innovations, Quality \u0026amp; Outcomes. 2018;2(1):60-8.\u003c/li\u003e\n\u003cli\u003eLahey T, Elwyn G. Sliding-scale shared decision making for patients with reduced capacity. AMA journal of ethics. 2020;22(5):358-64.\u003c/li\u003e\n\u003cli\u003eShay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical decision making. 2015;35(1):114-31.\u003c/li\u003e\n\u003cli\u003eRosenbaum L. The paternalism preference\u0026mdash;choosing unshared decision making. Obstetrical \u0026amp; Gynecological Survey. 2015;70(12):739-40.\u003c/li\u003e\n\u003cli\u003eUbbink DT, van Asbeck EV, Aarts JW, Stubenrouch FE, Geerts PA, Atsma F, Meinders MJ. Comparison of the CollaboRATE and SDM-Q-9 questionnaires to appreciate the patient-reported level of shared decision-making. Patient Education and Counseling. 2022;105(7):2475-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7486247/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7486247/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e\u003cp\u003ePersons with multiple long-term conditions (MLTCs) are often reliant on complex medication regimens where decisions surrounding medications are frequent and shared decision making (SDM) is beneficial.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eThe aim was to explore the perspectives of patients with MLTCs regarding SDM related to medications before, during and after a hospital stay.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eSemi-structured interviews with 21 patients and 3 next of kin were conducted. Normally home-dwelling patients\u0026thinsp;\u0026ge;\u0026thinsp;18 years with MLTCs, using a minimum of 4 medications for a minimum of 2 separate conditions were included from two geriatric wards and one internal medicine ward at a university hospital in Norway, and interviewed approximately 14 days post hospital discharge. The qualitative data was analyzed according to the three-talk model, by Elwyn et.al. 2017.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePatients reported a lack of invitation from HCPs to be part of the SDM process. Patients perceived their limited medical knowledge as a barrier that prevented HCPs from inviting them to participate in SDM. They reflected on themselves being primarily focused on single details regarding one medication option they had received. Furthermore, they were not encouraged to discuss several options by HCPs. Participants experienced how decisions being made by HCPs were expected to be accepted although the patient did not necessarily understand the treatment adequately. Although most patients trusted HCPs to act in their best interests, this reliance resulted in further disengagement from their own treatment.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOur findings revealed that patients were in general unfamiliar with SDM related to medications. Additionally, the participants reflected on a lack of invitation to team talk which resulted in limited patient involvement both in option and decision talk.\u003c/p\u003e","manuscriptTitle":"Perspectives on shared decision making related to medications from patients with multiple long- term conditions transitioning from hospital to home: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-12 15:14:35","doi":"10.21203/rs.3.rs-7486247/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-19T17:29:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T21:13:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146344025908595821588376099209520673350","date":"2025-09-10T17:33:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-07T10:00:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-30T09:20:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-30T09:19:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Pharmacy","date":"2025-08-29T07:49:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5f6dca69-4fdb-4d1b-ab67-1d1ba43dc2d1","owner":[],"postedDate":"September 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:05:49+00:00","versionOfRecord":{"articleIdentity":"rs-7486247","link":"https://doi.org/10.1007/s11096-026-02143-x","journal":{"identity":"international-journal-of-clinical-pharmacy","isVorOnly":false,"title":"International Journal of Clinical Pharmacy"},"publishedOn":"2026-04-21 15:59:04","publishedOnDateReadable":"April 21st, 2026"},"versionCreatedAt":"2025-09-12 15:14:35","video":"","vorDoi":"10.1007/s11096-026-02143-x","vorDoiUrl":"https://doi.org/10.1007/s11096-026-02143-x","workflowStages":[]},"version":"v1","identity":"rs-7486247","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7486247","identity":"rs-7486247","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}