Medical Decision Making

Developing a dyadic OPTION scale to measure perceptions of shared decisionmaking

Emma Melbourne, Kate Sinclair, Marie-Anne Durand, France Legare, Glyn Elwyn *

Department of Primary Care and Public Health, Cardiff University, Cardiff CF14 4XN, United Kingdom

Patient Education and Counseling 78 (2010) 177–183

A R T I C L E I N F O

Article history:

Received 8 January 2009

Received in revised form 2 July 2009

Accepted 7 July 2009

Keywords:

Shared decision making

Involvement

Decision making

Measurement

Dyadic analysis

A B S T R A C T

Objective: Our aim was to develop a measurement which enables research into the interdependent

nature of clinical encounters. The prime objective was to develop an instrument capable of assessing the

extent to which patients have been involved in (shared) decision making from two viewpoints—that of

the patient and the clinician.

Methods: To develop an initial ‘dyadic OPTION’ instrument, the twelve original third-person items were

drafted in passive, first person plural forms. Using this version initially, three rounds of cognitive

debriefing interviews were held. These were audio-recorded and analysed at the end of each round and

the results used to revise the dyadic OPTION scale.

Results: It was possible to modify the observer OPTION instrument into an instrument for completion by

both clinicians and patients after a dyadic interaction. Cognitive debriefing revealed five areas of

interpretative difficulty. Each item of the observer OPTION scale underwent modification in order to

develop a dyadic version of the scale.

Conclusions: The dyadic OPTION scale is acceptable and comprehensible by both clinicians and public

respondents. Cognitive debriefing adapted and refined an existing scale and provided confidence that the

core constructs of the scale (perceived involvement in decisions making) were understood.

Practice implications: Further validation of the dyadic OPTION scale is required prior to its use in research

settings.

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1. Introduction

Although shared decision making in clinical encounters isclearly the result of an interaction between two individuals,attempts to measure this phenomenon have, so far, been limited tosingle viewpoints, most often from the viewpoint of an observerassessing a recording of the dialogue [1,2]. Whilst such assess-ments have provided valuable information to researchers in thefield, they are inevitably limited in that they are restricted to whatis audible or observable. They take no account, nor can they, assessthe perceptions of those who are involved in the process ofunderstanding the nature of decisions, negotiating their role in thedecision process, and taking action to deliberate and decide. Yetthere is evidence that patients differ in their evaluations of suchencounters, their perception of involvement is different to theperception of clinicians [3]. We have little information as to

* Corresponding author at: Department of Primary Care and Public Health, School

of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN,

United Kingdom.

E-mail address: elwyng@cardiff.ac.uk (G. Elwyn).

0738-3991/$ – see front matter � 2009 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.pec.2009.07.009

whether these ‘internal’ perceptions correlate with those ofexternal observers, or indeed as to how this interdependence indyadic interaction affects the outcome of the encounter [4–6].There is a need therefore to develop a measure which attempts toaddress this research gap and which could provide moreinformation about the perceptions of those engaged in thesecomplex, negotiated encounters. For consultations that requireparticipation in decision making, and in particular where attemptsare made to share decisions, the interactions will require bothparties to address the issues of decisional equipoise, compare thefeatures of options and achieve consensus about the best actions:in short, to achieve ‘shared decision making’ [7].

Although the term ‘dyadic analysis’ is relatively novel inhealthcare settings, there is a growing interest in the concept ofinterdependence in health communication research [8]. Statisticalmethods used to analyse data gathered from health careencounters, including those focused on shared decision making,typically assume independent actors. However, in contrast, dyadicanalysis methods assume an interaction effect between theindividuals involved, and, rather than skate over the issue ofmutual influence, accept that non-independence should beinvestigated, and in some occasions, may be the main outcome

E. Melbourne et al. / Patient Education and Counseling 78 (2010) 177–183178

of interest [9]. To facilitate these investigations, new or adaptedmeasurement instruments are needed in order to allow assess-ments from dual, or more, perspectives. It is noteworthy how fewinstruments exist that are capable of providing such data in healthcare settings [10].

However, instruments do exist which have been designed tomeasure shared decision making in clinical practice, most oftenfrom a third observer point of view [1,2,11]. Two of the mostwidely used have been the Braddock scale, representing sixelements of informed decision making [12] and the observer

OPTION scale, developed to measure the extent to which cliniciansinvolve patients in decision making [13,14]. Both instrumentsrequire an independent, trained observer to rate achievementagainst defined competencies in audio or video-taped consulta-tions. Although these tools have provided valuable data aboutdecision making processes in clinical encounters, they are onlyable to represent external assessments: the perceptions ofparticipants engaged in the interactions remain unavailable [4].COMRADE [15] and the Perceived Involvement in Care (PICS) [16],are examples of instruments which aim to measure patients’perception of involvement in decision making but neither weredesigned so that they could assess interdependence betweenparticipants in the encounter.

We conclude therefore that a gap exists and that in order toapply the concept of dyadic analysis to clinical encounters,particularly to those where we wish to study perceived involve-ment and interdependence in shared decision making encounters,we either need to develop new tools or adapt existing tools. Wetook the view that an instrument used to tackle this task shouldmeet the following criteria: to have a sound developmentalpathway, clarity about its measurement construct, and evidence ofitem development and feasibility testing [17]. We also proposethat tools capable of providing data for dyadic analysis need tohave items that are identical for all respondents. In other words,item phrasing should be identical when administered to theclinician or to the patient. If we asked clinicians and patients torespond to items that were slightly different, we would run the riskof giving rise to different interpretations. We also decided to base anew scale on an existing tool, namely observer OPTION, a scale thathas been rigorously developed to assess the degree to whichclinicians involve patients in shared decision making, haspsychometric data to support its uni-dimensional nature [13,14].

These principles guided the adaptation of observer OPTION [14],into a ‘dyadic’ version’ and the steps taken are reported in thisarticle. The aim of this study was to develop a dyadic version of theOPTION tool which is acceptable and understood by both patientsand physicians and provides a platform for analysing interdepen-dence in the consultation, specifically with regard to themeasurement of shared decision making. To achieve this aim,we conducted three cycles of cognitive debriefing interviews.

2. Methods

2.1. Design and participants

Using the observer OPTION tool as a starting point, an initialmodified twelve item version was created (by GE), adapted so thatthe items could be read and completed by both patient andclinician at the end of a consultation. Potential ambiguities anddifficulties in comprehension were anticipated and an interviewschedule was prepared with suitable probes. Cognitive debriefinghas become an accepted method in questionnaire development[18]. The goal of cognitive debriefing is to facilitate a more uniforminterpretation of items by specified target audiences, a processwhich increases measurement validity. The method helps instru-ment developers understand how target audiences process and

respond to written or verbal materials [19] by allowing an analysisof the points at which respondents may be experiencing difficultiesin interpreting or mis-interpreting. Identifying and modifying suchitems increases the likelihood that respondents will respondappropriately in future versions [19]. Three cycles of cognitivedebriefing interviews with two different groups of participantswere planned. The first cycle of interviews considered the initialrevision. Changes and improvements were made to the evolvingversions of the dyadic OPTION instrument at the end of each cycle.

The proposed sample size was based on previous cognitivedebriefing studies [19]. Nine participants were planned for eachcycle of interviews, and so for each cycle we set out to recruit sixmembers of the general public and three clinicians. Members of thegeneral public would be recruited from public spaces, such as cafesand other locations. A sample matrix was designed to achieve abalance between genders and stratified by preferred readership ofa range of daily newspapers. Twenty-six million people of workingage in the UK have levels of literacy and numeracy below thoseexpected of school leavers [20], a figure which represents asignificant proportion of potential patient respondents. TheGunning Fog Index indicates the number of years of formaleducation required to read text. Tabloids scored less than 14 andbroadsheets greater than 14 on the scale and participants fromeach group were recruited. Clinicians were recruited by snowballsampling, using clinical contacts and existing academic networks.It was hypothesised that physicians were more likely to interpretitems more consistently than their patients due to their extensivecommon education and as such a representative conceptualequivalence could be attained with fewer participant physiciansthan patients. Thus three general practitioners and six publicrespondents were recruited for each round of interviewing.Standard consent procedures were designed and implemented.

2.2. Data collection

Interviews were conducted by a single researcher (KS), who wasfamiliar with the observer OPTION instrument, using a semi-structured interview schedule, probing for understanding, itemphrasing and completing field notes. All interviews were audio-taped and transcribed. Participants were asked to read theproposed ‘dyadic OPTION’ scale, where items had been rephrasedto allow completion by either patients or clinicians. To con-textualise responses, individuals were asked to think about their‘most recent visit to a clinician’ where a decision had beenrequired. Clinicians were asked to respond as if they hadcompleted a consultation where they had made efforts to sharean index decision during the encounter. Participants’ initialimpressions and interpretations of items were sought immediatelyafter each had been read. Anticipated and spontaneous probeswere used in order to elicit additional information. At the close ofthe interview, opportunities were given to respond in generalabout the instrument and about its anticipated use in practice.

2.3. Data analysis

At the end of each interview cycle, the data were analysed andcategorised. All items were read and discussed between GE and KSafter each round of interviewing. A summary was generated of themost salient issues prior to revision of the instrument ahead ofthe next cycle of interviews. This data summary enabled theinterviewer (KS) and the scale originator (GE) to assess how eachitem had been interpreted. After discussion, items wherecomprehension difficulties or mis-interpretations were encoun-tered were revised for further assessment. At the point when acycle of interviews failed to offer new information, the datacollection process would be stopped.

E. Melbourne et al. / Patient Education and Counseling 78 (2010) 177–183 179

3. Results

3.1. Participants characteristics

Between November 2007 and April 2008, 27 cognitive debrief-ing interviews were conducted, during each round of interviewing.Six members of the public and three clinicians with educational orresearch affiliations participated in each cycle of interviews.Table 1 shows the breakdown of participant characteristics. Half ofthe 18 public respondents were male; seven of the nine clinicianswere male. In each round, three of the public respondents regularlyread The Sun, The Daily Mail or the Mirror, newspapers scoring lessthan 14 on the Gunning Fog Index and three regularly readbroadsheets such as The Times, The Independent or the Guardian,scoring greater than 14 on the Gunning Fog Index.

3.2. Data from cognitive interviews

Analysis of the interviews revealed four areas of difficulty.These were

1. S

TaPa

Pa

GP

M

F

Pu

M

F

Ne

G

G

M

A

emantic difficulty. Significant variation in interpretation of theitems and elements of the vocabulary was encountered.Particular attention was given to interpretations of items whichwere inconsistent with the scale’s intended area of interest, i.e.degrees of involvement in decision making.

2. G

rammatical difficulty. Some sentence structures were consis-tently mis-interpreted. The decision to use the passive voice inorder to maximise item applicability to both patients andclinicians rendered some items ‘unnatural’ and their construc-tion required further attention.

3. C

onstruct mismatch. Particular attention was given to itemswhere it was clear that participant interpretation differed fromthat of the developers’ attempt to assess the core construct ofinvolvement in decision making processes. Suggestions forimprovement were particularly helpful and enabled new itemformulations which better achieved the aims of brevity, ease ofunderstanding and construct accuracy.

4. P

ersonal preferences. The pursuit of clarity, brevity andgrammatical consistency were used as justification andguidance for how to prioritise suggested modifications, aimingto achieve minimal respondent burden whilst maximisingcomprehension.

3.3. Synthesis of findings

3.3.1. First interview cycle

The first nine interviews resulted primarily in vocabularymodification. Anticipated probes were used to assess the precursor

ble 1rticipant characteristics.

rticipant characteristic First cycle Second cycle Third cycle

ale 2 2 3

emale 1 1 0

blic respondents

ale 3 3 3

emale 3 3 3

wspaper readership

unning Fog < 14 3 3 3

unning Fog > 14 3 3 3

ean age 49.42 42.83 35

ge range 19–72 18–74 20–58

dyadic OPTION scale. Verbs and nouns were both modified. Forexample, the word ‘checked’ was considered to be condescendingand was omitted. The word ‘management’ was considered by bothpatients and physicians to be applicable to medical treatment andas such was felt to be more appropriate than ‘deal with’ whenconsidering treatment issues. Probing of apparent constructmismatch resulted in three significant changes, such as thesubstitution of ‘considered’ for ‘respected’ in item 10. Whenconsidering item 9, one elderly public respondent indicated thatwhilst tacit opportunities to ask questions during consultationsoften existed, he was unlikely to ask any and thus agree with theitem unless specifically prompted. The issue was subsequentlyprobed and a number of respondents indicated that this was thecase and so ‘or prompts’ was added to the item as a result of thisinterview cycle. Several items which had double-barrelled queries,items 2, 11 and 12, were modified. Items which causedgrammatical difficulties for respondents, items, 3, 8 and 11 werecompletely overhauled using a conditional reactive probe of ‘canyou think of a better way to say it’ to respondents who understoodthe item. The need for an introductory statement to providerespondents with a context for completing the instrument wassignalled by many respondents and a short statement was added.

3.3.2. Second interview cycle

A second version of dyadic OPTION was produced, and a secondcycle of interviews led to further comments. Many of themodifications made after the first cycle were accepted, includingthe use of the term ‘respected’. One participant responded ‘‘I likethat term because you can respect a patient’s decision withouthaving to agree with it.’’ In general, the changes that had beenmade led to greater acceptance and ease of comprehension. Item 8had been given particular attention in the first cycle because of itscomplexity, and on specific probing it was much better understoodafter modification. The dual clause version of item 11 that enteredthis interview cycle was better understood than the initial versionhowever, a number of possible paths were still identified and it wasdeemed necessary to further overhaul this item. Finally, theaddition of ‘possibility of changing’ to item 12 was found to causethe item to be interpreted as an option not a necessity, but‘changing’ still provoked dissent and so underwent modificationduring the review. The focus of interviewing during this iterationshifted slightly as the most significant semantic and grammaticaldifficulties were remedied. Leads arising from anticipated probingwere extended upon and general issues that might affect theemployment of dyadic OPTION began to surface. One course ofemergent probing administered early in the iteration suggestedthat there was no point in talking about the advantages anddisadvantages of different treatment options without consideringthe possible outcomes, this point was subsequently investigatedby spontaneous probing throughout the remainder of the iteration.It was concluded that a construct mismatch existed because thiswas implicit to physicians but had up to that point been obscure todevelopers and ‘possible outcomes’ was subsequently included.

3.3.3. Third interview cycle

During this cycle, changes made in the second cycle wereanalysed in more detail and participants were asked to completethe third version of the dyadic OPTION scale. Suggested modifica-tions to item phrasing were minimal during this cycle: it was clearthat grammatical or semantic difficulties had been addressed andeliminated during the first two cycles. Two items however,required attention. Item 4 used the item phrasing: ‘Differentoptions (including doing nothing) were discussed’. This phrasingwas considered ambiguous. The following change was made:‘Different options, including the possibility of doing nothing, werediscussed’. Item 11 had been repeatedly modified during previous

Table 2Item development.

Observer OPTION

June 2006

First version of

‘dyadic OPTION’

Reason to modify Second version Reason to modify Third version Reason to modify Final version

Item 1 The clinician draws

attention to an identified

problem as one that requires

a decision making process

A problem for which

a decision was needed

was identified

Syntactical difficulty A health problem was

identified where it was

made clear that a

decision was needed

None needed A health problem

was identified where

it was made clear that

a decision was needed

None needed A health problem

was identified

where it was made

clear that a decision

was needed

Item 2 The clinician states that there

is more than one way to deal

with the identified problem

It was agreed that more

than one way to deal

with the problem existed

Construct mismatch-

double barreled

Syntactical difficulties

More than one way to

deal with the health

problem was identified

Syntactical

difficulties-capacity

to answer depends

upon the problem

More than one way

to manage the health

problem was described

None needed More than one way

to manage the health

problem was described

Item 3 The clinician assesses the

patient’s preferred approach

to receiving information to

assist decision making (e.g.

discussion, reading printed

material, assessing graphical

data, using videotapes

or other media)

Methods of presenting

information to best inform

the decision were discussed

Syntactical difficulties and

construct mismatch

Different types of

information (e.g. leaflets,

websites) to help make the

decision were given.

Syntactical difficulties Different sources of

information (e.g.

leaflets, websites,

contact with other

health professionals)

to help make the

decision were offered

Syntactical

difficulties

Different sources of

information (e.g.

leaflets, websites,

contact with other

people) to help make

the decision were

offered

Item 4 A health problem for which a

decision was needed was

identified

Different options (including

doing nothing) were explored

Syntactical difficulties Different options

(including doing nothing)

were discussed

None needed Different options

(including doing

nothing) were discussed

Construct

mismatch

Different options

(including the possibility

of doing nothing) were

discussed

Item 5 The clinician explains the

pros and cons of options to

the patient (taking no action

is an option)

The pros and cons of the

different options were explored

Syntactical difficulties,

inappropriate vocabulary

The advantages and

disadvantages of different

options were discussed

Construct

mismatch—

incomplete

construct.

Syntactical

difficulties

The advantages and

disadvantages of

possible outcomes of

options were discussed

None needed The advantages and

disadvantages of possible

outcomes of options

were discussed

Item 6 The clinician explores the

patient’s expectations (or ideas)

about how the problem(s) are

to be managed

Ideas or expectations about

how to deal with the

problem were addressed

Syntactical difficulties,

inappropriate vocabulary

Ideas or expectations about

managing the health problem

were discussed

None needed Ideas or expectations

about managing the

health problem were

discussed

None needed Ideas or expectations

about managing the

health problem were

discussed

Item 7 The clinician explores the

patient’s concerns (fears)

about how the problem(s)

are to be managed

Worries about how to manage

the problem were explored

Syntactical difficulties,

inappropriate vocabulary

Concerns or worries about

how to manage the health

problem were discussed

None needed Concerns or worries

about how to manage

the health problem

were discussed

None needed Concerns or worries

about managing the

health problem were

discussed

Item 8 The clinician checks that the

patient has understood the

information

The understanding of

information given to help

make a decision was checked

Grammatical difficulties-

overhaul

It was made sure that

the information had

been understood

None needed It was made sure that

the information had

been understood

None needed It was made sure that

the information had been

understood

Item 9 The clinician offers the patient

explicit opportunities to ask

questions during the decision

making process

Opportunities to ask

questions existed

Syntactical difficulties

and construct mismatch

There were opportunities or

prompts to ask questions

Construct

mismatch—

unnecessarily

complex

There were opportunities

to ask questions

None needed There were opportunities

to ask questions

Item 10 The clinician elicits the patient’s

preferred level of involvement

in decision making

The wish to take part in

the decision was considered

Syntactical difficulties

and construct mismatch

The desire/preference to take

part in the decision (or not)

was respected

Syntactical

difficulties

The preference to take

part in the decision (or not)

was respected

None needed The preference to take

part in the decision

(or not) was respected

Item 11 The clinician indicates the

need for a decision making

(or deferring) stage

It was clear that there was

a need to make/postpone

a decision

Construct mismatch—

double barrelled

The decision or an agreement

to postpone the decision

was made

Construct

mismatch—double

barrelled

Either a decision was

made, or there was an

agreement to postpone

making the decision

None needed Either a decision was

made, or there was an

agreement to postpone

making the decision

Item 12 The clinician indicates the

need to review the decision

(or deferment)

It was clear that

opportunities to check/change

a decision existed

Construct mismatch—

double barrelled

The possibility of changing

the decision in the future

was discussed

Syntactical

difficulties

The possibility of coming

back to the decision in the

future was discussed

Syntactical

difficulties

The possibility of coming

back to the decision was

discussed

E.

Melb

ou

rne

eta

l./Pa

tient

Ed

uca

tion

an

dC

ou

nselin

g7

8(2

01

0)

17

7–

18

31

80

Table 3The dyadic OPTION instrument (December 2008).

Most encounters about health

problems lead to decisions of one

sort or another. These questions ask

about the idea of being or feeling

involved in decisions, for example,

having an opinion or deciding whether

to take medication, and if so which one,

or what to do next. Answer the questions

from your point of view by putting a tick

in one box for each question. Please

answer every question.

What was the main problem you talked

about? Please describe it in a few words. . .

1. A health problem was identified, where

it was made clear that a decision was needed.

Strongly agree Agree Disagree Strongly disagree

2. More than one way to manage the

health problem was described.

Strongly agree Agree Disagree Strongly disagree

3. Different sources of information

(e.g. leaflets, websites, contact with other

people) to help make the decision were offered.

Strongly agree Agree Disagree Strongly disagree

4. Different options (including the possibility

of doing nothing) were discussed.

Strongly agree Agree Disagree Strongly disagree

5. The advantages, disadvantages and possible

outcomes of options were discussed.

Strongly agree Agree Disagree Strongly disagree

6. Ideas or expectations about managing the

health problem were discussed.

Strongly agree Agree Disagree Strongly disagree

7. Concerns or worries about managing the

health problem were discussed.

Strongly agree Agree Disagree Strongly disagree

8. It was made sure that information

had been understood.

Strongly agree Agree Disagree Strongly disagree

9. There were opportunities to ask questions. Strongly agree Agree Disagree Strongly disagree

10. The preference to take part in the

decision (or not) was respected.

Strongly agree Agree Disagree Strongly disagree

11. During the consultation, a decision was

made; or there was an agreement to

postpone making the decision.

Strongly agree Agree Disagree Strongly disagree

12. The possibility of coming back to

the decision was discussed.

Strongly agree Agree Disagree Strongly disagree

E. Melbourne et al. / Patient Education and Counseling 78 (2010) 177–183 181

iterations due to grammatical difficulties and in this interviewcycle it seemed that respondents were finding this item verysimple to answer. Anticipated probing revealed that respondentswere applying this item to any health problem they had previouslyconsulted with as opposed to specifically those discussed in thereference consultation. As a result it was decided to explicitlyground the item in time by adding ‘during the consultation. . .’

The introductory comments underwent further modification.Several respondents noted that not all consultations containeddiscussions about specific ‘decisions’ and the introductory state-ment was modified accordingly. It was also necessary to introducethe concept of an ‘index’ problem, i.e. to indicate that althoughmost consultations contain multiple decision making time points,it was sufficient for the purposes of the assessment to consider onedecision making issue, where involvement had been maximal.Table 2 shows how items were modified during the three interviewcycles. After the third interview cycle, few new insights weregained and ‘category saturation’ had been attained [21]. No furtherinterviews were thus conducted. Table 3 shows the final version ofthe scale.

4. Discussion and conclusions

4.1. Discussion

This study demonstrates that, although difficulties occurred, itwas possible to modify the observer OPTION instrument to be aninstrument capable of being completed by both clinicians andpatients after a dyadic interaction. The cognitive debriefing

interviews revealed five areas of interpretative difficulty, namely:construct clarity, syntactical and grammatical problems, contex-tual positioning of the instrument and issues of personalpreference. Interestingly, despite the apparent methodologicalvariation between cognitive debriefing research groups, problemsencountered are broadly similar. Five kinds of problems wereidentified in the consumer assessment of health providers andservices survey in 2005 [18]. These included items with ambiguousterms that caused them to be consistently understood or(misunderstood), corresponding to the syntactical difficultiesidentified in this study; and questions that were not measuringthe constructs that they were supposed to measure—correspond-ing to our construct mismatch. An advantage of the cognitivedebriefing process, previously acknowledged is the identificationof vague and unclear questions due to syntactical difficulties andconstruct mismatch [22,23].

The majority of data informing modifications due to semanticand grammatical difficulties was elicited during the first two roundsof cognitive debriefing, largely by the proactive administration ofanticipated and spontaneous probes. Studies in the literature arevague about their preparation and use of probes. It is our opinionthat the probes administered and resulting data should be viewed asone unit for analysis. Indeed a consistent feature of the literature byleading cognitive debriefing practitioners is the need for conscien-tious analysis of the probing techniques to allow further metho-dological development. It was to address this request and thusenable analysis of the question response patterns that we presentedthe probes we used and the data elicited as one unit, and urge teamstaking on future cognitive debriefing to do the same.

E. Melbourne et al. / Patient Education and Counseling 78 (2010) 177–183182

By using a series of cognitive debriefing interviews, the existingobserver OPTION scale was adapted into a tool that we considersuitable and now available for research into the interdependentnature of clinical encounters. Data from a dyadic version of theOPTION scale is capable of collecting data about involvement indecision making from the dual perspectives of clinicians andpatients and will enable the collection of data suited for dyadicanalysis [9]. This is a new area of research in healthcare and onewhich requires specifically designed instruments. We have usedthe term dyadic OPTION scale to differentiate this scale from theobserver (third party assessment) version.

A strength of this study is the use of a well described method todevelop a new tool [17,19]. We adopted an iterative design andassessment cycle and this allowed the modification and refine-ment of instrument items in response to respondents’ comments.By stratifying our sample by preferences for daily newspaperreadership we also ensured the sample diversity. Grammatical andsemantic problems were addressed in the first two rounds ofinterviewing whilst the introductory statement was amended afterthe final round of interviewing. Three cycles of interviews attaineddata saturation, with minimal modifications being made to theindividual items after the third round of interviewing. A furtherstrength was the use of a well established measurementinstrument [14,24] as the basis for the design of a new measure.The main limitation of the study is that a single interviewerconducted the analysis of the data prior to discussion with theoriginal scale developer. Although this ensured continuity andconsistency during interviewing and analysis, added rigour couldhave been achieved by dual analysis by an independent secondresearcher.

4.2. Conclusion

There is evidence that health services researchers are beginningto use a dyadic and relationship-centred approach to clinicaldecision making [10,25–27]. In other words, health servicesresearchers are moving from studying groups of patients andhealth professionals separately to studying both simultaneously.For example, five of the six most recently developed instrumentshad corresponding patient versions [28–35]. Moreover, theauthors of two of these instruments, only obtained evidence ofvalidity and reliability data for the combined use of the physician’sand patient’s questionnaires [28,30,36–40]. This observationsuggests that, increasingly, interdependence is being recognisedas an inherent factor within the patient–physician relationshipwhich ultimately impacts upon the outcome of the consultation.Furthermore, the patient–physician relationship is an importantcomponent of physicians’ satisfaction with their job [27].Physicians’ judgements about their experience with individualpatients both reflect and shape what takes place during office visitsand beyond [41]. This balance supports what has previously beendescribed on the basis of personal communication needs which canpotentially be fulfilled in the clinical encounter [41]. Therefore,future research in the field of clinical decision making should fosterthe use of patient and clinician versions of a similar instrument. Inline with the growing interest for shared decision making, this mayallow for a more comprehensive assessment of the complexity ofthe clinical decision making process and thus of its dynamic andreciprocal nature [32].

Saba has highlighted the need to evaluate the ‘subjectiveexperience of partnership’ when considering the degree ofcollaboration achieved within a consultation [3]. Previous attemptsto assess shared decision making have led to the development ofinstruments such as the Patients’ Perceived Involvement in CareScale (PICS) [16] and observer OPTION [13,14]. PICS is one of the fewquestionnaires which attempts to assess the patient’s role in the

consultation. It considers the patient’s involvement in the con-sultation as a whole as opposed to OPTION which focuses more onthe decision making aspects of the encounter. This leads todifficulties when trying to analyse the data from PICS specificallyto measure involvement in shared decision making. In addition tothis, many of the PICS items reflect the semantic, grammatical andconstruct mismatch problems which we encountered during thisstudy.

Acknowledging interdependence within a medical consulta-tion is central to understanding and evaluating the encounter andrealising the true relevance of such an interaction. We cannottherefore address this issue without attempting to assess theconsultation from the dual perspectives of the actors involved.This problem is at the centre of current debates about theassessment of shared decision making [4]. Dyadic OPTION is thefirst tool to allow us access to this dual perspective whilst usingidentical items and construct and we hope it use will provide newinsight the complex interdependent nature of clinical encounters,and in particular to the intricacies of attempts of achieve shareddecision making.

4.3. Implications for practice

This study has demonstrated that the dyadic OPTION instrumentis well understood by clinical and patient respondents and has thepotential to gather valid data about perceived patient involvementin shared decision making. We hope that by using cognitivedebriefing to develop dyadic OPTION, we have been able toconceptualise difficult, inconsistently practiced constructs asaccurate, accessible, comprehensible items and that these itemsallow truthful representative responses with minimal processingburden to respondents. However, cognitive debriefing alone doesnot guarantee that this has been achieved. We recommendtherefore that further validation be carried out on target clinicalpopulations to ascertain the scale’s true reliability and validity inpractice before it is used for the collection of dyadic interdepen-dence data.

Conflict of interest

The authors report no conflicts of interest.

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